Therapeutic Challenges in Patients With Noncardioembolic Acute Ischemic Stroke in Need of Double Antiplatelet Therapy for Coronary Artery Disease (vol 26, pg e213, 2019)

Background: The risk of ischemic stroke (IS) is significant within 6-12 months from the myocardial revascularization for an acute cardiac event. Consequently, we can expect to have patients with an acute IS occurring right in the time frame of dual antiplatelet therapy (DAPT) imposed by the coronary heart disease (CHD). Areas of Uncertainty: Until present, there are no evidence-based guidelines for the management of patients with acute IS in need of DAPT for ischemic heart disease. The aim of this article was to go through the available data and to depict the appropriate therapeutic strategy for this category of patients. Data Sources: We have performed a systematic review of the literature through June 2018, using Medline/PubMed database. Therapeutic Advances: DAPT (aspirin and only clopidogrel among all P2Y12 inhibitors) might be maintained or initiated for CHD in patients with minor acute stroke and high-risk transient ischemic attack patient with IS attributable to an important intracranial stenosis, as long as this drug combination proved to be safe for them in the prevention of stroke recurrence. In patients with IS receiving thrombolysis, with increased size of infarction or high National Institute of Health Stroke Score (NIHSS), the risk of hemorrhagic transformation under DAPT must be weighed against the risk of stent thrombosis in the coronary arteries, which, on its turn, depends on the clinical form for which myocardial revascularization was performed, the time interval from the complexity of a certain interventional procedure. Conclusions: In the acute phase of an IS, maintenance or initiation of DAPT therapy imposed by CHD relies, on one hand, on the risk of hemorrhagic transformation of the brain injury and, on the other hand, on the risk of stent thrombosis in the coronary arteries. The management of these patients must be carried on by a vascular team, on an individualized basis.