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Antiplatelet therapy to prevent recurrent stroke: Three good options

Drugs that prevent platelets from sticking together—ie, aspirin, dipyridamole, and clopidogrel—are an important part of therapy to prevent recurrence of ischemic stroke of atherosclerotic origin. We discuss current indications for these drugs and review the evidence behind our current use of aspirin, dipyridamole, and clopidogrel.

After a stroke, antiplatelet therapy lowers the rate of recurrent nonfatal stroke by about 25%. Aspirin is the most established, best tolerated, and least expensive of the three approved drugs.

Adding dipyridamole to aspirin increases the efficacy, with a 22% reduction in relative risk, but only a 1% reduction in absolute risk. Clopidogrel is similar in efficacy to aspirin and to dipyridamole.

All three agents are regarded as equal and appropriate for secondary prevention of stroke; the choice is based on individual patient characteristics.

A small number of strokes result from atherosclerotic disease of the common carotid bifurcation, and patients with symptomatic carotid disease can be treated with the combination of surgery or stenting and drug therapy, or with drug therapy alone.

AFTER A STROKE, an important goal is to prevent another one And for patients who have had an ischemic stroke or transient ischemic attack (TIA) due to atherosclerosis, an important part of secondary preventive therapy is a drug that inhibits platelets—ie, aspirin, extended-release dipyridamole, or clopidogrel. This has taken years to establish.

In the following pages, we discuss the antiplatelet agents that have been shown to be beneficial after stroke of atherosclerotic origin, and we briefly review the indications for surgery and stenting for the subset of patients whose strokes are caused by symptomatic carotid disease.

(Although managing modifiable risk factors such as smoking, hypertension, diabetes, and dyslipidemia is also important, we will not cover this topic here, nor will we talk about hemorrhagic stroke or stroke due to atrial fibrillation. Also not discussed here is cilostazol, which, although shown to be effective in preventing recurrent stroke when compared with placebo and aspirin,3,4 has not been approved for this use by the US Food and Drug Administration, as of this writing.)

 

Read more here: http://www.ccjm.org/content/80/12/787.full

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