An 82-year-old woman with suspected ischaemic stroke is being considered for antiplatelet therapy. Which regime is most appropriate to initiate?

An 82-year-old woman with suspected ischaemic stroke is being considered for antiplatelet therapy. Which regime is most appropriate to initiate?

• A. Aspirin 300 mg once daily indefinitely
• B. Clopidogrel 75 mg daily from day 1
• C. Aspirin 300 mg once a day for 14 days then clopidogrel 75 mg daily long-term
• D. Warfarin with heparin bridging

Answer: (C)

In acute ischemic stroke, the aim is to prevent early recurrence while balancing bleeding risk. Initiating antiplatelet therapy promptly reduces the chance of another event in the immediate period. Starting with a rapid, effective antiplatelet effect is best achieved by giving a single high dose of aspirin now, then moving to a maintenance agent for long-term prevention. Aspirin 300 mg given right away provides quick platelet inhibition to protect against recurrent ischemic injury in the first days. After about two weeks, continuing antiplatelet protection with a different mechanism—clopidogrel 75 mg daily—helps sustain protection without the ongoing bleeding risk associated with long-term high-dose aspirin. This sequential approach combines early risk reduction with a safer long-term plan. Using warfarin with bridging isn’t appropriate here unless there’s a specific cardioembolic source (like atrial fibrillation), and it adds bleeding risk without proven benefit in typical non-cardioembolic stroke. Starting clopidogrel from day one or keeping high-dose aspirin indefinitely also increases bleeding risk or doesn’t optimize long-term prevention the way a switch to a single agent does. So, beginning with aspirin for a short period (14 days) and then continuing with clopidogrel long-term provides rapid initial protection and durable, safer maintenance.

In acute ischemic stroke, the aim is to prevent early recurrence while balancing bleeding risk. Initiating antiplatelet therapy promptly reduces the chance of another event in the immediate period. Starting with a rapid, effective antiplatelet effect is best achieved by giving a single high dose of aspirin now, then moving to a maintenance agent for long-term prevention.

Aspirin 300 mg given right away provides quick platelet inhibition to protect against recurrent ischemic injury in the first days. After about two weeks, continuing antiplatelet protection with a different mechanism—clopidogrel 75 mg daily—helps sustain protection without the ongoing bleeding risk associated with long-term high-dose aspirin. This sequential approach combines early risk reduction with a safer long-term plan.

Using warfarin with bridging isn’t appropriate here unless there’s a specific cardioembolic source (like atrial fibrillation), and it adds bleeding risk without proven benefit in typical non-cardioembolic stroke. Starting clopidogrel from day one or keeping high-dose aspirin indefinitely also increases bleeding risk or doesn’t optimize long-term prevention the way a switch to a single agent does.

So, beginning with aspirin for a short period (14 days) and then continuing with clopidogrel long-term provides rapid initial protection and durable, safer maintenance.