What Is the Best Approach to Medical Therapy for Patients with Ischemic Stroke?

The Hospitalist. 2011 May;2011(05):

May 1, 2011|The Hospitalist

Gaurav Chaturvedi, MD;Anub Abraham, DO;Division OF

KEY Points

There is a substantially high cost of treatment and long-term disability or long-term care associated with stroke care. Costs can vary from 3% to 5% of the total annual healthcare budget.
The newer antiplatelet agents are more expensive than aspirin, and overall cost-effectiveness is difficult to estimate.
For patients ineligible for thrombolytic therapy, antiplatelet therapy is the best choice for treatment of acute ischemic stroke.
Aspirin is the only antiplatelet agent that has been shown to be effective in the early treatment of acute ischemic stroke and secondary prevention.
Clopidogrel is more effective than aspirin in preventing a combined endpoint of ischemic stroke, myocardial infarction, or vascular death, but it is not superior to aspirin in preventing recurrent stroke in transient ischemic attacks or stroke patients.

Additional Reading

European Stroke Initiative Executive Committee, EUSI Writing Committee, Olsen TS, et al. European Stroke Initiative Recommendations for Stroke Manage-ment update 2003. Cerebrovasc Dis. 2003;16:311-337.
Broderick JP, Adams HP Jr, Barsan W, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 1999;30:905-915.
Adams HP Jr, Davis PH, Leira EC, et al. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: A report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology. 1999;53: 126-131.
Goldstein LB, Simel DL. Is this patient having a stroke? JAMA. 2005;293:2391-2402.

Case

A 58-year-old woman with diabetes mellitus and hypertension presents with dysarthria and weakness on the right side of her body starting six hours prior to presentation. She is afebrile and has a blood pressure of 162/84 mmHg. Exam reveals the absence of a heart murmur and no lower-extremity swelling or calf tenderness. There is weakness of the right side of the body on exam with diminished proprioception. A noncontrast head CT shows no intracranial hemorrhage. She is admitted to the hospital with the diagnosis of acute ischemic stroke. What anticlotting or antiplatelet medications should she receive?

Overview

Stroke remains a significant cause of morbidity and mortality in the U.S. and around the world. The majority of strokes are ischemic in etiology. Although thrombolytic therapy is the most effective way to salvage ischemic brain tissue that has not yet infarcted, there is a narrow window for the use of thrombolytics in the treatment of acute ischemic stroke. As a result, many patients will not be eligible for thrombolysis. Outside of 4.5 hours from symptom onset, evidence suggests that the risk outweighs the benefit of using the thrombolytic alteplase. For patients ineligible for thrombolytic therapy, antiplatelet therapy remains the best choice for treatment.

Medications that prevent blood from coagulating or clotting are used to treat and prevent a recurring or second stroke. Typically, an antiplatelet agent (most often aspirin) is initiated within 48 hours of an ischemic stroke and continued in low doses as maintenance. Multiple studies suggest that antiplatelet therapy can reduce the risk for a second stroke by 25%. Specific anticlotting agents might be warranted in some patients with high-risk conditions for a stroke.

Review of Data

Early initiation of aspirin has shown benefit in the treatment of an acute ischemic stroke. Two major trials—the International Stroke Trial (IST) and the Chinese Acute Stroke Trial (CAST)— evaluated the role of aspirin (see Table 1, p. 15).^1,2 The IST and CAST trials showed that roughly nine nonfatal strokes were avoided per every 1,000 early treatments. Taking the endpoint of death, as well as focal deficits, the two trials confirmed a rate of reduction of 13 per 1,000 patients.

Overall, the consensus was that initiating aspirin within 48 hours of a presumed ischemic cerebrovascular accident posed no major risk of hemorrhagic complication and improved the long-term outcomes.