Antithrombotic Therapy to Prevent Recurrent Strokes in Ischemic Cerebrovascular Disease: JACC Scientific Expert Panel

Abstract

Stroke survivors carry a high risk of recurrence. Antithrombotic medications are paramount for secondary prevention and thus crucial to reduce the overall stroke burden. Appropriate antithrombotic agent selection should be based on the best understanding of the physiopathological mechanism that led to the initial ischemic injury. Antiplatelet therapy is preferred for lesions characterized by atherosclerosis and endothelial injury, whereas anticoagulant agents are favored for cardiogenic embolism and highly thrombophilic conditions. Large randomized controlled trials have provided new data to support recommendations for the evidence-based use of antiplatelet agents and anticoagulant agents after stroke. In this review, the authors cover recent trials that have altered clinical practice, cite systematic reviews and meta-analyses, review evidence-based recommendations based on older landmark trials, and indicate where there are still evidence-gaps and new trials being conducted.

Keywords: anticoagulants; antiplatelets; antithrombotics; ischemic stroke; secondary prevention.

FIGURE 1. Prevalence of Stroke Subtypes

(A) Small vessel disease: brain magnetic resonance imaging showing an acute left internal capsule lacunar infarct (<20 mm) on diffusion-weighted imaging (DWI) sequence. (B) Intracranial atherosclerotic disease: cerebral angiogram and computed tomography angiogram showing left middle cerebral artery stenosis (>90%) (arrow) associated with acute infarct on left insula. (C) Extracranial atherosclerotic disease: cerebral angiogram showing right middle cerebral artery occlusion associated with severe stenosis of ipsilateral cervical internal carotid (arrow). (D) Cardioembolic stroke: left frontal cortical infarct on DWI sequence associated with atrial fibrillation on electrocardiogram. (E) Other determined causes of stroke: dissection of the left cervical internal carotid artery (arrows) associated with ischemic stroke on the left frontal lobe. (F) Cryptogenic stroke: right frontal cortical infarct on DWI sequence with no definite cardioembolic source based on cardiac monitoring or echocardiography, and no evidence of large-artery steno-occlusive disease.

CENTRAL ILLUSTRATION. Approach to the Use of Antithrombotic Therapy for Secondary Prevention After Ischemic Stroke

AF = atrial fibrillation; CAS = carotid artery stenting; CEA = carotid endarterectomy; CT = computerized tomography; DAPT = dual antiplatelet therapy; DOAC = direct oral anticoagulant agents; ECAD = extracranial atherosclerotic disease; ECG = electrocardiogram; ESUS = embolic stroke of undetermined source; ICAD = intracranial atherosclerotic disease; INR = international normalized ratio; MRI = magnetic resonance imaging; PFO = patent foramen ovale; TEE = transesophageal echocardiogram; TTE = transthoracic echocardiogram; VKA = vitamin K antagonist.