Prevention of cerebral ischaemia: antiplatelet agents.

Besides the optimal management of risk factors for stroke and carotid surge ry, antiplatelet agents are the cornerstone for prevention of cerebral isch aemia. The aim of this overview is to determine their role in the preventio n of cerebral ischaemia, from available literature. in primary prevention, the benefit of aspirin has been established only for patients with non-valv ular atrial fibrillation and a low risk of cardioembolism, or as an alterna tive 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 1 300 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. Aspiri n 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 ris k of cerebral ischaemia in patients with other causes, especially lipohyali nosis of the deep perforators leading to lacunar infarcts? In daily practic e, does prescription follow recommendations? Will it be possible to reprodu ce the results of the European Stroke Prevention Study (ESPS) 2? Are antipl atelet agents other than aspirin effective in non-valvular atrial fibrillat ion? Are other associations of antiplatelet agents more effective than thes e agents alone? Finally, what will be the role of new antiplatelet agents i n the future?