What is the management of ischemic stroke with concurrent myocardial infarction (MI)?

From the Guidelines

Management of ischemic stroke with concurrent myocardial infarction should prioritize immediate intravenous thrombolysis with alteplase, followed by percutaneous coronary angioplasty and stenting if indicated, as this approach is reasonable and probably recommended according to the 2018 guidelines for the early management of patients with acute ischemic stroke 1. The recommended dose of alteplase is 0.9mg/kg, with a maximum of 90mg, and 10% given as a bolus and the remainder over 60 minutes. Key considerations in the management of these patients include:

• Immediate dual antiplatelet therapy with aspirin and clopidogrel for at least 14-21 days, then continuing with single antiplatelet therapy long-term
• Anticoagulation with heparin for cardiac protection, typically with unfractionated heparin if procedures are anticipated
• Blood pressure management, maintaining systolic pressure below 180mmHg but ensuring adequate cerebral perfusion
• Early statin therapy, such as high-intensity atorvastatin 80mg daily, regardless of baseline cholesterol levels
• Cardiac catheterization timing depends on stroke severity, with immediate catheterization for small strokes but delayed 3-7 days for larger strokes to minimize hemorrhagic transformation risk. It is essential to weigh the benefits of these treatments against the potential bleeding risks, particularly in patients with a history of recent myocardial infarction or other comorbid conditions 1. The 2018 guidelines provide a framework for managing patients with acute ischemic stroke and concurrent myocardial infarction, emphasizing the importance of individualized care and careful consideration of the potential risks and benefits of each treatment approach 1.

From the FDA Drug Label

1. 2 Recent MI, Recent Stroke, or Established Peripheral Arterial Disease

In patients with established peripheral arterial disease or with a history of recent myocardial infarction (MI) or recent stroke clopidogrel tablets are indicated to reduce the rate of MI and stroke.

The management of ischemic stroke with myocardial infarction involves the use of clopidogrel to reduce the rate of myocardial infarction (MI) and stroke.

• The recommended dosage is 75 mg once daily orally without a loading dose for patients with recent MI, recent stroke, or established peripheral arterial disease.
• Aspirin should be administered in conjunction with clopidogrel.
• It is essential to consider the patient's CYP2C19 genotype and potential drug interactions that may affect the antiplatelet activity of clopidogrel 2.

From the Research

Management of Ischaemic Stroke with Myocardial Infarction

• The management of ischaemic stroke with myocardial infarction involves the use of antiplatelet therapy to reduce the risk of recurrent stroke and myocardial infarction 3, 4, 5, 6, 7.
• Dual antiplatelet therapy with clopidogrel and aspirin has been shown to be effective in reducing the risk of recurrent stroke, but it also increases the risk of major bleeding 3, 4, 5, 7.
• The use of clopidogrel and aspirin for a short duration (≤ 1 month) after an ischaemic stroke or transient ischaemic attack has been shown to be effective in reducing the risk of recurrent stroke with minimal increase in bleeding risk 4, 6.
• The management of ischaemic stroke also involves the optimization of chronic disease management, non-pharmacologic lifestyle interventions, and pharmacologic interventions to reduce the risk of recurrent stroke and myocardial infarction 6.

Antiplatelet Therapy

• Clopidogrel and aspirin are commonly used antiplatelet agents for the management of ischaemic stroke and myocardial infarction 3, 4, 5, 6, 7.
• Dual antiplatelet therapy with clopidogrel and aspirin has been shown to be effective in reducing the risk of recurrent stroke, but it also increases the risk of major bleeding 3, 4, 5, 7.
• The use of clopidogrel and aspirin for a short duration (≤ 1 month) after an ischaemic stroke or transient ischaemic attack has been shown to be effective in reducing the risk of recurrent stroke with minimal increase in bleeding risk 4, 6.

Risks and Benefits

• The use of dual antiplatelet therapy with clopidogrel and aspirin increases the risk of major bleeding, but it also reduces the risk of recurrent stroke 3, 4, 5, 7.
• The benefits of dual antiplatelet therapy with clopidogrel and aspirin in reducing the risk of recurrent stroke outweigh the risks of major bleeding in patients with ischaemic stroke or transient ischaemic attack 4, 6.
• The management of ischaemic stroke involves weighing the risks and benefits of antiplatelet therapy and optimizing treatment to reduce the risk of recurrent stroke and myocardial infarction 6.