Therapeutic target
- Attempt to reduce harm and prevent recurrent (recurring) events.
Therapy recommendations*
- Initiation of secondary prophylaxis with acetylsalicylic acid (75-81 mg/d) and clopidogrel (initial 300 mg; 75 mg/d) should occur at least 24 hours after the onset of the first stroke symptoms and should continue for 10-21 days (see “Practice Recommendation for Dual Platelet Inhibition” below).
- See also agents for antihypertensive therapy in acute ischemic insult.
- Secondary prophylaxis
* S. u. Apoplexy (stroke)/drug therapy.
Secondary prevention
- A reanalysis of previous randomized clinical trials in the Lancet showed that early initiation of acetylsalicylic acid (ASA) therapy in patients with transient ischemic attack (TIA) or apoplexy may be the most effective secondary prevention measure. Here to the results of a study confirming this:
- 2 of 6,691 patients (0.03 percent) treated with ASA immediately after TIA suffered another major stroke in the next two weeks; control group: 23 of 5,726 patients (0.4 percent)
- Early initiation of acetylsalicylic acid (ASA) therapy after apoplexy, ie, within the first six weeks, 84 of 8,452 (0.9 percent) of patients who received ASA suffered another ischemic apoplexy. Comparison group without ASA: 175 of 7,326 patients (2.3 percent).
- December 2018, a practice recommendation for dual antiplatelet therapy with the anticoagulant drugs acetylsalicylic acid and clopidrogrel has been published. The German Society of Neurology (DGN) and the German Stroke Society (DSG) have endorsed this practice recommendation in 2019.
- If patients receive dual antiplatelet therapy (clopidogrel and aspirin) for secondary prevention of TIA/apoplexy, this should be aimed for only in the first 3 weeks after an ischemic event, and then switch to monotherapy. This leads to reduce the rate of severe ischemic events in the first 30 days, and at the same time takes into account that severe bleeding is more common after a week.
- THALES trial:Dual antiplatelet therapy with the anticoagulant drugs acetylsalicylic acid and clopidrogrel may be more effective in preventing the risk of recurrent disabling strokes or death than ASA monotherapy.Study design:All patients began treatment with ASA (300-325 mg on day 1, 75-100 mg on subsequent days) within 24 hours, and half also received ticagrelor 180 mg/d. Results: In the combination group, the rate of disabling stroke or death was reduced by 17% and for disabling stroke by 20%; disabling ischemic stroke occurred 22% less frequently – the rate of nondisabling insults was also reduced by 21%.
