Ischemic stroke medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S [2]

Overview

Treatment of stroke is occasionally with thrombolysis ("clot buster"), but usually with supportive care (physiotherapy and occupational therapy) and secondary prevention with antiplatelet drugs (aspirin and often dipyridamole), blood pressure control, statins and anticoagulation (in selected patients).^[1]

Medical Therapy

Ischemic Stroke


Medical treatment	Drug class	Recommendations
Medical treatment	Drug class	Acute	Long-Term
Reperfusion therapy	Tissue plasminogen activator (t-PA)	Recommended within 3-4.5 hours of onset of ischemic stroke in eligible patients^[2]^[3]^[4]^[5]^[6]^[7]	None
Antithrombotic agents	Antiplatelet agents	Oral administration of aspirin (initial dose is 325 mg) is recommended within 24 to 48 hours after stroke onset in most patients^[2] Aspirin is contraindicated in patients with ischemic stroke within 24 hours of t-PA administration^[2] DAPT therapy (aspirin and clopidogrel) is recommended for 90 days in patients with symptomatic intracranial large artery disease	Long term therapy with clopidogrel or aspirin extended release dipyridamole may be used for secondary prevention of non cardioembolic stroke
Antithrombotic agents	Anticoagulants	Parenteral or oral anticoagulation is not recommended within 48 hours of onset of ischemic stroke^[8]	Oral anticoagulants may be used for secondary prevention of ischemic stroke in patients with atrial fibrillation or other cardioembolic disease^[9]
Antilipid therapy	Statins	Among patients already taking statins at the time of onset of ischemic stroke, continuation of statin therapy during the acute period is reasonable^[2]	Long term management of ischemic stroke with high intensity statins may be recommended for patients with atherosclerotic disease Patients who cannot tolerate high intensity dose, medium or low intensity statins may prove beneficial
Antihypertensive therapy	Intravenous antihypertensives (Labetolol, nitroprusside)	Used to control high blood pressure in patients with BP>185/110 mmHg before starting t-PA^[2]	Long term oral antihypertensives may be used after 24 hours of ischemic stroke in patients having history of hypertension
Antihypertensive therapy	Oral antihypertensive therapy	Recommended after 24 hours in patient having hypertension	Long term oral antihypertensives may be used after 24 hours of ischemic stroke in patients having history of hypertension
Antihyperglycemic agents	Insulin	May be used to control blood glucose between range of 140-180 mg/dl since hyperglycemia is associated with worst outcome in patients with acute ischemic stroke^[2]	Long term oral antidiabetic may be used for secondary prevention of ischmeic stroke in patients with diabetes mellitus

For 2015 AHA/ASA guidelines on medical therapy of ischemic stroke, please click here.

The 2007 American Heart Association (AHA) / American Stroke Association (ASA) Guidelines (DO NOT EDIT)

Class III (Harm)
"1.Urgent anticoagulation with the goal of preventing early recurrent stroke, halting neurological worsening, or improving outcomes after acute ischemic stroke is not recommended for treatment of patients with acute ischemic stroke (Level of Evidence: A)This recommendation may change if additional data demonstrate the usefulness of very early intravenous administration of anticoagulants for treatment of patients with infarctions secondary to large-artery thrombosis or cardioembolism. Urgent anticoagulation should not be used in lieu of intravenous thrombolysis for treatment of otherwise eligible patients (Level of Evidence: A)"
"2.Urgent anticoagulation is not recommended for patients with moderate to severe strokes because of an increased risk of serious intracranial hemorrhagic complications (Level of Evidence: A)"
"3.Initiation of anticoagulant therapy within 24 hours of treatment with intravenously administered rtPA is not recommended (Level of Evidence: A)"

