Antithrombotic strategies for the secondary prevention of stroke: A review.

Each year, over 600,000 ischemic strokes occur in the US, one-fourth of which are recurrent. Although preventive strategies have advanced, recurrent events remain common, highlighting the need for antithrombotic regimens that minimize ischemic and bleeding risks. In patients with minor ischemic stroke or high-risk Transient Ischemic Attack (TIA), early dual antiplatelet therapy (DAPT) followed by monotherapy significantly reduces early ischemic stroke recurrence, with greatest benefit within first 21 days (5.2% versus 7.8%; HR, 0.66; 95% CI, 0.56-0.77). Beyond this window, ischemic benefit diminishes and bleeding risk increases (0.3% versus 0.2%; HR, 1.28; 95% CI, 0.58-2.81). For cardioembolic stroke, particularly with atrial fibrillation, direct oral anticoagulants (DOACs) are favored over vitamin K antagonists, offering superior efficacy and safety (5.2% versus 5.9%; odds ratio [OR] 0.85; 95% CI, 0.74-0.99) and major bleeding (5.36% versus 6.16%; OR, 0.86; 95% CI, 0.78-0.99). However, antithrombotic optimization remains challenging-especially in adherence, risk stratification, and patient selection. Emerging strategies, including low-dose anticoagulant-antiplatelet combinations and Factor XIa inhibitors, aim to preserve antithrombotic benefit while reducing bleeding.