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


The new guidelines still find no benefit in using anticoagulation for the treatment of AIS, regardless of the extent of stenosis or the duration of anticoagulant therapy. There is limited observational evidence on the usefulness of direct thrombin inhibitors and factor Xa inhibitors in the treatment of AIS. The guidelines highlight the need for further clinical trials, which are ongoing.[2]

Deep vein thrombosis prophylaxis in immobile AIS patients also remains controversial, with the guidelines noting no benefit with subcutaneous heparin or low-molecular-weight heparin, but rather recommending continued treatment with aspirin as well as intermittent pneumatic compression stockings.[15]

The proper time to resume a patient's therapeutic anticoagulant therapy following IV alteplase administration is currently an area of controversy in clinical practice, and the guidelines agree that the risk of conversion to intracranial hemorrhage upon resuming antithrombotic therapy up to 24 hours after IV alteplase remains uncertain.[2] The guidelines reference one study conducted in South Korea that did not find a difference in risk of hemorrhage with early initiation (<24 hours) of anticoagulant therapy compared with later initiation of anticoagulant therapy (>24 hours).[16] Guidelines suggest individualizing this decision for each patient, especially for those with a compelling indication for anticoagulation therapy in which withholding treatment would cause substantial risk to the patient.[2]