Table 3

Current guidelines on the use of antiplatelet therapy for secondary stroke prevention2 10

Noncardioembolic ischaemic stroke or TIA

  1. The use of antiplatelet agents is indicated to reduce the risk of recurrent ischaemic stroke and other cardiovascular events (class 1/Level A).

    • Aspirin 50–325 mg daily (1 /A) or aspirin 25 mg/extended-release dipyridamole 200 mg two times daily (1/B)

    • Clopidogrel 75 mg daily (2 a/B).

  2. For patients with minor-to-moderate acute noncardioembolic ischaemic stroke or high-risk TIA, DAPT (aspirin and clopidogrel or ticagrelor in carriers of CYP2C19 loss-of-function alleles) should be started within 24 hours for 21–30 days, followed by SAPT (1 /A).

  3. Long term use of DAPT increases the risk of haemorrhage and is not recommended (3 /A)

  4. Triple antiplatelet therapy (aspirin +clopidogrel + aspirin/dipyridamole) for secondary stroke prevention is harmful and should not be used (III harm/B-R).

Intracranial large artery atherosclerosis

  1. In patients with AIS or TIA caused by 50% to 99% stenosis of a major intracranial artery, aspirin 325 mg daily is recommended in preference to warfarin to reduce the risk of recurrent ischaemic stroke and vascular death (1/B).56

  2. In patients with 70%–99% stenosis of a major intracranial artery, the addition of clopidogrel 75 mg daily to aspirin for up to 90 days is reasonable (2 a/B).

  3. In patients with recent minor stroke or high-risk TIA and concomitant ipsilateral >30% intracranial stenosis, the addition of ticagrelor 90 mg two times a day to aspirin for 30 days might be considered to reduce recurrent stroke risk (2b/B).

  4. In patients with stroke or TIA attributable to 50%–99% intracranial stenosis, the addition of cilostazol 200 mg/day to aspirin or clopidogrel might be considered (2b/C).10 57 58

Extracranial carotid or vertebral artery stenosisAspirin, clopidogrel or aspirin-dipyridamole is recommended indefinitely (1/A).10 59
Extracranial carotid or vertebral arterial dissectionIn patients with ischaemic stroke or TIA, treatment with antiplatelet or anticoagulation therapy for at least 3 months is indicated to prevent recurrent stroke or TIA (I/ C).60
Aortic arch atherosclerosisIn patients with an aortic arch atheroma, antiplatelet therapy is recommended to prevent recurrent stroke (1 /C).10 29 52
Moyamoya diseaseThe use of aspirin monotherapy may be reasonable for the prevention of ischaemic stroke or TIA (2b/C).
Carotid webIn patients with carotid web in the distribution of ischaemic stroke and TIA, antiplatelet therapy is recommended to prevent recurrent ischaemic stroke or TIA (1/B)
DolichoectasiaIn patients with vertebrobasilar dolichoectasia, the use of antiplatelet or anticoagulant therapy is reasonable for the prevention of recurrent ischaemic events (2 a/ C).
Fibromuscular dysplasiaIn patients with fibromuscular dysplasia (FMD), antiplatelet therapy is recommended for the prevention of future ischaemic events (1 /C).
Antiphospholipid syndromeIn patients with isolated antiphospholipid antibody, antiplatelet therapy is recommended to reduce the risk of recurrent stroke (1/B).
Haematologic traitsIn patients with prothrombin 20 210A mutation, activated protein C resistance, elevated factor VIII levels or deficiencies of protein C, protein S or antithrombin III, antiplatelet therapy is reasonable for prevention of recurrent stroke or TIA (2 a/C)
Embolic stroke of undetermined source (ESUS)In patients with ESUS, treatment with ticagrelor or direct oral anticoagulants is not recommended to reduce the risk of stroke (3/B)
Atrial fibrillation and CADThe usefulness of adding antiplatelet therapy to anticoagulation therapy is uncertain for reducing the risk of ischaemic stroke (2b/C).

  • AF, atrial fibrillation; AIS, acute ischaemic stroke; CAD, coronary artery disease; CAS, carotid artery stenting; CEA, carotid endarterectomy; DAPT, dual-antiplatelet therapy.