Key Points
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In noncardioembolic cerebrovascular disease (CVD), the use of antiplatelet agents rather than anticoagulants is recommended to reduce the risk of recurrent stroke and other cardiovascular events
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Patients with prior noncardioembolic ischaemic stroke or transient ischaemic attack (TIA) can receive aspirin and clopidogrel in the setting of acute coronary syndrome (ACS) or percutaneous coronary intervention
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New antiplatelet drugs investigated in the setting of ACS and secondary prevention should currently not be used in patients with prior ischaemic stroke or TIA
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Duration of therapy should be individualized, considering the main determinant of risk (coronary or cerebrovascular), and the effectiveness, safety, and cost of drugs, as well as patient characteristics and preferences
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In the setting of ischaemic stroke during antiplatelet therapy, if the patient's need for treatment offsets the risk of haemorrhagic conversion, aspirin plus clopidogrel seems to be the regimen of choice
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If ischaemic stroke occurs during antiplatelet therapy, antiplatelet medications should not be abruptly suspended, particularly when therapy is recommended for an event such as ACS or stent implantation
Abstract
Atherothrombosis is the common underlying process for numerous progressive manifestations of cardiovascular disease, including coronary artery disease (CAD) and cerebrovascular disease (CVD). Antiplatelet therapy is the cornerstone of pharmacological management in patients with atherothrombosis. Over the past 20 years, major advances in antiplatelet pharmacotherapy have been made, particularly for the treatment of patients with CAD. The treatment of patients with concomitant CAD and CVD is complex, owing to their increased risk of both ischaemia and bleeding. When CVD arises from large artery atherosclerosis, antithrombotic therapies are essential to prevent stroke or transient ischaemic attack (TIA). However, the use of antithrombotic medications in patients with CVD can put them at high risk of intracranial haemorrhage. As such, the risk–benefit profile of various combinations of antiplatelet agents in patients with both CAD and CVD is uncertain. This Review provides a state-of-the-art account of the available evidence on antithrombotic therapies for the secondary prevention of atherothrombotic events in patients with concomitant CAD and CVD, particularly those with a history of noncardioembolic stroke or TIA.
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D.C. and D.J.A. researched data for the article, discussed its content, wrote the manuscript, and reviewed and edited the article before submission. M.A. contributed to discussions of content.
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D.C. declares receiving consultant and/or speaker honoraria from Abbott Vascular, Aspen, AstraZeneca, Bayer, Daiichi-Sankyo, Eli Lilly, Sanofi-Aventis, and Stentys. M.A. declares receiving consultant and/or speaker honoraria from Avanir, Boehringer-Ingelheim, Bristol Myers Squibb, Chiesi, Daiichi-Sankyo, Genentech, Janssen, Medtronic, Nestec, Portola, and Pzifer; and royalty payments from Duke University. D.J.A. declares receiving payments as an individual for consulting fees or honoraria from Abbott Vascular, AstraZeneca, Daiichi-Sankyo, Eli Lilly, Merck, PLx Pharma, Sanofi, and The Medicines Company; and for participation in review activities from CeloNova, Johnson & Johnson, and St. Jude Medical; and receiving institutional payments for grants from AstraZeneca, CSL Behring, Daiichi-Sankyo, Eli Lilly, Gilead, GlaxoSmithKline, Janssen Pharmaceuticals, Novartis, Osprey Medical, and The Medicines Company.
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Capodanno, D., Alberts, M. & Angiolillo, D. Antithrombotic therapy for secondary prevention of atherothrombotic events in cerebrovascular disease. Nat Rev Cardiol 13, 609–622 (2016). https://doi.org/10.1038/nrcardio.2016.111
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DOI: https://doi.org/10.1038/nrcardio.2016.111
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