"Decoding Antithrombotics in Acute Ischemic Events with Dr. Ganesh" 🌟 Greetings, everyone! I'm Dr. Ganesh, and today we're diving into a critical topic: Antithrombotics in Acute Ischemic Events. Whether you're a healthcare professional, a patient, or just someone keen on understanding the complexities of cardiovascular health, this discussion is for you.

1. ANTITHROMBOTIC THERAPY
IN ACUTE ISCHEMIC EVENTS
Dr Ganeshgouda Majigoudra
Consultant Neurologist
Nanjappa Hospitals
Davanagere
ganeshgoudam4@gmail.com
9380906082

2. INTRODUCTION
 The goal of management in the initial phase of patients with acute
ischemic stroke involve:
 Insuring medical stability
 Determining eligibility for thrombolytic therapy and/or
mechanical thrombectomy
 Determining the pathophysiologic basis of the stroke
 Timely restoration of blood flow using intravenous thrombolysis
within 4.5 hours and mechanical thrombectomy within 24 hours
are most effective maneuver for salvaging ischemic brain tissue

3. INTRODUCTION
 In addition to reperfusion therapies for acute treatment, there are
two major classes of antithrombotic drugs that can be used to
prevent recurrent ischemic stroke:
 Antiplatelets
 Anticoagulants
“Use of antiplatelet for patients in the first days after acute
ischemic stroke onset”

4. TIA
• DEFINITION?
‘’A brief episode of neurological dysfunction
caused by focal brain or retinal ischemia, with
clinical symptoms typically lasting less than one
hour, and without evidence of acute infarction”
• NIHSS,ASPECT,MRS,ICH SCORE,CT VOLUME
SCORES,ABCD2 ,TOAST CLASSIFICATION

5. WHILE WRITING DIAGNOSIS OF STROKE
1. DURATION
2. ISCHEMIC
3. TERRITORY
4. DEFICIT
5. TOAST CLASSIFICATION
6. SEVERITY (NIHSS)
7. IF TIA – SAME ABOVE +TERRITORY AND
RISK CATEGORY
8. IF HAEMORRHAGIC SAME ABOVE
MEMTIONED WITH NIHSS AND ICH
SCORE
EXAMPLE; ACUTE ISCHEMIC STROKE LEFT
MCA TERRITORY,R HP R FACIAL,APHASIA,
LARGEVESSEL ATHERO (NIHSS …)
DON’T USE CVA, R STROKE LEFT STROKE
TERMS

6. IMMEDIATE ANTITHROMBOTIC TREATMENT

7. IMPORTANCE OF ABCD2 SCORE

8. TRANSIENT ISCHEMIC ATTACK
 For patients with TIA without a known cardioembolic source at
presentation, antiplatelet should be started immediately while evaluating
the ischemic mechanism
• Low-risk TIA, (ABCD2 score <4)- Aspirin (162 to 325 mg/daily) alone
• High-risk TIA (ABCD2 score of ≥4)- Previously not on treatment, dual
antiplatelet therapy (DAPT) using aspirin (160 to 325 mg loading dose,
followed by 50 to 100 mg daily) plus clopidogrel (300 to 600 mg loading
dose, followed by 75 mg daily) for the first 21 days.
• High-risk TIA (ABCD2 score of ≥4), on single antiplatelet therapy at the
time of TIA onset: DAPT using aspirin plus clopidogrel for the first 21
days
• This strategy reduces the risk of recurrent ischemic stroke with a possible
small increase in the risk of moderate or major bleeding and no apparent
impact on mortality.

9. TRANSIENT ISCHEMIC ATTACK
 For patients either already on anticoagulation at the time of TIA
onset, or with a clear indication for anticoagulation (eg, atrial
fibrillation, venous thromboembolism, mechanical heart valve)-
Anticoagulation rather than antiplatelet therapy
 Those sub-therapeutically or not anticoagulated at presentation,
bridging anticoagulation low molecular weight heparin, or a direct
oral anticoagulant (DOAC) should be considered.
 Those in therapeutical range for anticoagulation, management to
be individualized based on the underlying mechanism of the TIA.
• If atherosclerosis is more likely than cardioembolism-
reasonable to add single antiplatelet therapy.
• Triple therapy (ie, anticoagulation plus DAPT) is associated
with a high risk of hemorrhage and should be avoided.
 Once the ischemic mechanism is determined, antithrombotic therapy
can be modified as necessary.

