Contemporary antiplatelet therapy for secondary stroke prevention: a narrative review of current literature and guidelines

Abstract

Antiplatelet therapy is one of the mainstays for secondary stroke prevention. This narrative review aimed to highlight the current evidence and recommendations of antiplatelet therapy for stroke prevention.We conducted advanced literature search for antiplatelet therapy. Landmark studies and randomised controlled trials evaluating antiplatelet therapy for secondary stroke prevention are reviewed. Results from Cochrane systematic review, pooled data analysis and meta-analysis are discussed.Single-antiplatelet therapy (SAPT) with aspirin, aspirin/extended-release dipyridamole or clopidogrel reduces the risk of recurrent ischaemic stroke in patients with non-cardioembolic ischaemic stroke or transient ischaemic attack (TIA). Dual-antiplatelet therapy (DAPT) with aspirin and clopidogrel or ticagrelor for 21–30 days is more effective than SAPT in patients with minor acute noncardioembolic ischaemic stroke or high-risk TIA. Prolonged use of DAPT is associated with higher risk of haemorrhage without reduction in stroke recurrence than SAPT. Compared with placebo, aspirin reduces the relative risk of recurrent stroke by approximately 22%. Aspirin/dipyridamole and cilostazol are superior to aspirin but associated with significant side effects. Cilostazol or ticagrelor might be more effective than aspirin or clopidogrel in patients with intracranial stenosis.SAPT is indicated for secondary stroke prevention in patients with non-cardioembolic ischaemic stroke or TIA. DAPT with aspirin and clopidogrel or ticagrelor for 21–30 days followed by SAPT is recommended for patients with minor acute noncardioembolic stroke or high-risk TIA. Selection of appropriate antiplatelet therapy should also be based on compliance, drug tolerance or resistance.

Antiplatelet effect of ginkgo diterpene lactone meglumine injection in acute ischemic stroke: A randomized, double‐blind, placebo‐controlled clinical trial

“…Finally, formation of occlusive platelet‐rich thrombus at the site of plaque rupture is mainly responsible for the occurrence of AIS (Lordan et al, 2021; Yeung, Li, & Holinstat, 2018). Platelet aggregation has been recognized as critical event during the thrombus formation in AIS patients (Del Brutto, Chaturvedi, Diener, Romano, & Sacco, 2019; Minhas et al, 2022; Shah, Liu, & Yu, 2022). Therefore, antiplatelet drugs, which inhibit platelet aggregation and reduce the risk of vascular events, have been the primary treatment of AIS.…”

“…Aspirin is the most widely used antiplatelet agent in the world, which irreversibly targets COX‐1 in the platelets to block the prostanoid production from arachidonic acid (AA) (Guirguis‐Blake, Evans, Perdue, Bean, & Senger, 2022; Minhas et al, 2022). However, more than 20% of patients with AIS would experience recurrent vascular events even when taking aspirin regularly (Lv et al, 2022; Shah et al, 2022). Therefore, it is of great practical significance to find therapeutic drugs to improve antiplatelet efficacy for AIS patients, especially in the early phase of onset.…”

Analysis of CYP2C19 gene polymorphism and influencing factors of pharmacological response of clopidogrel in patients with cerebral infarction in Zhejiang, China

“…Platelets are activated by ADP, collagen, and the arachidonic acid metabolite thromboxane, A2. Activated platelets aggregate to form blood clots, leading to AIS ( 20 ). Clopidogrel is commonly used as an antiplatelet agent and its active metabolite can specifically and irreversibly block the binding of ADP to platelet receptors, thereby inhibiting platelet aggregation and reducing the risk of AIS ( 21 ).…”

Genetic Association Study and Machine Learning to Investigate Differences in Platelet Reactivity in Patients with Acute Ischemic Stroke Treated with Aspirin

“…As there is an alternative to aspirin for secondary stroke prevention, such as dual antiplatelet therapy or ticagrelor [ 76 ], identifying patients with a predisposition to AR can be used for personalized therapy to reduce the risk of adverse events. However, it is possible that the risk alleles for AR might also be associated with platelet aggregation when taking other antiplatelet drugs requiring special attention for such patients.…”