Antiplatelet Use in Ischemic Stroke

Abstract

Objective: A literature review of antiplatelet agents for primary and secondary stroke prevention, including mechanism of action, cost, and reasons for lack of benefit. Data sources: Articles were gathered from MEDLINE, Cochrane Reviews, and PubMed databases (1980-2021). Abstracts from scientific meetings were considered. Search terms included ischemic stroke, aspirin, clopidogrel, dipyridamole, ticagrelor, cilostazol, prasugrel, glycoprotein IIb/IIIa inhibitors. Study selection and data extraction: English-language original and review articles were evaluated. Guidelines from multiple countries were reviewed. Articles were evaluated independently by 2 authors. Data synthesis: An abundance of evidence supports aspirin and clopidogrel use for secondary stroke prevention. In the acute phase (first 21 days postinitial stroke), these medications have higher efficacy for preventing further stroke when combined, but long-term combination therapy is associated with higher hemorrhage rates. Antiplatelet treatment failure is influenced by poor adherence and genetic polymorphisms. Antiplatelet agents such as cilostazol may provide extra benefit over clopidogrel and aspirin, in certain racial groups, but further research in more diverse ethnic populations is needed. Relevance to patient care and clinical practice: This review presents the data available on the use of different antiplatelet agents poststroke. Dual therapy, recurrence after initiation of secondary preventative therapy, and areas for future research are discussed. Conclusions: Although good evidence exists for the use of certain antiplatelet agents postischemic stroke, there are considerable opportunities for future research to investigate personalized therapies. These include screening patients for platelet polymorphisms that confer antiplatelet resistance and for randomized trials including more racially diverse populations.

Reply: Antiplatelet Use in Ischemic Stroke

“…We thank our colleagues for their response to our review article of antiplatelet use in ischemic stroke. 1 We agree with their discussion of the evidence behind dual antiplatelet therapy (DAPT) in intracranial atherosclerotic disease (ICAD), as well as the caveats in this under-researched subtype of stroke. 2 Recommendations for up to 90 days of DAPT in severe cases of ICAD (70%-99% stenosis) with low risk of haemorrhagic transformation have also been echoed by a recent systematic review (Level B evidence).…”

“…ICAD is a condition with large potential for further research, and would benefit from randomized control trials investigating single versus dual antiplatelet therapy, choice of antiplatelet or antithrombotic agent (with consideration of genetic polymorphisms previously discussed in the review), 1 length of treatment, endovascular treatments, and novel therapies such as ischemic preconditioning. 11 The role that racial background may play on ICAD and its response to particular therapies should also be considered in these trials.…”

Synthesis of Novel 3‐Butylphthalide Derivatives Containing Isopentenylphenol Moiety as Potential Antiplatelet Agents for the Treatment of Ischemic Stroke

“…Many experimental and clinical studies have shown that platelet aggregation mediated thrombosis was the main cause of ischemic stroke, which could lead to irreversible ischemic and hypoxic necrosis of brain tissue. Therefore, antithrombotic is well recognized to be the preferred strategy for the treatment of ischemic stroke [2,3] . Currently, the clinically used antithrombotic drugs can be divided into anticoagulants, thrombolytics and antiplatelet aggregation drugs according to the mechanisms of action, but all of them existed a certain degree of defects and side effects in their application, such as narrow therapeutic window, high bleeding risk, increased drug resistance, etc [4] .…”

“…Therefore, antithrombotic is well recognized to be the preferred strategy for the treatment of ischemic stroke. [2,3] Currently, the clinically used antithrombotic drugs can be divided into anticoagulants, thrombolytics and antiplatelet aggregation drugs according to the mechanisms of action, but all of them existed a certain degree of defects and side effects in their application, such as narrow therapeutic window, high bleeding risk, increased drug resistance, etc. [4] Thus, there is an urgent need to explore novel antithrombotic drugs with less side effects and better efficacy to protect patients from ischemic injuries.…”

Comment: Antiplatelet Use in Ischemic Stroke

“…Kamarova et al 1 reviewed antiplatelet agents used in primary and secondary stroke prevention. In their analysis on dual antiplatelet therapy (DAPT) following an acute ischemic stroke, the authors concluded that DAPT for up to 21 days reduced recurrent ischemic strokes in patients with minor stroke or high-risk transient ischemic attack (TIA) according to the CHANCE and POINT clinical trials.…”