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Chapter 9 - Acute Antiplatelet Therapy for the Treatment of Ischaemic Stroke and Transient Ischaemic Attack

from Part III - Acute Treatment of Ischaemic Stroke and Transient Ischaemic Attack

Published online by Cambridge University Press:  15 December 2020

By
Jeffrey L. Saver
Edited by
Jeffrey L. Saver  and
Graeme J. Hankey
Jeffrey L. Saver
Affiliation:
David Geffen School of Medicine, University of Ca
Graeme J. Hankey
Affiliation:
University of Western Australia, Perth
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Summary

Aspirin 160–300 mg daily started within 48 h of onset of acute ischaemic stroke is associated with a small beneficial reduction in recurrent ischaemic stroke (6 fewer per 1000 patients treated) and pulmonary embolism (1.5 fewer per 1000) that outweighs increased risk of bleeding (2 extra symptomatic ICHs and 4 extra major extracranial haemorrhages). The net effect is that, for every 1000 patients treated early with aspirin, 22 have reduced long-term disability, including 11 more achieving full recovery. Only two single antiplatelet regimens have been compared head to head against aspirin alone: cilostazol (a phosphodiesterase inhibitor) performed similarly to aspirin; ticagrelor (a GP IIa/IIIb receptor antagonist) showed tended to reduce ischaemic events but increased minor bleeding and dyspnea. In minor, non-cardioembolic ischaemic stroke or TIA, early dual antiplatelet therapy (DAPT) has shown advantages over early monotherapy. Most well-studied is clopidogrel and aspirin, with similar findings for dipyridamole and aspirin. DAPT reduces all-type (ischaemic and haemorrhagic) recurrent stroke (27 fewer per 1000 treated patients), but minimally increases major extracranial bleedings (3 more per 1000). Confining DAPT to the first 3 w maximizes the benefit to harm ratio. Anticoagulants alone and arterial-dose anticoagulants added to antiplatelet agents offer no net advantages over antiplatelet drugs alone. Venous prophylaxis-dose anticoagulants and aspirin, compared with aspirin alone, reduced recurrent ischaemic stroke more than it tend increased major extracranial haemorrhage.

Keywords

Antiplateletanticoagulantantithromboticprogressionhaemorrhagic transformationdual antiplatelet therapyaspirinclopidogrelischaemic stroketransient ischaemic attackmanagementtreatment
Type
Chapter
Information
Stroke Prevention and Treatment
An Evidence-based Approach
 , pp. 154 - 178
Publisher: Cambridge University Press
Print publication year: 2020

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