page171
Transient ischaemic attack
Patients
suspected of
having a
transient
ischaemic
attack
should
immediately
receive
aspirin
300 mg
once daily (patients
with aspirin hypersensitivity,
or
those intolerant
of
aspirin despite the addition of
a
proton
pump
inhibitor,
should
receive
clopidogrel
75 mg once daily [unlicensed use]
as an alternative).
Following
a
confirmed
diagnosis,
patients
should
receive treatment for secondary prevention (see Long-
term Management,
under Ischaemic Stroke,
below).
Ischaemic stroke
Initial
management
Alteplase (section 2.10.2)
is
recommended in the
treatment
of
acute ischaemic
stroke if
it
can be administered within 3 hours
of
symptom onset;
it
should be given by medical
staff
experienced in the
administration of
thrombolytics
and the treatment of
acute stroke,
preferably within a
specialist stroke centre.
Treatment with aspirin 300 mg
once daily for 14 days should be initiated 24 hours after
thrombolysis (or as soon as possible within 48 hours of
symptom onset in patients not receiving thrombolysis);
patients with aspirin hypersensitivity, or those intolerant
of
aspirin despite the addition of
a proton pump inhi-
bitor, should receive clopidogrel 75 mg once daily [unli-
censed use] as an alternative.
Anticoagulants are not recommended as an alternative
to antiplatelet
drugs
in acute
ischaemic
stroke
in
patients who are in sinus rhythm.
However,
parenteral
anticoagulants
(section 2.8.1)
may
be
indicated in
patients who are symptomatic of,
or
at
high risk of
developing, deep vein thrombosis or pulmonary embo-
lism;
warfarin should not be commenced in the acute
phase of ischaemic stroke.
Anticoagulants
(section 2.8.2)
should be considered
after cardio-embolic ischaemic stroke in patients with
atrial fibrillation, however patients presenting with atrial
fibrillation following a disabling ischaemic stroke should
receive aspirin 300 mg once daily for 14 days,
before
being
considered
for
warfarin
treatment.
Patients
already receiving anticoagulation for a prosthetic heart
valve who experience a disabling ischaemic stroke and
are at significant risk of
haemorrhagic transformation,
should have their anticoagulant treatment stopped for 7
days and substituted with aspirin 300 mg once daily.
Treatment
of
hypertension
in
the
acute
phase
of
ischaemic stroke can result in reduced cerebral
perfu-
sion, and should therefore only be instituted in the event
of
a hypertensive emergency (see section 2.5),
or
in
those patients considered for thrombolysis.
Long-term management
Patients
should receive
long-term treatment
following a transient
ischaemic
attack or
an ischaemic stroke to reduce the risk of
further
cardiovascular
events.
Following a
transient
ischaemic attack,
long-term treatment
with modified-
release dipyridamole in combination with aspirin is
recommended;
if
patients are intolerant
of
aspirin,
or
it
is
contra-indicated,
then modified-release dipyrid-
amole alone is recommended.
Clopidogrel
75 mg once
daily is recommended as long-term treatment following
an ischaemic stroke (not associated with atrial
fibrilla-
tion (see below));
if
clopidogrel
is contra-indicated or
not tolerated,
patients should receive modified-release
dipyridamole in combination with aspirin;
modified-
release
dipyridamole
alone
can
be
considered
for
patients with contra-indications to,
or
intolerance of,
aspirin and clopidogrel.
Patients with stroke associated
with atrial fibrillation should be reviewed for long-term
treatment with aspirin or warfarin (see Initial
Manage-
ment under Ischaemic Stroke,
above,
and section 2.3).
Anticoagulants are not
routinely recommended in the
long-term prevention of
recurrent
stroke,
except
in
patients with atrial fibrillation (section 2.3).
A statin (section 2.12) should be initiated 48 hours after
stroke symptom onset,
irrespective of
the
patient’s
serum-cholesterol concentration.
Following the acute phase of
ischaemic stroke,
blood
pressure should be measured and treatment initiated to
achieve a target blood pressure of <130/80 mmHg (see
section 2.5).
Beta-blockers should not
be used in the
management of hypertension following a stroke, unless
they are indicated for a co-existing condition.
All
patients should be advised to make lifestyle mod-
ifications that include beneficial
changes to diet,
exer-
cise,
weight, alcohol intake,
and smoking.
Intracerebral haemorrhage
Initial
management
Surgical
intervention may be
required
following
intracerebral
haemorrhage
to
remove the haematoma and relieve intracranial
pres-
sure.
Patients taking anticoagulants should have this
treatment
stopped and reversed (see section 2.8.2);
anticoagulant
therapy
has,
however,
been
used
in
patients with intracerebral haemorrhage who are symp-
tomatic of
deep vein thrombosis or pulmonary embo-
lism;
placement of a caval filter is an alternative in this
situation.
Long-term management
Aspirin therapy should only
be given to patients at a high risk of a cardiac ischaemic
event.
Blood pressure should be measured and treat-
ment initiated where appropriate (see section 2.5),
tak-
ing care to avoid hypoperfusion.
Statins
should be
avoided following intracerebral
haemorrhage,
however
they can be used with caution when the risk of
a
vascular event
outweighs the risk of
further haemorr-
hage.
ABCIXIMAB
Indications
prevention of ischaemic cardiac compli-
cations in patients undergoing percutaneous coronary
intervention;
short-term prevention of myocardial
infarction in patients with unstable angina not
responding to conventional treatment and who are
scheduled for percutaneous coronary intervention
(use under specialist supervision)
Cautions
measure baseline prothrombin time,
acti-
vated clotting time,
activated partial thromboplastin
time,
platelet count,
haemoglobin and haematocrit;
monitor haemoglobin and haematocrit 12 hours and
24 hours after start of treatment and platelet count 2–
4 hours and 24 hours after start of treatment;
con-
comitant use of drugs that increase risk of bleeding;
discontinue if uncontrollable serious bleeding occurs
or emergency cardiac surgery needed;
consult pro-
duct literature for details of procedures to minimise
bleeding;
elderly
BNF 61
2.9 Antiplatelet drugs
151
2
Cardiovascular system