Journal: Stroke
This review focuses on optimizing antithrombotic therapy for secondary prevention after noncardioembolic ischemic stroke or TIA.
Key points:
- Antiplatelet monotherapy: Antiplatelet monotherapy (e.g., aspirin, clopidogrel) is well established as the standard for long‑term secondary prevention in noncardioembolic stroke, based on multiple randomized trials.
- Short‑term dual antiplatelet therapy (DAPT): Short‑term dual antiplatelet therapy (DAPT) after minor ischemic stroke or high‑risk TIA provides superior early protection from recurrent ischemic events compared with monotherapy, but its benefit is time‑limited and must be balanced against bleeding risk. It is reserved for specific acute-phase scenarios.
- More intensive strategies: More intensive strategies—such as prolonged DAPT or full‑dose anticoagulation in noncardioembolic stroke—have generally failed to show meaningful additional ischemic benefit, while consistently increasing major bleeding, making them unsuitable for routine long‑term secondary prevention in this population.
- Factor XI/XIa inhibition: Factor XI/XIa inhibition is highlighted as a promising new approach that may better separate thrombosis prevention from hemostasis, potentially reducing ischemic events with less bleeding compared with conventional antithrombotics.
- OCEANIC‑STROKE trial: The review emphasizes the recent positive data from the OCEANIC‑STROKE trial, which evaluated dual‑pathway inhibition using the factor XIa inhibitor asundexian on top of antiplatelet therapy in noncardioembolic stroke, and frames this as a major advance in the field.
- Next‑generation options: The article synthesizes existing evidence for current antithrombotic strategies and outlines completed and ongoing clinical trials of factor XI/XIa inhibitors, positioning them as a next-generation option for secondary stroke prevention pending further results and regulatory decisions.