The following are key points to remember from a state-of-the-art review on antithrombotic therapy for primary and secondary prevention of ischemic stroke:

1. Decisions regarding antithrombotic treatment in primary and secondary stroke prevention should always involve consideration of the individual patient’s bleeding risk.
2. The default treatment for secondary stroke prevention should be an antiplatelet agent (e.g., aspirin or clopidogrel monotherapy), generally initiated within 24-48 hours after symptom onset.
3. Dual antiplatelet therapy (DAPT) with clopidogrel and aspirin or ticagrelor and aspirin is indicated for a short time (~21 days) after minor acute ischemic stroke or transient ischemic attack. Antiplatelet monotherapy should be initiated after the short course of DAPT is completed.
4. Ischemic stroke patients with nonvalvular atrial fibrillation (AF) and no contraindication should receive anticoagulation with a DOAC or warfarin.
5. Decisions regarding timing of initiation or reinitiation of anticoagulation for AF after ischemic stroke should be informed by infarct size, evidence of hemorrhagic transformation, and patient-specific factors (e.g., presence of comorbid deep vein thrombosis).
6. The treatment of choice for secondary stroke prevention after ESUS (embolic stroke of undetermined source) is antiplatelet monotherapy.
7. Anticoagulation is generally the antithrombotic treatment of choice for antiphospholipid antibody syndrome and for recurrent ischemic stroke felt secondary to malignancy-related hypercoagulability.
8. In the first 3 months after a vertebral or carotid artery dissection, either aspirin or warfarin may be used.
9. Anticoagulation with warfarin is the treatment of choice for left ventricular thrombus to prevent stroke and/or systemic embolism.

Clinical Topics: Anticoagulation Management, Prevention, Vascular Medicine

Keywords: Anticoagulants, Ischemic Stroke, Platelet Aggregation Inhibitors, Secondary Prevention, Thrombosis

< Back to Listings