Stroke

Medications

It is very important to seek emergency medical attention for stroke symptoms. If you are having an ischemic stroke, which is caused by a blood clot, you may be given medicines that get rid of the clot. If you are having a hemorrhagic stroke, which is caused by bleeding in the brain, you will not be given medicines.

If you are having an ischemic stroke, you may be able to receive tissue plasminogen activator (t-PA), a clot-dissolving medicine. This medicine is strongly recommended, but it is most effective if given within 3 hours of the onset of stroke symptoms.¹ If you receive t-PA within this 3-hour window, it may improve your recovery. Evidence shows that there may be some benefit in giving t-PA even beyond 3 hours.¹³ However, t-PA can be life-threatening because it can cause bleeding in the brain. It is not used to treat hemorrhagic stroke.

Blood clots cause most strokes, so medicines that prevent the formation of blood clots are used to prevent additional ischemic strokes. These medicines are usually given after the initial treatment for stroke. They are not recommended in the first 24 hours after t-PA has been given.¹ The two types of medicines used to prevent clotting are:

• Antiplatelet medicines, which prevent the smallest cells in blood (platelets) from sticking together. Aspirin is the antiplatelet medicine most commonly used to prevent strokes. Two large studies showed that taking aspirin within 48 hours of a stroke may reduce the chance of another stroke and prevent death.³ People who cannot take aspirin or who have transient ischemic attacks (TIAs) or a stroke while taking aspirin are sometimes given other antiplatelet medicines, such as clopidogrel (Plavix). Another medicine that can prevent ischemic stroke is Aggrenox, which is aspirin combined with extended-release dipyridamole. Aspirin is not recommended within the first 24 hours of giving t-PA.¹ For more information, see:

  Should I take daily aspirin to prevent a heart attack or a stroke?

• Anticoagulants, which prevent the production of proteins needed for blood to clot normally. Anticoagulants (particularly warfarin) are the best method of preventing blood clots that form in the heart because of atrial fibrillation, heart attack, heart valve problems, or heart failure. Anticoagulants are not given as emergency treatment for stroke. If you take warfarin (such as Coumadin), see:

  Eating a steady amount of vitamin K when you take warfarin (Coumadin).

For people with coronary artery disease, treatment with cholesterol-lowering drugs called statins can slow the development of atherosclerosis in the carotid arteries and may also reduce the chance of having a TIA or stroke. Studies have shown a reduced risk of stroke in people taking statins.^{9, 14} (For more information on statins, see the topic High Cholesterol.)

Medication Choices

Medicine used in the emergency treatment of stroke caused by a clot (ischemic stroke) includes tissue plasminogen activator (t-PA), a medicine that breaks up clots.

After emergency treatment for a stroke, the focus will turn to preventing future transient ischemic attacks (TIAs) or another stroke. Your doctor will decide which medicines to use based on the risks and possible side effects of the medicines. These medicines are not usually given until at least 24 hours after treatment with t-PA.

Antiplatelet medicines

Antiplatelets decrease blood clot formation by preventing the smallest blood cells (platelets) from sticking together and forming blood clots. Antiplatelet medicines include the following:

• Aspirin with extended-release dipyridamole (Aggrenox) is used for the prevention of ischemic stroke.
• Aspirin is an antiplatelet medicine often used for a first TIA or ischemic stroke or if you have atherosclerosis. Talk with your doctor before you start taking aspirin to prevent a stroke.
• Clopidogrel (Plavix) may be used if you have had a TIA or ischemic stroke and cannot take aspirin.

Anticoagulant medicines

Anticoagulants (warfarin and heparin) are often used instead of or in combination with antiplatelets, such as aspirin or clopidogrel. Anticoagulants are used for people who are at risk for stroke because of:

• Abnormal heart rhythms (atrial fibrillation).
• Heart attack, if a clot is present in the heart.
• Heart failure.
• Abnormal or artificial heart valves.

If you have high blood pressure, your doctor may want you to take medicines to lower it. Blood pressure medicines include:

• Angiotensin-converting enzyme (ACE) inhibitors.
• Angiotensin II receptor blockers (ARBs).
• Beta-blockers.
• Diuretics.
• Calcium channel blockers.

Medicines used to treat depression and pain may be prescribed after a stroke.

What To Think About

Choosing which medicine to use to prevent stroke is based on evaluation of your risks and the benefits of taking that medicine. The American College of Physicians recommends:

• Warfarin for people who are at risk for stroke because of abnormal heart rhythms (atrial fibrillation) or blood clots that form in the heart or another place in the body. Warfarin is usually given to people age 65 and older.
• Aspirin for people who have had a transient ischemic attack (TIA). Talk with your doctor before you start taking aspirin to prevent a stroke.
• Other antiplatelet medicines, such as aspirin with extended-release dipyridamole (Aggrenox) or clopidogrel (Plavix).

However, the American College of Cardiology and the American Heart Association recommend that short-acting dipyridamole alone not be used by people who have chronic stable angina (an indicator of coronary artery disease) because dipyridamole may reduce blood flow to portions of the heart (ischemia) during exercise.¹⁵ Extended-release formulations, such as Aggrenox, do not appear to have this risk and may be safe for people with angina. Talk to your doctor if you are considering taking a medicine that contains dipyridamole.

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Author:	Robin Parks, MS	Last Updated: March 6, 2007
Medical Review:	Anne C. Poinier, MD - Internal Medicine Richard D. Zorowitz, MD - Physical Medicine and Rehabilitation
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