A 65-year-old man with a history of ischemic stroke 6 months ago presents to cardiology clinic to establish care. An event monitor was negative for atrial fibrillation and TTE with agitated saline study was negative for a patent foramen ovale. Therefore, his ischemic stroke was presumed to be non-cardioembolic in origin. He is currently taking lisinopril 5 mg daily for hypertension (BP in clinic is 115/70) and atorvastatin 40 mg daily. He has no history of significant gastrointestinal or other bleeding. What do you recommend next?

A

Start apixaban 5 mg BID

B

Increase lisinopril to 10 mg daily

C

Start aspirin 81 mg daily

D

Start aspirin 81 mg daily and clopidogrel 75 mg daily

E

Start aspirin 81 mg daily and ticagrelor 90 mg BID

Explanation

The correct answer is C – start aspirin 81mg daily.

For the secondary prevention of non-cardioembolic ischemic stroke or TIA, anti-platelet therapy is recommended with aspirin only (75-150 mg/day), dipyridamole + aspirin (slightly superior to aspirin), or clopidogrel alone (slightly superior to aspirin) (Class I, LOE A).

DAPT with aspirin and clopidogrel or aspirin and ticagrelor should be considered in the immediate period after a minor ischemic stroke or TIA (3 weeks after event, Class IIa), but not 6 months after an ischemic stroke. Dual antiplatelet therapy with aspirin and clopidogrel increases bleeding risk without a significant benefit over either agent alone. Dual antiplatelet therapy with aspirin and ticagrelor increases bleeding risk, but does not improve disability incidence.

Oral anticoagulation would be recommended for a cardioembolic stroke, which does not fit the clinical picture.

His BP is well controlled so increasing lisinopril is not necessary.

Main Takeaway

For the secondary prevention of an ischemic stroke or TIA, anti-platelet therapy with aspirin, aspirin + dipyridamole, or clopidogrel alone is recommended.

Guideline Loc.

6.3, page 3296-3297