ESOC 2025 | Why is antithrombotic use controversial in stroke patients receiving reperfusion therapy?

This is a very interesting point. We have been seeing over the last few decades dramatic improvement and an increasing number of antithrombotic strategies that we have to treat thrombotic disease. But there’s a huge gap between the difference between the use of antithrombotics in myocardial infarction and in stroke. So for myocardial infarction patients, they usually use a lot of different combinations of antithrombotic therapy, even anticoagulation within the setting of reperfusion therapies. In stroke, the antithrombotic medications are really contraindicated in the setting of reperfusion therapies, mainly with thrombolytic agents. But over the last few years, several new studies have shown that the use of selective antiplatelet agents may be helpful in selected populations of patients who have had a stroke. Part of the problem is related to the fact that myocardial infarction has a much more homogeneous etiology than stroke. For MI, usually you know 90% of the myocardial infarctions are caused by atherothrombotic disease and only 20% of the strokes are really attributed to large arteriosclerosis. So there’s a much more complicated scenario in terms of etiology. And it’s probable that antithrombotic therapy may be more helpful in patients with atherothrombotic stroke, those related to intracranial or extracranial arteriosclerotic stroke. So most of the new studies that have shown the benefit of adding antithrombotic therapy on top of reperfusion therapy have been successful in the setting of large arterial sclerotic disease.

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