Aspirin and Clopidogrel Loading in Acute Ischemic Stroke

Recommendations for Antiplatelet Therapy in Acute Stroke

• The American Heart Association recommends oral administration of aspirin (initial dose 160-325 mg) within 24 to 48 hours after stroke onset for most patients with acute ischemic stroke 1, 3, 4
• Aspirin administration provides a small but statistically significant reduction in mortality and morbidity when started within 48 hours of stroke onset, with a primary benefit of reducing early recurrent stroke 3, 5, 6
• The American College of Cardiology and American Heart Association state that the administration of clopidogrel alone or in combination with aspirin is not recommended for the treatment of acute ischemic stroke (Class III, Level of Evidence C) 1, 2

Dual Antiplatelet Therapy (DAPT) Considerations

• Dual antiplatelet therapy with aspirin and clopidogrel is recommended only for patients with minor stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4), initiated within 24 hours of symptom onset, and limited to 21 days followed by long-term single antiplatelet therapy 4, 7
• The American Heart Association and American Stroke Association introduced a new recommendation for dual antiplatelet therapy in 2018, but only for minor stroke or high-risk TIA, not for all acute strokes 4

Safety and Efficacy Concerns

• The administration of aspirin as adjunctive therapy within 24 hours of thrombolytic therapy is not recommended (Class III, Level of Evidence A) 1, 3
• For patients who have received IV thrombolysis (rtPA), aspirin administration should generally be delayed until 24 hours later 4
• In patients with impaired swallowing, rectal aspirin (325 mg) or aspirin (81 mg) or clopidogrel (75 mg) via enteral tube are reasonable alternatives 7