What is the best course of action for a patient with a history of left middle cerebral artery (MCA) stroke, currently presenting with stable neurological status, elevated liver enzymes, thrombocytosis, neutrophilia, and malnutrition, on dual antiplatelet therapy (aspirin and clopidogrel), atorvastatin, and other medications for secondary stroke prevention and comorbid conditions?

Management of Post-Stroke Patient on Dual Antiplatelet Therapy with Laboratory Abnormalities

Primary Recommendation

Continue dual antiplatelet therapy (aspirin + clopidogrel) for secondary stroke prevention, maintain atorvastatin despite mild transaminitis, and address the reactive thrombocytosis and malnutrition with supportive measures while monitoring trends. 1, 2

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Antiplatelet Therapy Management

Continue Current DAPT Regimen

• Dual antiplatelet therapy with aspirin and clopidogrel is appropriate for secondary stroke prevention in this patient with established left MCA stroke. 1, 2
• The Canadian Stroke Best Practice guidelines recommend that if a patient experiences stroke while on aspirin alone, switching to clopidogrel or adding dipyridamole is reasonable; however, this patient is already on optimal DAPT. 1
• For long-term management beyond the acute phase (this patient is now in chronic phase), single antiplatelet therapy is typically recommended, but the decision to continue DAPT should weigh individual thrombotic risk against bleeding risk. 1, 2

Critical Decision Point: Duration of DAPT

• For minor ischemic stroke, DAPT is typically recommended for 21-90 days, then transition to single antiplatelet therapy. 2, 3
• Given this patient's stable neurological status and the time elapsed since stroke, consider transitioning from DAPT to single antiplatelet therapy (clopidogrel 75 mg daily preferred over aspirin alone) to reduce bleeding risk while maintaining stroke prevention efficacy. 1, 2
• The thrombocytosis (platelets 443) is likely reactive and does not contraindicate antiplatelet therapy, but it does not justify continuing DAPT indefinitely either. 1

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Statin Management with Elevated Liver Enzymes

Continue Atorvastatin with Monitoring

• The benefits of high-intensity statin therapy for secondary stroke prevention far outweigh the risks of mild transaminitis (ALT 52, down from 67). 1, 4
• Asymptomatic ALT elevation up to 3 times the upper limit of normal is common in stroke patients on statins (incidence 2.3-2.1% for mild elevation) and is associated with older age and chronic liver disease, not necessarily statin toxicity. 4
• The downward trend in ALT (67→52) and stable AST (28) indicates improving hepatic function, not progressive injury. 4
• Continue weekly LFT monitoring as currently ordered; discontinue atorvastatin only if ALT rises above 3 times the upper limit of normal or if symptoms of hepatic dysfunction develop. 4

Drug Interaction Alert

• The current use of pantoprazole is appropriate, but avoid switching to omeprazole or esomeprazole, as these significantly reduce clopidogrel's antiplatelet activity through CYP2C19 inhibition. 5
• Pantoprazole has less effect on clopidogrel metabolism than omeprazole or esomeprazole. 5

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Thrombocytosis Management

Reactive Thrombocytosis Approach

• Platelets at 443 represent reactive thrombocytosis, likely secondary to inflammation, malnutrition, or post-stroke physiology—not a primary hematologic disorder. 1
• No evidence of thrombosis, bleeding, or infection is present to suggest pathologic thrombocytosis. 1
• Continue current antiplatelet regimen as it provides protection against thrombotic complications; do not add additional anticoagulation. 1
• Monitor CBC weekly as ordered; escalate to hematology consultation only if platelets exceed 600,000 or if new thrombotic/bleeding symptoms emerge. 1

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Neutrophilia Management

Observation Without Antibiotics

• WBC 9.8 with neutrophils 77% represents mild neutrophilia without leukocytosis—likely stress response or reactive process. 1
• No fever (T 98.1°F), respiratory symptoms, urinary complaints, or other signs of infection are present. 1
• Continue daily vital sign surveillance; obtain urinalysis and culture only if fever, dysuria, or other localizing symptoms develop. 1
• Do not initiate empiric antibiotics in the absence of clinical infection. 1

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Malnutrition and Hypoalbuminemia

Nutritional Optimization

• Albumin 3.2 (low-normal) and total protein 5.8 (low) indicate ongoing protein-calorie malnutrition requiring aggressive nutritional support. 1
• Continue ProStat supplementation, mechanical soft diet with honey-thick liquids per speech therapy recommendations, and weekly weights. 1
• Malnutrition contributes to reactive thrombocytosis, impaired wound healing, and increased infection risk. 1
• Maintain daily skin surveillance with Braden score monitoring (currently 15, mild risk) and zinc oxide barrier cream to prevent pressure injuries. 1

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Magnesium Repletion

• Magnesium 1.6 (slightly low) should be repleted per facility protocol if symptomatic or if levels drop further. 1
• Hypomagnesemia can contribute to cardiac arrhythmias, muscle weakness, and impaired rehabilitation progress. 1
• Trend with weekly labs as currently ordered. 1

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Blood Pressure Management

Current BP Control

• BP 138/74 is acceptable for post-stroke management; target systolic BP <140 mmHg is appropriate for secondary stroke prevention. 1, 3
• No antihypertensive medications are currently ordered beyond the stroke prevention regimen. 1
• Monitor for orthostatic hypotension during therapy sessions, as this can impair rehabilitation progress and increase fall risk. 1

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Bleeding Risk Assessment

Balancing Thrombotic vs. Bleeding Risk

• The current pain score of 2/10 (generalized, unchanged) and absence of GI symptoms, hematuria, or other bleeding manifestations suggest acceptable bleeding risk on current DAPT. 1, 6, 7
• DAPT increases major hemorrhage risk by approximately 2-fold compared to aspirin alone (0.9% vs. 0.4% in POINT trial), but this must be weighed against 25% reduction in major ischemic events. 6, 7
• Given the patient's stability and time elapsed since stroke, transitioning to single antiplatelet therapy (clopidogrel 75 mg daily) is reasonable to reduce bleeding risk while maintaining stroke prevention efficacy. 1, 2, 6

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Critical Pitfalls to Avoid

• Do not discontinue antiplatelet therapy based on thrombocytosis alone—reactive thrombocytosis does not contraindicate antiplatelet use and may actually benefit from it. 1
• Do not switch pantoprazole to omeprazole or esomeprazole, as these significantly reduce clopidogrel efficacy. 5
• Do not discontinue atorvastatin based on mild transaminitis with downward trend—benefits for secondary stroke prevention outweigh risks. 1, 4
• Do not initiate antibiotics for neutrophilia without clinical evidence of infection. 1
• Do not add anticoagulation for reactive thrombocytosis—this increases bleeding risk without reducing thrombotic risk. 1

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Recommended Action Plan

1. Transition from DAPT to single antiplatelet therapy: Discontinue aspirin and continue clopidogrel 75 mg daily for long-term secondary stroke prevention. 1, 2, 6

2. Continue atorvastatin with weekly LFT monitoring; discontinue only if ALT exceeds 3× upper limit of normal. 1, 4

3. Continue aggressive nutritional support with ProStat, mechanical soft diet, and weekly weights to address malnutrition. 1

4. Monitor CBC weekly; escalate to hematology only if platelets exceed 600,000 or new symptoms develop. 1

5. Replete magnesium per facility protocol and trend with weekly labs. 1

6. Continue current rehabilitation regimen (PT/OT/ST) with fall and aspiration precautions. 1

7. Maintain pantoprazole for GI protection; do not switch to omeprazole or esomeprazole. 5