What are the recommended take‑home medications for secondary prevention after an ischemic cerebrovascular infarct in a patient without a known cardio‑embolic source?

Take-Home Medications for Cerebrovascular Ischemic Infarct

Antiplatelet Therapy Selection Algorithm

For patients with non-cardioembolic ischemic stroke, the choice of antiplatelet regimen depends on stroke severity, timing of presentation, and patient-specific factors. 1

Minor Stroke (NIHSS ≤3) or High-Risk TIA (ABCD² ≥4) Presenting Within 24 Hours

Initiate dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel for exactly 21 days, then transition to single-agent therapy. 2

Loading doses (within 12–24 hours of onset):

• Clopidogrel 300 mg (acceptable range 300–600 mg) 2
• Aspirin 160–325 mg 2

Maintenance phase (days 2–21):

• Clopidogrel 75 mg once daily 2
• Aspirin 75–100 mg once daily 2

After day 21, switch to single antiplatelet therapy indefinitely:

• Aspirin 75–100 mg daily (first-line) 2
• OR clopidogrel 75 mg daily (alternative for aspirin intolerance, diabetes, or peripheral arterial disease) 2
• OR aspirin 25 mg + extended-release dipyridamole 200 mg twice daily 2

This 21-day DAPT regimen reduces recurrent stroke by 25–32% (hazard ratio 0.68–0.75) with a number needed to treat of 67–91, while major bleeding increases modestly from 0.4% to 0.9% (number needed to harm ≈200). 2

Moderate-to-Severe Stroke (NIHSS >3) or Presentation >24 Hours

Use single antiplatelet therapy from the outset:

Loading dose:

• Aspirin 160–325 mg within 24–48 hours after excluding hemorrhage 2

Maintenance therapy (starting day 2):

• Aspirin 75–100 mg daily indefinitely 2
• OR clopidogrel 75 mg daily (for aspirin intolerance or specific patient factors) 2

Critical Timing Considerations

If the patient received IV alteplase, delay all antiplatelet agents until ≥24 hours post-thrombolysis and obtain repeat neuroimaging to confirm absence of hemorrhagic transformation. 2 Starting aspirin earlier markedly raises bleeding risk. 2

Do not delay aspirin beyond 48 hours when eligibility criteria are met; maximal benefit occurs within the first 24–48 hours. 2

Blood Pressure Management

Initiate or optimize antihypertensive therapy before hospital discharge or within the first week after stroke. 3 Blood pressure control is essential for secondary prevention, though specific targets should be individualized based on comorbidities. 1

Lipid-Lowering Therapy

Start high-intensity statin therapy for all patients with non-cardioembolic ischemic stroke regardless of baseline LDL cholesterol level. 4, 5 Statins reduce recurrent vascular events by approximately 20–30% and are a cornerstone of secondary prevention. 4

Glucose Management

For patients with diabetes, optimize glycemic control following national diabetes management standards. 3 Routine glucose monitoring should be performed for all stroke patients during hospitalization. 3

Special Population: Cardioembolic Stroke (Atrial Fibrillation)

For patients with atrial fibrillation-related stroke, anticoagulation—not antiplatelet therapy—is required for secondary prevention. 6

Timing of anticoagulation initiation (based on stroke severity):

Stroke Severity (NIHSS)	Start Anticoagulation	Imaging Requirement
TIA	1 day after confirming no hemorrhage	Baseline CT/MRI
Mild (NIHSS <8)	3 days; repeat imaging day 6	Repeat CT/MRI day 6
Moderate (NIHSS 8–15)	6–8 days; repeat imaging day 6	Repeat CT/MRI day 6
Severe (NIHSS ≥16)	12–14 days; repeat imaging day 12	Repeat CT/MRI day 12

6

Direct oral anticoagulants (DOACs) are strongly preferred over warfarin, reducing intracranial hemorrhage by approximately 56%. 6

Preferred DOAC options:

• Dabigatran 150 mg twice daily 6
• Apixaban 5 mg twice daily (or 2.5 mg twice daily if dose-reduction criteria apply) 6
• Rivaroxaban or edoxaban at standard atrial fibrillation dosing 6

Aspirin 160–325 mg should be given immediately and continued until therapeutic anticoagulation is achieved. 6 Do not combine aspirin with long-term therapeutic anticoagulation after the transition period unless there is a clear indication (e.g., recent acute coronary syndrome), as this increases bleeding risk. 6

Critical Contraindications and Pitfalls

Absolute contraindications to antiplatelet therapy:

• Intracranial hemorrhage not excluded on imaging 2
• Active major bleeding 2
• Severe thrombocytopenia 2
• Known hypersensitivity to aspirin or clopidogrel 2

Common pitfalls to avoid:

• Never substitute aspirin for thrombolysis or thrombectomy in eligible patients—this delays definitive treatment and worsens outcomes 2
• Never extend DAPT beyond 21–30 days in routine secondary prevention; prolonged therapy markedly increases hemorrhage risk (hazard ratio 2.22–2.32) without additional stroke-prevention benefit 2
• Never use ticagrelor instead of clopidogrel for acute minor stroke; no proven benefit and higher bleeding risk 2
• Never use glycoprotein IIb/IIIa inhibitors (abciximab, eptifibatide, tirofiban) in acute ischemic stroke; they are potentially harmful 2
• Never use anticoagulation for non-cardioembolic stroke; antiplatelet therapy is the standard of care 6

Additional Discharge Medications

Lifestyle modification counseling should address:

• Smoking cessation 4, 7
• Dietary modification (Mediterranean or DASH diet) 4
• Regular exercise 4
• Alcohol moderation 7, 5
• Weight management 8

The combination of antiplatelet therapy, statin, antihypertensive agent, dietary modification, and exercise could result in a cumulative relative risk reduction of 80% for recurrent vascular events over 5 years. 4