Pharmacotherapy for Ischemic Stroke

Acute Phase Management

The American College of Chest Physicians recommends IV r-tPA if treatment can be initiated within 3 hours of symptom onset (Grade 1A) 1
The American College of Chest Physicians recommends IV r-tPA if treatment can be initiated within 4.5 hours but not within 3 hours of symptom onset (Grade 2C) 1
Early aspirin therapy (160-325 mg) should be started within 48 hours of symptom onset (Grade 1A) 1, 3
Aspirin is preferred over therapeutic parenteral anticoagulation in the acute phase (Grade 1A) 3

The American College of Chest Physicians recommends long-term antiplatelet therapy with one of the following (Grade 1A) 3, 4
Clopidogrel or aspirin/extended-release dipyridamole are preferred over aspirin (Grade 2B) or cilostazol (Grade 2C) 3, 4
For minor ischemic stroke or high-risk TIA, dual antiplatelet therapy with aspirin 81 mg daily and clopidogrel 75 mg daily should be initiated early, ideally within 12-24 hours of symptom onset 4
Oral anticoagulation is recommended over no antithrombotic therapy (Grade 1A), aspirin (Grade 1B), or combination therapy with aspirin and clopidogrel (Grade 1B) for cardioembolic stroke with atrial fibrillation 2, 3

Dabigatran is contraindicated in patients with severe renal impairment (estimated creatinine clearance ≤30 mL/min) 5
For patients with embolic stroke of undetermined source, antiplatelet therapy is recommended rather than oral anticoagulants 4