Antithrombotic Therapy for Stroke Prevention in Patients With Ischemic Stroke With Aspirin Treatment Failure

Jay B. Lusk, BSc; Haolin Xu, MS; Eric D. Peterson, MD, MPH; Deepak L. Bhatt, MD, MPH; Gregg C. Fonarow, MD; Eric E. Smith, MD, MPH; Roland Matsouaka, PhD; Lee H. Schwamm, MD; Ying Xian, MD, PhD


Stroke. 2021;52(12):e777-e781. 

In This Article

Abstract and Introduction


Background and Purpose: Many older patients presenting with acute ischemic stroke were already taking aspirin before admission. However, the management strategy for patients with aspirin treatment failure has not been fully established.

Methods: We used data from the American Heart Association Get With The Guidelines Stroke Registry to describe discharge antithrombotic treatment patterns among Medicare beneficiaries with ischemic stroke who were taking aspirin before their stroke and were discharged alive from 1734 hospitals in the United States between October 2012 and December 2017.

Results: Of 261 634 ischemic stroke survivors, 100 016 (38.2%) were taking aspirin monotherapy before stroke. Among them, 44.4% of patients remained on aspirin monotherapy at discharge (20.9% 81 mg, 18.2% 325 mg, 5.3% other or unknown dose). The next most common therapy choice was dual antiplatelet therapy (24.6%), followed by clopidogrel monotherapy (17.8%). The remaining 13.2% of patients were discharged on either aspirin/dipyridamole, warfarin, or nonvitamin K antagonist oral anticoagulants with or without antiplatelet, or no antithrombotic therapy at all.

Conclusions: Nearly half of patients with ischemic stroke while on preventive therapy with aspirin are discharged on aspirin monotherapy without changing antithrombotic class, while the other half are discharged on clopidogrel monotherapy, dual antiplatelet therapy, or other less common agents. These findings emphasize the need for future research to identify best management strategies for this very common and complex clinical scenario.

Graphic Abstract: An online graphic abstract is available for this article.


More than 40% of adults over the age of 70 in United States take aspirin for primary prevention of cardiovascular disease, and >70% of patients of any age with a history of cardiovascular disease take aspirin daily.[1,2] While aspirin is commonly used for cardiovascular disease and stroke prevention, many patients taking aspirin monotherapy still experience an ischemic stroke (so called aspirin failure).[3] Although increasing the dose of aspirin, adding a second drug, or switching to an alternative antiplatelet agent are often considered, there is no evidence of superiority of any of these approaches.[3,4] This study evaluates the prevalence of aspirin failure among older patients presenting with acute ischemic stroke and describes their discharge prescription patterns of antithrombotic therapy for secondary stroke prevention.