Acute evaluation and management of ischemic stroke-1

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Two trials have evaluated the benefits and risks

of aspirin in the treatment of patients with acute stroke.

In the International Stroke Trial, patients who received aspirin (300 mg) within 48 hours of the onset of symptoms

of acute ischemic stroke experienced significant reductions in the 14-day recurrence of ischemic stroke (2.8 versus 3.9 percent) and in the combined outcome of nonfatal stroke or death (11.3 versus 12.4 percent).

In the Chinese Acute Stroke Trial (CAST), 21,100 patients were randomized to 160 mg of aspirin daily or placebo, also within 48 hours of the onset of acute ischemic stroke. Aspirin-allocated patients experienced a 14 percent reduction in total morality at four weeks (3.3 versus 3.9 percent).

The fifth ACCP Consensus Conference recommended that aspirin therapy (160 to 325 mg/day) be given to patients with ischemic stroke who are not receiving rt-PA, intravenous heparin, or oral anticoagulants. The optimal dose of aspirin is uncertain; there is no compelling evidence that any specific dose is more effective tan another, and fewer side effects occur with lower doses.

Aspirin, clopidogrel (75 mg/day), ticlopidine (250 mg BID), and the combination of aspirin and dipyridamole are all acceptable options, however, initial therapy with aspirin (50 to 325 mg/day) is recommended. Clopidogrel or ticlopidine are alternatives for patients intolerant to aspirin.

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