The Question
A 68-year-old man with a history of hypertension and hyperlipidemia presents to the emergency department after an episode of slurred speech and right-hand clumsiness that lasted approximately 30 minutes. His symptoms have completely resolved. He has not been taking his prescribed lisinopril or atorvastatin for several months. His blood pressure is 162/94 mmHg and heart rate is 78/min and regular. A neurologic examination is now normal. A non-contrast CT scan of the head shows no acute hemorrhage, but a subsequent MRI reveals a 6-mm focus of diffusion restriction in the left corona radiata. An electrocardiogram shows normal sinus rhythm. His calculated ABCD2 score prior to the MRI result was 5. In addition to resuming high-intensity statin therapy, which of the following is the most appropriate antithrombotic therapy to reduce his risk of recurrent stroke?
See the answer and explanation below:
Post-Call Recovery Reads
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View on AmazonThe Correct Answer
C
Explanation
Clinical Pearl:
For patients with a minor non-cardioembolic ischemic stroke (NIHSS ≤3) or high-risk TIA (ABCD2 score ≥4), a 21-day course of dual antiplatelet therapy with aspirin and clopidogrel is recommended over monotherapy to reduce the early risk of stroke recurrence.
Explanation:
The correct answer is C. This patient has experienced a minor acute ischemic stroke, confirmed by MRI, in the setting of a presentation consistent with a high-risk transient ischemic attack (ABCD2 score of 5). The 2021 AHA/ASA guidelines recommend dual antiplatelet therapy (DAPT) with aspirin and clopidogrel for 21 days for such patients with minor non-cardioembolic ischemic stroke. This strategy has been shown to be superior to antiplatelet monotherapy in reducing the 90-day risk of recurrent stroke. After the initial 21-day period, DAPT should be transitioned to a single antiplatelet agent for long-term prevention. Initiating monotherapy with either aspirin (A) or clopidogrel (B) is less effective in this early high-risk period. Lifelong DAPT (D) is not recommended as it increases the risk of major bleeding without providing additional benefit over monotherapy for long-term prevention. Anticoagulation with apixaban (E) is incorrect as there is no evidence of a cardioembolic source like atrial fibrillation.
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