Use of Dual Antiplatelet Therapy Following Ischemic Stroke

Illustrative Teaching Cases e78 A 50-year-old male with hypertension, insulin-dependent diabetes mellitus, hyperlipidemia, and obstructive sleep apnea presented with left hemiplegia, hemisensory loss, and dysarthria.Home medications include aspirin and atorvastatin.On arrival to the emergency department, blood pressure was 188/108 and glucose 287.National Institutes of Health Stroke Scale (NIHSS) score was 0, and his neurological examination was normal except for mild left lower extremity weakness not registered on NIHSS.Computed tomography of the head was normal.He was outside of the thrombolytic window.Magnetic resonance imaging of the brain showed diffusion restriction in the right aspect of the pons (Figure ), and magnetic resonance angiogram showed no large vessel occlusion.Workup revealed poorly controlled vascular risk factors including hemoglobin A1c of 11.5 and low-density lipoprotein of 128.Transthoracic echocardiography was normal.He was loaded with 300 mg clopidogrel and placed on dual antiplatelet therapy (DAPT) with aspirin and clopidogrel for 21 days followed by single antiplatelet therapy.The role of single antiplatelet agents after stroke is well established, and several large studies support its use.Use of DAPT is more controversial and only recently found effective in selective circumstances after ischemic stroke.DAPT with aspirin and clopidogrel was found effective in coronary artery disease but initial studies of chronic DAPT in stroke showed no additional benefit and increased bleeding over single antiplatelets.Recent trials, however, suggest or find benefit in specific stroke subtypes in the acute setting for limited duration (Table ).