national-clinical-guidelines-for-stroke-fourth-edition

National clinical guideline for stroke
alternative, particularly among older patients (Mant et al 2007). In the only RCT of
anticoagulation and antiplatelet treatment after cardioembolic stroke or TIA (EAFT
Study Group 1993), aspirin was no more effective than placebo in the prevention of
disabling stroke or thromboembolic events. In selected cases it may be appropriate to
consider a left atrial appendage occlusion device if patients could safely take the shortterm
anticoagulation required following the procedure (Holmes et al 2009).
New oral anticoagulants including direct thrombin inhibitors and factor Xa inhibitors
may ultimately replace warfarin in stroke secondary prevention in patients with
creatinine clearance greater than 30 ml/min. These drugs have a rapid onset of action
suggesting a specific practical advantage following cardioembolic TIA and have few
interactions with other drugs and food-stuffs, and do not require coagulation
monitoring. Due to the lack of an antidote patients on such drugs should be excluded
from thromboylsis should they have a stroke, unless, in the case of dabigatran, the
prothrombin time (PTT) and activated partial thromboplastin time (aPTT) are both
normal. There are currently no monitoring tests for rixaroxaban.
NICE technology appraisals recommend dabigatran or rivaroxaban as an option for
secondary prevention following TIA or ischaemic stroke in patients with non-valvular AF
(National Institute for Health and Clinical Excellence 2012a; National Institute for Health
and Clinical Excellence 2012b). Among people with AF not considered appropriate for
warfarin, apixaban was superior to aspirin in the prevention of thromboembolism,
offering another alternative in some specific circumstances (Connolly et al 2011). In the
RE-LY study the benefit of dabigatran over warfarin in the prevention of
thromboembolic events was greatly reduced in centres where the quality of anticoagulant
control was high, as assessed by the centre-specific time in the therapeutic range (TTR)
(Connolly et al 2009). Average TTR in UK centres was 72% (Wallentin et al 2010).
Bearing in mind that participants had to be eligible for both treatments in all the
comparative studies of new oral anticoagulants with warfarin, the existing studies provide
no evidence regarding the safety or efficacy of the new agents in patients where the
bleeding risk is considered to be too high to use warfarin safely.
5.5.1 Recommendations
A For patients with ischaemic stroke or TIA in sinus rhythm, clopidogrel should be the
standard antithrombotic treatment:
● Clopidogrel should be used at a dose of 75 mg daily.
● For patients who are unable to tolerate clopidogrel, offer aspirin 75 mg daily in
combination with modified-release dipyridamole 200 mg twice daily.
● If both clopidogrel and modified-release dipyridamole are contraindicated or not
tolerated, offer aspirin 75 mg daily.
● If both clopidogrel and aspirin are contraindicated or not tolerated offer modifiedrelease
dipyridamole 200 mg twice daily.
● The combination of aspirin and clopidogrel is not recommended for long-term
prevention after TIA or stroke unless there is another indication such as acute
coronary syndrome or recent coronary stent procedure.
B For patients with ischaemic stroke or TIA in paroxysmal, persistent or permanent
atrial fibrillation (valvular or non-valvular) anticoagulation should be the standard
treatment. Anticoagulation:
68 © Royal College of Physicians 2012