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ACCP Guidelines for Stroke Prevention
Non-cardioembolic Cerebral Ischaemic Events
- Treatment with aspirin (50-325 mg), aspirin (25 mg) plus extended-release dipyridamole (200mg) bid; or clopidogrel (75mg) qd are all acceptable initial options (Grade 1A recommendation).
- Aspirin plus dipyridamole option may be preferable to aspirin (Grade 2A recommendation) and that clopidogrel may be preferable to aspirin (Grade 2B recommendation).
References:
Albers et al. Chest 2004; 126 (Suppl): 438S-512S.
 
ACCP Guidelines: Outcome Events in the ESPS 2 Study
References:
Albers et al. Chest 2004; 126 (Suppl): 438S-512S.
ACCP Guidelines: Outcome Events in the CAPRIE Study
Based on the indirect comparison in the figures, the combination of extended-release dipyridamole and aspirin may be more effective than clopidogrel for prevention of stroke. The performance of antiplatelet drugs in separate trials varies because patient populations and protocols differ, and unrecognised biases may exist. No trial has performed a direct comparison between these alternative agents and physicians must make comparisons and clinical judgments based on the available data.
References:
Albers et al. Chest 2004; 126 (Suppl): 438S-512S.
International Guidelines Secondary Prevention Recommendations
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ACCP |
EUSI |
NICE* |
RCP |
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ASA |
ASA 50-325 mg
Grade 2A |
ASA 50-325 mg
First Choice |
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ASA 50-300 mg
First Choice |
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ER-DP + ASA |
ER-DP + ASA 25 mg/200 mg more effective than ASA and clopidogrel
(Grade 1A) |
ER-DP + ASA
First Choice |
ER-DP + ASA for 2 years.
First Choice |
ER-DP + ASA
First Choice |
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ER-DP |
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DP when ASA and Clopidogrel/Ticlopidine not tolerated.
Second Choice |
DP for intolerance of ASA, for 2 years.
Second Choice |
DP when ASA not tolerated
Second choice |
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CP |
CP 75 mg (preferred over ASA)
Grade 2B |
CP slightly more effective than ASA
When ASA or DP not tolerated + high risk patients
First Choice |
CP for intolerance of both ASA and DP, for 2 years
Third Choice |
CP
First Choice
Also when ASA not tolerated
Third Choice |
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ER-DP = Dipyridamole modified release; ASA = Aspirin; CP = Clopidogrel
* preliminary
Guidelines for the secondary prevention of stroke, such as those from EUSI and from the American College of Chest Physicians (ACCP) advocate the use of appropriate antiplatelet therapy and state that there are three acceptable, first choice options: aspirin alone, the combination of aspirin with modified-release dipyridamole or clopidogrel alone. While the European recommendations do not favour one of the options, the combination of aspirin with dipyridamole is favoured as a first choice, in the ACCP guidelines, whereas the RCP recommend all the three antiplatelets on the same level.
Reference:
Hacke W. ESC Mannheim 2004, updated by Kreutz J.
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