Evolving perspectives on clopidogrel in the treatment of ischemic stroke

Antiplatelet therapy is indicated for the treatment of ischemic stroke or transient ischemic attack (TIA). Aspirin reduces subsequent occlusive vascular events, including recurrent stroke, by about 25%. In such patients, clopidogrel has been evaluated in an effort to further reduce risk. In the Management of Atherothrombosis with Clopidogrel in High-risk Patients trial, the combination of clopidogrel plus aspirin was compared with clopidogrel alone, and the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance trial tested the addition of clopidogrel to aspirin. Combination therapy with aspirin plus clopidogrel provided no significant incremental benefit compared with aspirin or clopidogrel alone. In addition, combination therapy increased the risk of serious bleeding. On the basis of the current totality of evidence for long-term treatment of survivors of ischemic stroke or TIA, clopidogrel is an effective alternative for patients who are intolerant to aspirin.