Case Study – Antithrombotic treatment for secondary stroke prevention in a patient with ischemic stroke and heart failure

Case vignette TOPIC

A 67 year-old male patient was transferred to the emergency department of our hospital due to severe right hemiplegia and aphasia.

The family mentioned that the patient woke up unable to speak and to move his right limbs. He was last seen at his previous state approximately 8 hours ago.

The patient had a medical history of coronary artery disease, firstly diagnosed 10 years ago due to unstable angina. He was treated with balloon stenting of the left anterior descending artery but 5 years later he had a myocardial infarction at the same territory, resulting in severe ischemic cardiomyopathy (NYHA III) and an ejection fraction of 20%.

The patient was treated with carvedilol, eplerenone, ramipril, aspirin, atorvastatin and omeprazole.

On presentation, his oxygen saturation was 92% on ambient air and his blood pressure was 140/85mmHg. He was awake, aphasic and right-sided hemiplegic with an NIHSS score of 12. Early ischemic changes in the insula region and the precentral gyrus were identified at the emergency plain CT.  The patient was admitted in the Stroke Unit of our department under continuous monitoring of vital signs, ECG and BP.

What is the optimal antithrombotic treatment in this patient?