- Aspirin is recommended within 24-48 hours for acute ischemic stroke (AIS) and after 24 hours if IV thrombolysis is administered. - For minor strokes, dual antiplatelet therapy with aspirin and clopidogrel for 21 days begun within 24 hours is recommended, followed by clopidogrel alone for 90 days. - The efficacy of IV antiplatelet drugs like tirofiban and eptifibatide for AIS is not well established and requires further research.

1. Antiplatelet & Anticogulant in
stroke
Prashant shringi
DM Neurology resident

2. AHA Guidelines for starting of antiplatelets
in acute ischemic stroke (AIS)
• Adminstration of aspirin is recommended in
patients with AIS within 24 to 48 hrs of onset.
• After IV thrombolysis aspirin should be given
after 24 hrs.
• Aspirin is not recommended as a substitute for
acute stroke treatment in patients who are
otherwise eligible for IV alteplase ormechanical
thrombectomy.
• COR-1
• LOE- A

3. Minor stroke-
• NIHSS<3
• ABCD2 SCORE >4
• Dual antiplatelet (aspirin with clopidogrel) for
21 days begun within 24 hrs followed by
clopidogrel alone to 90 days, in patients with
minor stroke
• COR-2A
• LOE-B

4. • Efficacy of IV Tirofiban and eptifibatide is npt
well established . Further clinical trials are
needed
• COR-2B
• LOE -B

5. • administration of other glycoprotein IIb/IIIa
receptor antagonists, including abciximab, in
the treatment of AIS is potentially harmful and
should not be performed. Further
researchtesting the safety and efficacy of
these medications in patients with AIS is
required
• COR-3-harm

6. Aspirin in sec. prevention
• For patients with non-cardioembolic AIS, the
use of antiplatelet agents rather than oral
anticoagulation is recommended to reduce
the risk of recurrent stroke and other
cardiovascular events.
• COR-1
• LOE- A

7. • For patients who have a noncardioembolic AIS
while taking antiplatelet therapy, switching to
warfarin is not beneficial for secondary stroke
prevention
• COR-III: No Benefit

8. • For most patients with an AIS in the setting of
atrial fibrillation, it is reasonable to initiate
oral anticoagulation within 4 to 14 days after
the onset of neurological symptoms
• COR-2A

9. • For patients with AIS and extracranial carotid
or vertebral arterial dissection, treatment with
either antiplatelet or anticoagulant therapy
for 3 to 6 months may be reasonable.
• COR -IIb

10. Reintroduction of anti‐thrombotic therapy after a gastrointestinal haemorrhage: if and when?
British Journal of Haematology, Volume: 177, Issue: 2, Pages: 185-197, First published:
08 March 2017, DOI: (10.1111/bjh.14599)

11. Anticogulants in cardioembolic stroke

15. Guidelines for anticogulant in acute
stroke
• Urgent anticoagulation, with the goal of
preventing early recurrent stroke, halting
neurological worsening, or improving
outcomes after AIS, is not recommended for
treatment of patients with AIS.
• COR- III: No Benefit

16. • usefulness of dabigatran, rivaroxaban, or
apixaban in patients with atrial fibrillation and
past ICH to decrease the risk of recurrence is
uncertain (Class IIb; Level of Evidence C)

17. • The usefulness of urgent anticoagulation in patients
with severe stenosis of an internal carotid artery
ipsilateral to an ischemic stroke is not well
established.
• COR- IIb
• At present, the usefulness argatroban, dabigatran, or
other thrombin inhibitors for the treatment of
patients with AIS is not well established.

18. Reintroduction of anti‐thrombotic therapy after a gastrointestinal haemorrhage: if and when?
British Journal of Haematology, Volume: 177, Issue: 2, Pages: 185-197, First published: 08 March 2017, DOI: (10.1111/bjh.14599)

19. Reintroduction of anti‐thrombotic therapy after a gastrointestinal haemorrhage: if and when?
British Journal of Haematology, Volume: 177, Issue: 2, Pages: 185-197, First published: 08 March 2017, DOI: (10.1111/bjh.14599)

20. Guidelines for restarting of
antiplatelet/anticogulant after ICH
• Anticoagulation after nonlobar ICH and
antiplatelet monotherapy after any ICH might
be considered, particularly when there are
strong indications for these agents (Class IIb;
Level of Evidence B)

22. • optimal timing to resume oral
anticoagulation after anticoagulant-related
ICH is uncertain.
• Avoidance of oral anticoagulation for at least
4 weeks, in patients without mechanical heart
valves, might decrease the risk of ICH
recurrence (Class IIb; Level of Evidence B)

23. • If indicated, aspirin monotherapy can
probably be restarted in the days after ICH,
although the optimal timing is uncertain (Class
IIa; Level of Evidence B).

24. When to start
• American College of Chest Physicians
recommends starting prophylactic-dose
heparin the day after an ICH, with no clear
guidance on restarting warfarin
• If risk of thromboemboloism very high (in a
case of DVT/pulmonary thromboembolism)

25. When to start
• European Stroke Initiative recommends that
patients with a strong indication for
anticoagulation, such as a history of embolic
stroke with atrial fibrillation, should be restarted
on warfarin after 10 to 14 days
• American Heart Association suggests that, in
patients with a very high risk of
thromboembolism for whom restarting warfarin
is considered, warfarin may be restarted 7 to 10
days after ICH onset

27. Role of aspirin in TBM-cerbral infarct
Not established

28. • Thank you