What are the AHA/ASA guidelines on use the prevention of stroke following a noncardioembolic ischemic stroke or transient ischemic attack (TIA)?

Updated: Dec 18, 2018
  • Author: Salvador Cruz-Flores, MD, MPH, FAHA, FCCM, FAAN, FACP, FANA; Chief Editor: Helmi L Lutsep, MD  more...
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Antiplatelet agents rather than oral anticoagulation are recommended to reduce the risk of recurrent stroke and other cardiovascular events (Class I, level of Evidence A). Aspirin (50 to 325 mg/d) monotherapy, the combination of aspirin and extended-release dipyridamole, and clopidogrel monotherapy are all acceptable options for initial therapy (IA).

For patients who have an ischemic cerebrovascular event while taking aspirin, there is no evidence that increasing the dose of aspirin provides additional benefit. The combination of aspirin and extended-release dipyridamole is recommended over aspirin alone (IB).

Class II recommendations

Clopidogrel may be considered over aspirin alone (IIbB), and clopidogrel is reasonable for patients allergic to aspirin (IIaB).

Class III recommendation

The addition of aspirin to clopidogrel increases the risk of hemorrhage; therefore, combination therapy with aspirin and clopidogrel is not routinely recommended unless patients have a specific indication for this therapy (ie, coronary stent or acute coronary syndrome)(I).

A study by Bushnell et al found that one fourth of patients who have experienced a stroke stop taking one or more of their prescribed secondary prevention medications within 3 months of hospitalization for acute stroke. [48] Patients reported many reasons, but several were modifiable; because of this reason, improvement in long-term secondary stroke prevention is possible.

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