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Drug management of ischaemic stroke

Aspirin tablets (James Griffith 74-year-old man was admitted to the stroke ward yesterday with rapid onset left-sided weakness, dysphasia and slurred speech. On reviewing his drug chart you see that he received alteplase shortly after admission, but he is not currently prescribed any regular medication.

His blood pressure is 150/90mmHg, pulse is 70 beats per minute and he is in sinus rhythm. The computed tomography scan on admission confirms an ischaemic stroke. Blood tests show that his hepatic and renal function are normal, and his urea, electrolytes, and blood glucose are within normal ranges.

He has a history of osteoarthritis. His current medication is co-codamol 8/500 two tablets qds prn. He has no known allergies and has been assessed as safe to have a soft diet by the speech and language therapy team.

What initial treatment should you recommend? According to the prescribing notes on ischaemic stroke (section 2.9, BNF 61), 24 hours after thrombolysis, patients should be started on aspirin 300mg daily for 14 days (reflecting the National Institute for Health and Clinical Excellence clinical guideline on Stroke, 2008).

Treatment of hypertension in the acute phase of ischaemic stroke can result in reduced cerebral perfusion, and should therefore, only be initiated in the event of a hypertensive emergency. This patient does not require immediate antihypertensive therapy because his hypertension is not severe.

A statin should be initiated 48 hours after onset of stroke symptoms, irrespective of his serum-cholesterol concentration.

What long-term treatment should you recommend? This patient should receive long-term treatment to reduce the risk of further cardiovascular events. Because he is in sinus rhythm, he should receive clopidogrel 75mg daily after completing the 14-day course of aspirin. Clopidogrel should be continued long-term, as should the statin.

Following the acute phase of ischaemic stroke, this man’s blood pressure should be measured and, if necessary, treatment initiated to achieve a target blood pressure of less than 130/80mmHg. Beta-blockers should not be used for hypertension after a stroke, unless they are indicated for a co-existing condition.

The patient should be advised to make lifestyle modifications where applicable, which could include beneficial changes to diet, exercise, weight, alcohol intake and smoking status.

Adapted from BNF 61 Hospital e-Update an e-learning module produced by the Centre for Pharmacy Postgraduate Education and the British National Formulary and now available at

Citation: The Pharmaceutical Journal URI: 11080632

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