Current Guidelines on Antiplatelet Agents for Secondary Prevention of Noncardiogenic Stroke: An Evidence-Based Review

Abstract

Antiplatelet therapy is a mainstay of secondary prevention of ischemic strokes. Recent studies, such as Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS), the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial, and the European/Australasian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT), have added much to our understanding about how best to utilize the various antiplatelet agents available. Aspirin has been shown to reduce the risk of recurrent strokes, and the combination of aspirin and dipyridamole has repeatedly been shown to outperform aspirin alone. Recently, clopidogrel was demonstrated to be "noninferior" to an aspirin/dipyridamole combination, and can be considered as a first-line agent. The American Stroke Association and American Heart Association have clear recommendations on how to utilize these agents.

Platelet–leukocyte interactions link inflammatory and thromboembolic events in ischemic stroke

“…Blockade of the ADP receptor dampens signaling events in platelets that promote platelet hyperactivity, including subsequent activation of the glycoprotein IIbIIIa receptor. 48 …”

“…The active metabolite of clopidogrel prevents platelet aggregation by specifically and irreversibly inhibiting the P2Y 12 subtype of ADP receptor on platelet membranes. Blockade of the ADP receptor dampens signaling events in platelets that promote platelet hyperactivity, including subsequent activation of the glycoprotein IIbIIIa receptor 48 …”

Prior antiplatelet or anticoagulant therapy and mortality in stroke

“…Good evidence exists for the use of these agents in secondary prevention following ischaemic stroke1 2 but their use in primary prevention especially for AP agents remains controversial 3 4…”

High On-Treatment Platelet Reactivity in Peripheral Arterial Disease: A Pilot Study to Find the Optimal Test and Cut Off Values

“…However, APT is also prescribed to prevent secondary CVEs. 34,35 With regard to the latter, other expressions of platelet activation than aggregate formation (VerifyNow) might be more relevant and should be tested in platelet reactivity testing. More studies on differential platelet activation and the clinical consequences should be assessed.…”