Think of “ABCs” to optimize medications after stroke

Overview

Questions are coming up about reducing risk of RECURRENT ischemic stroke. Continue to focus on optimizing the “ABCs”. These key elements—Aspirin (or other antiplatelet agents), Blood pressure control, and Cholesterol management—are essential components in a robust strategy aimed at preventing subsequent strokes...

ABCs approach

Antithrombotics

Recommend aspirin 81 mg/day alone for most patients. Reinforce that higher doses may increase bleeding and aren’t more effective. Or consider clopidogrel (Plavix, Clopex). Dipyridamole ER/aspirin seems a bit more effective than aspirin. But it’s BID and headache is common. Get our note "Antiplatelets options for recurrent ischemic stroke".

Consider discharging patients on short-term DUAL antiplatelet therapy after a minor ischemic stroke or high-risk TIA.

Aspirin plus clopidogrel for 10 to 21 days or aspirin plus Brilique (ticagrelor) for 30 days limits recurrent stroke more than aspirin alone in these patients.

Usually stick with aspirin plus clopidogrel. Brilique must be taken BID can cause dyspnea. But ensure only ONE medication is continued long-term for recurrent stroke and usually aspirin.

Blood pressure (BP)

Generally aim for a long-term BP goal of less than 130/80 mm Hg as soon as it’s practical and safe after a stroke. In most cases, choose a thiazide, ACEI, or ARB, these have the best evidence of reducing recurrent stroke.

Cholesterol

Start with a high-intensity statin (atorvastatin 80 mg/day, etc) for most patients and check LDL in about 4 to 12 weeks. Typically target an LDL below 70 mg/dL. Emphasize adherence and help patients stick with the statin. If LDL stays above 70 mg/dL, consider adding ezetimibe. It’s well tolerated. Manage other risks, such as diabetes and reinforce lifestyle changes (exercise, weight loss, smoking cessation, etc).

References

Kleindorfer DO, Towfighi A, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2021 Jul;52(7):e364-e467.
Johnston SC, Amarenco P, et al. Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA. N Engl J Med. 2020 Jul 16;383(3):207-217.
Amarenco P, et al. A Comparison of Two LDL Cholesterol Targets after Ischemic Stroke. N Engl J Med. 2020 Jan 2;382(1):9.
Lun R, Dhaliwal S, et al. Comparison of Ticagrelor vs Clopidogrel in Addition to Aspirin in Patients With Minor Ischemic Stroke and Transient Ischemic Attack: A Network Meta-analysis. JAMA Neurol. 2021 Dec 6:e214514.