Medical therapy for ischemic stroke: Current state and problems

Abstract

To prevent recurrent ischemic stroke in patients with non‒valvular atrial fibrillation, it is recom-mended to start the administration of oral anticoagulants within 14 days of onset. In recurrent non‒cardio-embolic stroke cases, administration of dual antiplatelet therapy（clopidogrel plus aspirin for the first 21 days, followed by single antiplatelet therapy）can effectively reduce the risk of stroke recurrence and the risk of hemorrhage. The combination of cilostazol with aspirin or clopidogrel reduced the ischemic stroke recurrence and did not increase severe or life‒threatening bleeding complications when compared with using aspirin or clopidogrel alone. For the treatment of patients with embolic stroke of undetermined sources（ESUS）, direct oral anticoagulants were not superior to aspirin. ESUS may include underlying covert atrial fibrillation, patent foramen ovale, and aortogenic embolism. In emergencies, idarucizumab can rapidly reverse the anticoagulant effect of dabigatran. The four‒factor prothrombin complex concentrate is not only effective, but also superior to plasma in the rapid reversal of the prothrombin time‒international normalized ratio induced by vitamin K antagonists. After an ischemic stroke or transient ischemic attack in patients with atherosclerosis, the low target level of low‒density lipoprotein of ＜70 mg/dl is superior to the high target range of 90‒110 mg/dl in preventing subsequent cardiovascular events. For patients with active cancer, anticoagulant therapy, including subcutaneous heparin injections, may be recommended.