Titrated initiation of acetylsalicylic acid-dipyridamole therapy reduces adverse effects and improves tolerance in patients with stroke.

BACKGROUND: Standard aspirin (acetylsalicylic acid [ASA])-dipyridamole therapy twice daily is associated with high rates of discontinuation in large part because of headache and gastrointestinal side effects. Attempts to address dipyridamole-induced headache through reduced dose initiation have produced variable results. Moreover, it has been suggested that migraineurs are more likely to have a dipyridamole-induced headache. OBJECTIVE: We sought to evaluate whether titrated initiation of ASA-dipyridamole in patients with stroke/transient ischemic attack (TIA) improves tolerance and to assess the appearance of headache in those with pre-existing history of headaches. METHODS: ASA-dipyridamole (25/200 mg) once daily together with ASA (81 mg) daily was started in 130 patients given the diagnosis of stroke/TIA with instructions to increase ASA-dipyridamole to twice daily after 7 days and discontinue ASA (81 mg). Patients received a telephone call on days 7 and 14 to assess for adverse events, discontinuation, and recurrent stroke/TIA. RESULTS: Two patients were lost to follow-up. After 2 weeks, 113 patients were using the medication without any major complications. Fifteen patients were off therapy; 10 (8%) patients stopped because of headache and/or gastrointestinal symptoms, whereas 4 patients were switched to other antiplatelet agents by their primary care physician as a matter of choice rather than ASA-dipyridamole side effects. One patient had recurrent stroke because of intracranial dissection and was switched to anticoagulation. Only 4 of 27 (14%) patients with a history of headache discontinued therapy. CONCLUSIONS: Titrated initiation of ASA-dipyridamole (25/200 mg) appears to have low discontinuation rate and approximately 90% tolerance after 2 weeks. History of migraine or tension headaches was not directly associated with discontinuation because of headaches.

Thrombus detection by echocardiography in patients with acute ischemic stroke and chronic or new-onset atrial fibrillation.

INTRODUCTION: Recent articles have promoted anticoagulation for potential sources of embolism detected on echocardiography, despite lack of data regarding risk/benefit ratio for anticoagulating many of these abnormalities. Conversely, we have found echocardiography use in ambulatory stroke care to be of low yield. However, direct visualization of a thrombus might be considered a reasonable indication for anticoagulation. The current study assesses the use of transthoracic echocardiography (TTE) in thrombus detection in atrial fibrillation (AF) associated with acute stroke, which should present a good substrate for thrombus detection. METHODS: We conducted a chart review of patients admitted to our stroke department during a 6-month period, identifying and analyzing those with associated AF who were also submitted to TTE. RESULTS: In all, 31 patients with AF (12 chronic and 19 new onset) were studied. TTE was conducted within approximately 60 +/- 41 hours. Thrombus was detected in only one patient with severe left ventricular dysfunction. Moderate to severe left ventricular function was detected in two additional patients with history of myocardial infarction. There were no other pertinent findings in 28 of 31 patients. All patients were anticoagulated on the basis of AF detection. Two died in hospital from stroke-related complications and 26 of 31 were discharged home or to rehabilitation. CONCLUSIONS: TTE has a low yield of thrombus detection in patients with acute cardioembolic (AF-associated) stroke and has no impact on antithrombotic therapy in this patient population.