Management of Acute Ischemic Stroke: A Review of Pertinent Guideline Updates

Carley E. DeVee, PharmD, BCPS; Ryan J. Sangiovanni, PharmD


US Pharmacist. 2019;44(2):HS2-HS5. 

In This Article

Antiplatelet Therapy

Aspirin continues to be the drug of choice for the antiplatelet treatment of AIS, with administration required within 24 to 48 hours after onset of stroke symptoms. However, the guidelines emphasize that aspirin alone is not a substitute for mechanical thrombectomy or IV alteplase if indicated. If IV alteplase is given, however, aspirin may be withheld for 24 hours after IV alteplase administration unless the patient has a compelling condition in which withholding aspirin would cause greater harm than benefit. Guidelines state that in patients with a contraindication to aspirin, an alternate agent may be considered, provided that glycoprotein IIb/IIIa-receptor antagonists are not used.[2] Compared with other antiplatelet agents, glycoprotein IIb/IIIa-receptor antagonists have been associated with a higher risk of intracranial hemorrhage without improvement in clinical outcomes of death and poststroke disability.[9]

The guidelines state that there is not enough clinical data to provide a well-balanced recommendation regarding patients who have a subsequent (noncardioembolic) AIS while already on aspirin therapy. It is not well established whether this type of patient will receive any additional benefit in stroke prevention with increasing doses of aspirin upon a subsequent AIS, but he or she certainly will have a higher risk of bleeding. The guidelines also do not provide any recommendation on the appropriateness of switching to an alternative antiplatelet agent after experiencing an AIS while on aspirin therapy. However, it is stated clearly that these patients will not receive any benefit in switching from aspirin to warfarin for secondary stroke prevention.[2]

Aspirin has also continued to be the guideline-recommended, first-line antiplatelet option for the secondary prophylaxis of AIS.[2] Perhaps the most controversial updates in the guidelines are the recommendations regarding DAPT for secondary prophylaxis of AIS. Historically, trials such as CHARISMA, MATCH, and SPS3 all suggested that DAPT increased bleeding risk without reducing the risk of stroke.[10–12] However, the CHANCE trial, which included 5,170 Chinese patients with minor AIS (NIHSS score ≤3), found a reduction in 90-day stroke incidence with DAPT for 21 days followed by aspirin monotherapy compared with aspirin monotherapy for the entire treatment course.[13] The guidelines now permit considering (with a low quality of evidence) treatment for 21 days with DAPT followed by antiplatelet monotherapy for up to 90 days poststroke in patients classified with a minor stroke.[2] However, the POINT trial (recently published and therefore not yet included in these guidelines) which included 4,881 patients from multiple countries with minor AIS or high-risk transient ischemic attack, failed to find reduction in a composite outcome of ischemic stroke, myocardial infarction, or death from ischemic/vascular causes in the DAPT arm compared with the aspirin monotherapy arm. In fact, this trial was stopped early due to more major bleeding in the DAPT arm.[14] Ongoing clinical trials will be forthcoming and may shed more light on recommendations regarding the appropriateness of DAPT for secondary prophylaxis.