What are the guidelines on antithrombotic therapy for the secondary prevention of noncardioembolic stroke?

Updated: Jan 10, 2016
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Answer

The ACCP guidelines for secondary prevention of noncardioembolic stroke recommend long-term treatment with aspirin (75-100 mg once daily), clopidogrel (75 mg once daily), aspirin/extended-release dipyridamole (25 mg/200 mg bid), or cilostazol (100 mg bid) over no antiplatelet therapy (grade 1A), oral anticoagulants (grade 1B), the combination of clopidogrel plus aspirin (grade 1B), or triflusal (grade 2B). An antiplatelet regimen of clopidogrel or aspirin/extended-release dipyridamole is preferred over aspirin (grade 2B) or cilostazol (grade 2C). [11]

The AHA/ASA recommendations for antithrombotic therapy for noncardioembolic stroke include the following:

  • Antiplatelet agents rather than oral anticoagulation to reduce the risk of recurrent stroke and other cardiovascular events (class I).
  • Selection of an antiplatelet agent individualized on the basis of patient risk factor profiles, cost, tolerance, relative known efficacy of the agents, and other clinical characteristics (class I).
  • Aspirin (50–325 mg/d) monotherapy or the combination of aspirin 25 mg and extended-release dipyridamole 200 mg twice daily as initial therapy (class I)
  • Clopidogrel (75 mg) monotherapy is a reasonable option in place of aspirin or combination aspirin/dipyridamole. (class IIa)
  • The combination of aspirin and clopidogrel might be considered for initiation within 24 hours of a minor ischemic stroke or TIA and for continuation for 21 days (class IIb)
  • The combination of aspirin and clopidogrel increases the risk of hemorrhage relative to either agent alone and is not recommended for routine long-term secondary prevention after ischemic stroke or TIA (class III).
  • For patients who have an ischemic stroke or TIA while taking aspirin, there is no evidence that increasing the dose of aspirin provides additional benefit. Although alternative antiplatelet agents are often considered, no single agent or combination has been adequately studied in patients who have had an event while receiving aspirin (class IIb).

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