Table II.
American College of Chest Physicians recommendations for antiplatelet and anticoagulant therapy in secondary stroke prevention[15]
| Therapy | Patient population | Gradea | Dosage |
|---|---|---|---|
| Antiplatelet | Patients who have experienced a cryptogenic stroke and have a PFO | 1C+ | Dependent on therapy chosenb |
| Patients who have aortic atherosclerotic lesions or mitral valve strands or prolapse | 1C+ | Dependent on therapy chosenb | |
| Option for patients who have experienced a cryptogenic stroke associated with mobile aortic arch thrombi | 2C | Dependent on therapy chosenb | |
| Aspirin (acetylsalicylic acid) | Option for all patients who have experienced a noncardioembolic stroke or TIA | 1A | 50–100 mg/day |
| Patients undergoing CEA (treatment should start prior to CEA and continue thereafter) | 1A | 50–100 mg/day | |
| Patients with a cardioembolic stroke who have contraindications to anticoagulant therapy | 1A | 75–325 mg/day | |
| Patients with a moderate to high risk of bleeding complications | 1C+ | 50–100 mg/day | |
| Aspirin + dipyridamolec | Option for all patients who have experienced a noncardioembolic stroke or TIA | 1A | 25 mg aspirin + 200 mg dipyridamole twice daily |
| Clopidogreld | Option for all patients who have experienced a noncardioembolic stroke or TIA | 1A | 75 mg/day |
| Oral anticoagulant, vitamin K antagonists (e.g. warfarin) | Patients with AF | 1A | Target INR, 2.5; INR range, 2–3 |
| Patients with cerebral venous sinus thrombosis | 1B | Target INR, 2.5; INR range, 2–3 | |
| Patients with well documented prothrombotic disorders | 2C | Target INR, 2.5; INR range, 2–3 | |
| Option for patients who have experienced a cryptogenic stroke associated with mobile aortic arch thrombi | 2C | Target INR, 2.5; INR range, 2–3 |
Grade 1 recommendations are strong and indicate that the ratio of benefit to risk, cost and burden is favourable. Grade 2 recommendations indicate patients’ values may lead to different choices. A full description of the grading system can be found in Guyatt et al.[16]
Aspirin 50–325 mg/day, aspirin 25 mg + dipyridamole 200 mg twice daily and clopidogrel 75 mg/day are equivalent.
Recommended over aspirin alone (grade 2A).
Recommended over aspirin alone (grade 2B).
AF = atrial fibrillation; CEA = carotid endarterectomy; INR = international normalized ratio; PFO = patent foramen ovale; TIA = transient ischaemic attack.