References

↑ Hackam DG, Spence JD (2007). "Combining multiple approaches for the secondary prevention of vascular events after stroke: a quantitative modeling study". Stroke. 38 (6): 1881–5. doi:10.1161/STROKEAHA.106.475525. PMID 17431209.
↑ ^2.0 ^2.1 ^2.2 ^2.3 ^2.4 ^2.5 Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM; et al. (2013). "Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association". Stroke. 44 (3): 870–947. doi:10.1161/STR.0b013e318284056a. PMID 23370205.
↑ "Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group". New England Journal of Medicine. 333 (24): 1581–7. 1995. PMID 7477192.
↑ Dubinsky, R (2006). "Mortality of stroke patients treated with thrombolysis: analysis of nationwide inpatient sample". Neurology. 66 (11): 1742–1744. PMID 16769953. Unknown parameter |coauthors= ignored (help); |access-date= requires |url= (help)
↑ "Position Statement on the Use of Intravenous Thrombolytic Therapy in the Treatment of Stroke". American Academy of Emergency Medicine. Retrieved 2008-01-25.
↑ Wardlaw JM, Murray V, Berge E, del Zoppo GJ (2014). "Thrombolysis for acute ischaemic stroke". Cochrane Database Syst Rev. 7: CD000213. doi:10.1002/14651858.CD000213.pub3. PMC 4153726. PMID 25072528.
↑ Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E; et al. (2014). "Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials". Lancet. doi:10.1016/S0140-6736(14)60584-5. PMID 25106063.
↑ Paciaroni M, Agnelli G, Micheli S, Caso V (2007). "Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: a meta-analysis of randomized controlled trials". Stroke. 38 (2): 423–30. doi:10.1161/01.STR.0000254600.92975.1f. PMID 17204681. ACP JC synopsis
↑ Hart RG, Pearce LA, Aguilar MI (2007). "Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation". Ann. Intern. Med. 146 (12): 857–67. PMID 17577005.

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[1] Hackam DG, Spence JD (2007). "Combining multiple approaches for the secondary prevention of vascular events after stroke: a quantitative modeling study". Stroke. 38 (6): 1881–5. doi:10.1161/STROKEAHA.106.475525. PMID 17431209.

[pmid23370205-2] 2.0 ^2.1 ^2.2 ^2.3 ^2.4 ^2.5 Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJ, Demaerschalk BM; et al. (2013). "Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association". Stroke. 44 (3): 870–947. doi:10.1161/STR.0b013e318284056a. PMID 23370205.

[3] "Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group". New England Journal of Medicine. 333 (24): 1581–7. 1995. PMID 7477192.

[Dubinsky06-4] Dubinsky, R (2006). "Mortality of stroke patients treated with thrombolysis: analysis of nationwide inpatient sample". Neurology. 66 (11): 1742–1744. PMID 16769953. Unknown parameter |coauthors= ignored (help); |access-date= requires |url= (help)

[5] "Position Statement on the Use of Intravenous Thrombolytic Therapy in the Treatment of Stroke". American Academy of Emergency Medicine. Retrieved 2008-01-25.

[pmid25072528-6] Wardlaw JM, Murray V, Berge E, del Zoppo GJ (2014). "Thrombolysis for acute ischaemic stroke". Cochrane Database Syst Rev. 7: CD000213. doi:10.1002/14651858.CD000213.pub3. PMC 4153726. PMID 25072528.

[pmid25106063-7] Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E; et al. (2014). "Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials". Lancet. doi:10.1016/S0140-6736(14)60584-5. PMID 25106063.

[pmid17204681-8] Paciaroni M, Agnelli G, Micheli S, Caso V (2007). "Efficacy and safety of anticoagulant treatment in acute cardioembolic stroke: a meta-analysis of randomized controlled trials". Stroke. 38 (2): 423–30. doi:10.1161/01.STR.0000254600.92975.1f. PMID 17204681. ACP JC synopsis

[pmid17577005-9] Hart RG, Pearce LA, Aguilar MI (2007). "Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation". Ann. Intern. Med. 146 (12): 857–67. PMID 17577005.

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