Prevention of cerebral ischaemia: antiplatelet agents.

Besides the optimal management of risk factors for stroke and carotid surgery, antiplatelet agents are the cornerstone for prevention of cerebral ischaemia. The aim of this overview is to determine their role in the prevention of cerebral ischaemia, from available literature. in primary prevention, the benefit of aspirin has been established only for patients with non-valvular atrial fibrillation and a low risk of cardioembolism, or as an alternative choice of warfarin, and in subjects at highrisk of atherosclerosis. In secondary prevention, antiplatelet agents are effective to reduce the risk in patients with ischaemic stroke due to atherosclerosis: aspirin (50 to 1300 mg), ticlopidine (500 mg), clopidogrel (75 mg) and dipyridamole (400 mg) are effective, but the higher levels of risk reduction are obtained with clopidogrel, ticlopidine and the association aspirin - dipyridamole. Aspirin is recommended in most other causes of cerebral ischaemia, except in high risk cardiopathies when anticoagulation is possible. Other domains should still be explored: are antiplatelet agents also effective to reduce the risk of cerebral ischaemia in patients with other causes, especially lipohyalinosis of the deep perforators leading to lacunar infarcts? In daily practice, does prescription follow recommendations? Will it be possible to reproduce the results of the European Stroke Prevention Study (ESPS) 2? Are antiplatelet agents other than aspirin effective in non-valvular atrial fibrillation? Are other associations of antiplatelet agents more effective than these agents alone? Finally, what will be the role of new antiplatelet agents in the future?