This article about treatment and prevention of
stroke is part of the Antithrombotic and
Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading, see the "Grades of Recommendations" chapter by Guyatt et al, CHEST 2008; 133:123S-131S). Among the key recommendations in this chapter are the following: For patients with
acute ischemic stroke, we recommend administration of IV
tissue plasminogen activator (tPA) if treatment is initiated within 3 h of clearly defined symptom onset (Grade 1A). For patients with
acute ischemic stroke of > 3 h but < 4.5 h, we suggest clinicians do not use IV tPA (Grade 2A). For patients with
acute stroke onset of > 4.5 h, we recommend against the use of IV tPA (Grade 1A). For patients with
acute ischemic stroke who are not receiving thrombolysis, we recommend early
aspirin therapy (Grade 1A). For
acute ischemic stroke patients with restricted mobility, we recommend prophylactic low-dose subcutaneous
heparin or low-molecular-weight heparins (Grade 1A). For long-term
stroke prevention in patients with noncardioembolic
stroke or
transient ischemic attack (TIA) [ie, atherothrombotic, lacunar, or cryptogenic], we recommend treatment with an
antiplatelet agent (Grade 1A), including
aspirin (recommended dose, 50-100 mg/d), the combination of
aspirin and extended-release
dipyridamole (25 mg/200 mg bid), or
clopidogrel (75 mg qd). In these patients, we recommend use of the combination of
aspirin and extended-release
dipyridamole (25/200 mg bid) over
aspirin (Grade 1A) and suggest
clopidogrel over
aspirin (Grade 2B), and recommend avoiding long-term use of the combination of
aspirin and
clopidogrel (Grade 1B). For patients who are allergic to
aspirin, we recommend
clopidogrel (Grade 1A). In patients with
atrial fibrillation and a recent
stroke or TIA, we recommend long-term oral anticoagulation (target international normalized ratio, 2.5; range, 2.0 to 3.0) [Grade 1A]. In patients with venous
sinus thrombosis, we recommend
unfractionated heparin (Grade 1B) or
low-molecular-weight heparin (Grade 1B) over no
anticoagulant therapy during the acute phase.