Antiplatelet Therapy for Acute Ischemic Stroke

Initial Management

For patients with acute ischemic stroke already on aspirin 150mg, continue the aspirin therapy after confirming absence of intracranial hemorrhage on brain imaging, as recommended by the American College of Chest Physicians 2, 3
If the patient received thrombolysis, delay initiation of any antiplatelet therapy until after the 24-hour post-thrombolysis scan has excluded intracranial hemorrhage, according to the American Heart Association 4, 1
For non-thrombolyzed patients with mild to moderate stroke or high-risk TIA, add clopidogrel to the existing aspirin regimen, as suggested by the International Journal of Stroke 1

The recommended loading dose is clopidogrel 300mg as a one-time dose, followed by 75mg daily plus aspirin 150mg daily for a limited duration of 21-30 days, as recommended by the International Journal of Stroke 1
Dual antiplatelet therapy should be started as soon as possible after brain imaging, ideally within 12 hours but no later than 24 hours after symptom onset, according to the International Journal of Stroke 1
After 21-30 days, discontinue one of the antiplatelet agents and continue with monotherapy indefinitely, as suggested by the International Journal of Stroke 1

The CHANCE and POINT trials demonstrated that dual antiplatelet therapy with clopidogrel plus aspirin reduced the risk of recurrent stroke compared to aspirin alone when initiated early after minor stroke or high-risk TIA, as reported by the International Journal of Stroke 1

The optimal duration of dual antiplatelet therapy is 21-30 days, as recommended by the International Journal of Stroke 1
Continuing dual therapy beyond this period increases bleeding risk without additional benefit in stroke prevention, according to the International Journal of Stroke 1
In the POINT trial, for every 1000 patients treated with clopidogrel plus aspirin for 90 days, 15 ischemic strokes would be prevented but 5 major hemorrhages would result, as reported by the International Journal of Stroke 1

Monitor for bleeding complications, especially during the dual antiplatelet therapy period, as recommended by the International Journal of Stroke 1
Perform dysphagia screening before administering oral medications; in dysphagic patients, medications may be given via enteral tube, according to the International Journal of Stroke 3, 1

For patients with severe stroke, the benefit of adding clopidogrel is less established, as reported by the International Journal of Stroke 1
In patients with atrial fibrillation, oral anticoagulation is generally preferred over dual antiplatelet therapy for long-term secondary prevention, but should typically be initiated 1-2 weeks after stroke onset, as recommended by the American College of Chest Physicians 2, 5
The loading dose of clopidogrel is essential for rapid platelet inhibition, as the standard 75mg dose takes approximately 5 days to achieve maximal effect, according to the American Heart Association 4

After the 21-30 day dual antiplatelet period, continue with either aspirin or clopidogrel as monotherapy, as recommended by the American College of Chest Physicians 2, 5
For long-term secondary prevention, clopidogrel or aspirin/extended-release dipyridamole may be preferred over aspirin alone, according to the American College of Chest Physicians 5