Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
OBJECTIVE
This article provides recommendations on the use of antithrombotic therapy in patients with stroke or transient ischemic attack (TIA).


METHODS
We generated treatment recommendations (Grade 1) and suggestions (Grade 2) based on high (A), moderate (B), and low (C) quality evidence.


RESULTS
In patients with acute ischemic stroke, we recommend IV recombinant tissue plasminogen activator (r-tPA) if treatment can be initiated within 3 h (Grade 1A) or 4.5 h (Grade 2C) of symptom onset; we suggest intraarterial r-tPA in patients ineligible for IV tPA if treatment can be initiated within 6 h (Grade 2C); we suggest against the use of mechanical thrombectomy (Grade 2C) although carefully selected patients may choose this intervention; and we recommend early aspirin therapy at a dose of 160 to 325 mg (Grade 1A). In patients with acute stroke and restricted mobility, we suggest the use of prophylactic-dose heparin or intermittent pneumatic compression devices (Grade 2B) and suggest against the use of elastic compression stockings (Grade 2B). In patients with a history of noncardioembolic ischemic stroke or TIA, we recommend long-term treatment with aspirin (75-100 mg once daily), clopidogrel (75 mg once daily), aspirin/extended release dipyridamole (25 mg/200 mg bid), or cilostazol (100 mg bid) over no antiplatelet therapy (Grade 1A), oral anticoagulants (Grade 1B), the combination of clopidogrel plus aspirin (Grade 1B), or triflusal (Grade 2B). Of the recommended antiplatelet regimens, we suggest clopidogrel or aspirin/extended-release dipyridamole over aspirin (Grade 2B) or cilostazol (Grade 2C). In patients with a history of stroke or TIA and atrial fibrillation we recommend oral anticoagulation over no antithrombotic therapy, aspirin, and combination therapy with aspirin and clopidogrel (Grade 1B).


CONCLUSIONS
These recommendations can help clinicians make evidence-based treatment decisions with their patients who have had strokes.
Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA.
Maarten G
MG
Lansberg
HRB-Clinical Research Faculty, National University of Ireland Galway, Galway, Ireland.
Martin J
MJ
O'Donnell
Department of Neurology, University of Cincinnati, Cincinnati, OH.
Pooja
P
Khatri
University of Calgary, Calgary, AB, Canada.
Eddy S
ES
Lang
Department of Neurology, University of California, San Francisco, CA.
Mai N
MN
Nguyen-Huynh
Stanford Stroke Center, Department of Neurology and Neurological Sciences, Stanford University, Palo Alto, CA.
Neil E
NE
Schwartz
Division of General Internal Medicine, UMDNJ/Robert Wood Johnson Medical School, New Brunswick, NJ.
Frank A
FA
Sonnenberg
Department of Medicine, McMaster University, ON, Canada.
Sam
S
Schulman
Norwegian Knowledge Centre for the Health Services, Oslo, Norway.
Per Olav
PO
Vandvik
St. Joseph's Healthcare, Hamilton, ON, Canada.
Frederick A
FA
Spencer
Iberoamerican Cochrane Centre, CIBERESP-IIB Sant Pau, Barcelona, Spain.
Pablo
P
Alonso-Coello
Department of Medicine, McMaster University, ON, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
Gordon H
GH
Guyatt
State University of New York at Buffalo, Buffalo, NY; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. Electronic address: elieakl@buffalo.edu.
Elie A
EA
Akl
D001241:Aspirin / Q000009:adverse effects / Q000627:therapeutic use; D003131:Combined Modality Therapy; D004305:Dose-Response Relationship, Drug; D004359:Drug Therapy, Combination; D019317:Evidence-Based Medicine; D005343:Fibrinolytic Agents / Q000009:adverse effects* / Q000627:therapeutic use*; D006493:Heparin / Q000009:adverse effects / Q000627:therapeutic use; D006801:Humans; D048228:Intermittent Pneumatic Compression Devices; D020767:Intracranial Thrombosis / Q000097:blood / Q000188:drug therapy* / Q000209:etiology / Q000517:prevention & control*; D002546:Ischemic Attack, Transient / Q000097:blood / Q000188:drug therapy* / Q000209:etiology; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects / Q000627:therapeutic use; D011994:Recombinant Proteins / Q000009:adverse effects / Q000627:therapeutic use; D012955:Societies, Medical; D020521:Stroke / Q000097:blood / Q000188:drug therapy* / Q000517:prevention & control*; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000009:adverse effects / Q000627:therapeutic use; D014481:United States
D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors; D011994:Recombinant Proteins; D006493:Heparin; D010959:Tissue Plasminogen Activator; D001241:Aspirin