Clopidogrel 75 mg daily is recommended as first-line treatment for all patients with ischaemic stroke not treated with oral anticoagulants, unless contraindicated.
Clopidogrel monotherapy is indicated for long-term stroke secondary prevention – it is an inexpensive and fully subsidized medication with a modest additional benefit when compared with aspirin.
Combination therapy of aspirin + clopidogrel is not indicated for long-term vascular secondary prevention due to increased bleeding risk.
Aspirin 75-100 mg daily + dipyridamole 150 mg BD is an alternative treatment option, equally effective as clopidogrel.
Aspirin 75-100 mg daily monotherapy may be a reasonable treatment for some patients.
Statin lipid-lowering therapy. Atorvastatin 80 mg daily is proven to reduce the risk of recurrent stroke in patients with fasting LDL 2.6 or greater. Simvastatin 40 mg is proven to reduce the risk of recurrent vascular disease events in patients with random total cholesterol greater than 3.5 mmol/L.
Lower doses of atorvastatin or simvastatin may be required depending on patient tolerability.
At least two-year life-expectancy is required for patients to gain significant stroke-prevention benefit from statin treatment.
Patients with low HDL, high triglycerides, and clinical features of a metabolic syndrome may be better treated with other therapies for correction of the lipid disorder and require further assessment.
Antihypertensive therapy is recommended for all patients after stroke or TIA unless there is symptomatic hypotension.
Combination ACE inhibitor+diuretic treatment is supported by the PROGRESS trial (Lancet 2001;358:1033-41). This study demonstrated a 40% relative risk reduction of recurrent stroke with a mean 12 mm Hg lowering of systolic BP, even for "non-hypertensive" patients.
Treatment initiation generally delayed >7-14 days from stroke onset.
Cautious introduction low dose to avoid hypotension, titration subsequently.
This treatment is additional to any previous antihypertensive therapy, which should be continued.
Warfarin is recommended for cardioembolic stroke.
Optimal time for initiation of warfarin after stroke is not known. For patients with AF, the risk of early recurrent stroke is low and anticoagulation is usually delayed for 7-14 days, which may reduce the risk of haemorrhagic transformation of stroke. However, for minor stroke or TIA, initiation of anticoagulation after 48 hours is reasonable. It is preferable to commence warfarin treatment in hospital.
For patients with atrial fibrillation (AF) who have had a stroke or TIA the benefits of oral anticoagulants usually far outweigh the risk of haemorrhage (including risk of subdural haematoma due to falls) due to oral anticoagulants.
In atrial fibrillation, dabigatran is available as an alternative to warfarin. The usual dose is 150 mg BD PO. This drug should be used with caution in the elderly. If it is given, a lower dose of 110 mg BD PO is recommended for patients over 80 years of age. Dabigatran should not be used for patients with severe renal impairment (CrCl <30 L/min). For full details of dabigatran therapy, see the Thrombosis section.
Carotid Endarterectomy is recommended for patients with minor ischaemic stroke or TIA in the internal carotid artery (ICA) territory when a severe (>70%) stenosis of the ipsilateral ICA is present. See Transient Ischaemic Attacks.
Patients benefit most when endarterectomy is performed early after symptoms.
Some patients with ipsilateral 50-70% stenosis might benefit from endarterectomy and should also be referred to vascular surgery for urgent assessment.