10. ACUTE ISCHEMIC STROKE
 For patients without serious bleeding complications who are not on
anticoagulation or antiplatelet therapy at baseline, antiplatelet should
be started as soon as possible while evaluating the stroke mechanism.
 Aspirin (162 to 325 mg/daily) monotherapy for patients with
moderate or higher stroke severity, defined by an National
Institutes of Health Stroke Scale (NIHSS) score >5
 DAPT for 21 days using aspirin (160 to 325 mg loading dose,
followed by 50 to 100 mg daily) plus clopidogrel (300 mg loading
dose, followed by 75 mg once daily) for most patients with minor
ischemic stroke, defined by an NIHSS score ≤5
 DAPT for 90 days using aspirin plus clopidogrel as above for
patients with stroke due to intracranial large artery atherosclerosis

11. ACUTE ISCHEMIC STROKE
 Aspirin and other antithrombotic agents should not be given
alone or in combination for the first 24 hours following
treatment with intravenous tPA.

12. ACUTE ISCHEMIC STROKE
 For patients on single antiplatelet therapy with aspirin or
clopidogrel at the time of stroke onset
 Switch to DAPT for minor ischemic stroke (defined by an
NIHSS score ≤5)
 Continue existing antiplatelet regimen for more severe
strokes.
 Duration of DAPT- 21 days for patients with minor ischemic
stroke and 90 days for patients with stroke due to
intracranial large artery atherosclerosis

13. ACUTE ISCHEMIC STROKE
 Patients on anticoagulation at stroke onset, anticoagulation
should be stopped, at least for the short-term, while determining
eligibility for acute reperfusion therapies.

14. ACUTE ISCHEMIC STROKE
 In a setting of cardioembolic stroke starting of OACS depends on
severity of stroke
 European guidelines or DIENRS rules can be followed
 Repeat brain imaging should be obtained to exclude significant
hemorrhagic transformation within 24 hours prior to starting or
resuming anticoagulation.
 Start aspirin if anticoagulation is delayed because of large
infarction, high risk of symptomatic hemorrhagic transformation,
and/or poorly controlled hypertension

16. DIENRS RULES

17. GENERAL RECOMMENDATIONS

18. HEMORRHAGIC TRANSFORMATION AND SYSTEMIC BLEEDING
 Severe systemic or intracranial bleeding complications, including
symptomatic hemorrhagic transformation of the ischemic infarct
 Withhold all anticoagulant and antiplatelet therapy for one to two weeks
or until the patient is stable
 Asymptomatic hemorrhagic transformation of an ischemic infarct
 Hemorrhage is petechial (ie, scattered and punctate)- Reasonable to
continue aspirin.
 Parenchymal hematoma (ie, larger confluent bleeding within an infarct)
• Management to be individualized
• Not clear that stopping aspirin will have much impact on hematoma
progression, as aspirin has long-lasting effect of on platelet function
• It may be reasonable to continue aspirin
 If antiplatelet therapy is not started, it may be reasonable to delay initiation
in patients with parenchymal hemorrhage until the patient's neurologic
condition becomes stable.
 DAPT – Avoided in all

20. EXTRACRANIAL INTERNAL CAS
 Symptomatic internal carotid artery stenosis as the cause of TIA or ischemic
stroke should be treated with early antiplatelet therapy.
 For patients undergoing carotid endarterectomy- aspirin monotherapy is
recommended by some experts prior to endarterectomy.
 For patients designated for carotid artery stenting, DAPT with aspirin plus
clopidogrel is suggested prior to and continuing for 30 days after stenting.

