Antiplatelet Management in Ischemic Stroke

Acute Phase Management

For patients with minor ischemic stroke or high-risk TIA, the American Heart Association recommends dual antiplatelet therapy with aspirin and clopidogrel as early as possible, ideally within 12-24 hours of symptom onset, after excluding intracranial hemorrhage on neuroimaging 1, 2
The American College of Cardiology recommends a loading dose of aspirin 160-325 mg and clopidogrel 300 mg (CHANCE trial) or 600 mg (POINT trial) for patients with minor ischemic stroke or high-risk TIA 1, 2
For patients with moderate-to-severe ischemic stroke who are not candidates for thrombolysis or thrombectomy, the American Stroke Association recommends aspirin monotherapy initiated within 24-48 hours of symptom onset 4, 3, 5

The American Heart Association recommends transitioning to single antiplatelet therapy for long-term secondary prevention after completing the short-term DAPT course (21-30 days) 1, 2
Clopidogrel 75 mg daily is the preferred agent for long-term therapy, according to the American College of Cardiology 2, 6
Aspirin 81 mg daily is an alternative option for long-term secondary prevention, as recommended by the American Stroke Association 1, 2

For patients with symptomatic moderate-to-severe intracranial stenosis, the American Heart Association recommends DAPT with aspirin and clopidogrel, combined with systolic blood pressure target <140 mmHg, high-dose statin therapy, and at least moderate physical activity 2
Patients with embolic stroke of undetermined source (ESUS) should receive antiplatelet therapy, not oral anticoagulants, according to the American Stroke Association 1, 2, 6

The American College of Cardiology recommends avoiding concomitant use of clopidogrel with omeprazole or esomeprazole, as these CYP2C19 inhibitors reduce clopidogrel's effectiveness 2
Premature discontinuation of antiplatelet therapy increases the risk of subsequent cardiovascular events, according to the American Heart Association [4, 3
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Do not delay aspirin beyond 48 hours in patients not receiving thrombolysis, as early administration reduces early recurrent stroke and improves long-term outcomes, as recommended by the American Stroke Association 4, 3