Pharmacotherapy Case: Post-Ischemic Stroke Management

Age: 68 years

Gender: Female

Subjective Data

Chief Complaint:

“I want to make sure my medications are working to prevent another stroke.”

History of Present Illness:

Ms. Smith is a 68-year-old female with a history of hypertension, type 2 diabetes, hyperlipidemia, and ischemic stroke 3 weeks ago. She presents for follow-up after hospital discharge. The stroke caused mild left-sided weakness, which has partially improved with rehabilitation. She denies chest pain, palpitations, or new neurological deficits. Reports adherence to medications but occasionally forgets her afternoon dose of clopidogrel.

Medical History:

• Ischemic stroke (3 weeks ago, left middle cerebral artery distribution).

• Hypertension (diagnosed 15 years ago).

• Type 2 diabetes mellitus (HbA1c 7.2% 3 months ago).

• Hyperlipidemia.

Family History:

• Father: myocardial infarction at age 70.

• Mother: type 2 diabetes.

Social History:

• Retired nurse, lives with spouse.

• Former smoker (1 pack/day for 20 years, quit 5 years ago).

• No alcohol use.

Medications:

• Aspirin 81 mg PO daily

• Clopidogrel 75 mg PO daily (started post-stroke for dual antiplatelet therapy)

• Atorvastatin 40 mg PO nightly

• Lisinopril 10 mg PO daily

• Metformin 500 mg PO BID

Allergies:

• No known drug allergies.

Adherence:

• ~80% adherence (occasionally misses clopidogrel).

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Objective Data

Vital Signs:

• BP: 145/88 mmHg

• HR: 76 bpm (regular rhythm)

• RR: 14 breaths/min

• SpO2: 99% on room air

• Weight: 78 kg

• Height: 160 cm

Physical Exam:

• Neurologic: Mild left-sided facial droop and upper extremity weakness (4/5 strength). Gait steady with cane.

• Cardiovascular: Regular rate and rhythm, no murmurs.

• Skin: No bruising or petechiae.

Laboratory Results:

• LDL: 78 mg/dL (down from 145 mg/dL pre-statin)

• HbA1c: 7.0% (improved from 7.2%)

• Platelets: 210,000/µL

• Creatinine: 0.9 mg/dL (eGFR >60 mL/min/1.73m²)

Diagnostics:

• CT head (post-stroke): Residual right parietal ischemic infarct.

• Carotid ultrasound: Mild bilateral carotid atherosclerosis (no stenosis >50%).

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Assessment

1. Secondary Stroke Prevention:

   • ABCD2 Score: 5 (Age >60 [1], BP >140/90 [1], Clinical features [1], Diabetes [1], Duration >10 min [1]). High risk of early recurrence.

   • ASCVD Risk: Very high (history of stroke).

2. Current Pharmacotherapy:

   • Dual antiplatelet therapy (DAPT) with aspirin + clopidogrel is appropriate for early secondary prevention (within 21 days of minor stroke).

   • BP above target (<130/80 mmHg for diabetes/stroke).

3. Adherence Concerns:

   • Partial nonadherence to clopidogrel increases risk of recurrent stroke.

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Plan

1. Pharmacotherapy:

   • Continue DAPT: Aspirin 81 mg + clopidogrel 75 mg daily for 21 total days post-stroke, then transition to aspirin monotherapy.

   • BP Management: Increase lisinopril to 20 mg daily. Recheck BP in 2 weeks.

   • Statin: Continue high-intensity atorvastatin 40 mg (LDL goal <70 mg/dL).

2. Monitoring:

   • Repeat HbA1c in 3 months.

   • Annual renal function and liver enzymes.

   • Neurologic follow-up for residual deficits.

3. Education:

   • Use pill organizer to improve adherence.

   • Recognize signs of transient ischemic attack (TIA): sudden weakness, speech difficulty, vision changes.

   • Avoid NSAIDs; use acetaminophen for pain.

4. Lifestyle Modifications:

   • Low-sodium, heart-healthy diet.

   • Continue physical therapy for strength and balance.

5. Follow-Up:

   • Return in 4 weeks for BP check and DAPT transition plan.

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Rationale:

DAPT with aspirin and clopidogrel is guideline-recommended for 21 days following a minor ischemic stroke to reduce early recurrence risk. Transitioning to monotherapy mitigates long-term bleeding risk. Tight BP control (goal <130/80 mmHg) and LDL reduction with high-intensity statins are critical for secondary prevention. Addressing adherence barriers and lifestyle factors optimizes outcomes.