Less is more? The selection and combination of antithrombotic agents

Abstract

Antithrombotic agents for ischemic stroke or transient ischemic attack (TIA) should be considered based on three points : acute or chronic, antiplatelets or anticoagulants, and risk of ischemic event and hemorrhagic risk. The baseline treatment on the acute settings is aspirin 160–300mg within 48 hours of onset. In addition, the efficacy of dual antiplatelet therapy (DAPT) with aspirin and loading dose of clopidogrel for non–cardioembolic stroke or high–risk TIA within 24 hours of onset has been established. On the other hand, there is not enough evidence for intravenous anticoagulants for acute ischemic stroke. In the chronic settings, DAPT including cilostazol might be reasonable with decrease of recurrent stroke without increasing bleeding risk, whereas continuous DAPT with aspirin and clopidogrel is not recommended due to the increased risk of bleeding that outweighs the reduction of ischemic events. In patients complicated with both cardioembolic stroke and atherosclerosis, randomised controlled trial, which is called ATIS–NVAF, is on going to elucidate the effect of additional antiplatelets to oral anticoagulants.