21. INTRACRANIAL LARGE ARTERY ATHEROSCLEROSIS
 TIA or ischemic stroke attributed to atherosclerotic intracranial
large artery stenosis of 70 to 99 percent (within 30 days): DAPT
with aspirin plus clopidogrel for 21 to 90 days
 50 to 69 percent
 low-risk TIA (defined by an ABCD2 score <4) - Aspirin alone
 Moderate to major ischemic stroke (NIHSS score >5) - Apirin
alone
 high-risk TIA (ABCD2 score ≥4)- DAPT for 21 days
 Minor ischemic stroke (NIHSS score ≤5)- DAPT for 21 days
SAMMPRIS trial

22. SMALL VESSEL DISEASE
 low-risk TIA (defined by an ABCD2 score <4) - Aspirin alone
 Moderate to major ischemic stroke (NIHSS score >5) - Apirin
alone
 high-risk TIA (ABCD2 score ≥4)- DAPT for 21 days
 Minor ischemic stroke (NIHSS score ≤5)- DAPT for 21 days

23. LARGE ARTERY ATHEROSCLEROSIS OF THE AORTA,
COMMON CAROTID/ EXTRACRANIAL VERTEBRAL
ARTERIES
 low-risk TIA (defined by an ABCD2 score <4) - Aspirin alone
 Moderate to major ischemic stroke (NIHSS score >5) - Apirin
alone
 high-risk TIA (ABCD2 score ≥4)- DAPT for 21 days
 Minor ischemic stroke (NIHSS score ≤5)- DAPT for 21 days

24. CRYPTOGENIC TIA/ STROKE
 low-risk TIA (defined by an ABCD2 score <4) - Aspirin alone
 Moderate to major ischemic stroke (NIHSS score >5) - Apirin
alone
 high-risk TIA (ABCD2 score ≥4)- DAPT for 21 days
 Minor ischemic stroke (NIHSS score ≤5)- DAPT for 21 days

25. ANTIPLATELET AGENTS
Aspirin
 In large randomized controlled trials, early (within 48 hours) initiation
of aspirin was beneficial for the treatment of acute ischemic stroke
 The International Stroke Trial (IST) enrolled 19,435 patients with
suspected acute ischemic stroke. Aspirin (300 mg) experienced
significant reductions in the 14-day recurrence of ischemic stroke
(2.8 versus 3.9 percent) and in the combined outcome of nonfatal
stroke or death (11.3 versus 12.4 percent).
 Chinese Acute Stroke Trial (CAST), 21,100 patients were randomized
to 160 mg of aspirin daily or placebo. Aspirin-allocated patients
experienced a 14 percent relative risk reduction in mortality at four
weeks (3.3 versus 3.9 percent).

26. ANTIPLATELET AGENTS
Ticagrelor
SOCRATES trial:
 13,000 subjects with acute ischemic stroke or TIA, ticagrelor
monotherapy was not significantly better than aspirin
monotherapy

27. ANTIPLATELET AGENTS
Clopidogrel
 Clopidogrel has not been well-studied as monotherapy in trials
that start treatment in the first 24 to 48 hours of acute ischemic
stroke
Dual antiplatelet therapy — Early, short-term dual antiplatelet
therapy (DAPT) is beneficial for select patients with high-risk TIA
or minor ischemic stroke
 POINT and CHANCE trials
 THALES trial :

29. ANTICOAGULANTS IN NEUROLOGY

32. ANY GUIDELINES FOR HYPERTRIGLYCERIDEMIA???

34. Role of neuroprotectives
• Citicholine
• Piracetam
• Nicergolline
• Ginko baliba
• Biclotiv

36. THANK YOU
• ganeshgoudam4@gmail.com
• 9380906082

37. REFERENCE
• European Heart Journal (2018) 39, 1330–1393
• Stroke, Bruce C V Campbell, Pooja KhatriLancet 2020; 396: 129–42
• Chimowitz MI, Lynn MJ, Derdeyn CP, et al. Stenting versus aggressive
medical therapy for intracranial arterial stenosis. N Engl J Med 2011;
365:993.
• Johnston SC, Amarenco P, Denison H, et al. Ticagrelor and Aspirin or
Aspirin Alone in Acute Ischemic Stroke or TIA. N Engl J Med 2020;
383:207.
• Von Kummer R, et,al. The Heidelberg bleeding classification:
classification of bleeding events after ischemic stroke and reperfusion
therapy. Stroke. 2015 Oct;46(10):2981-6.