AAN 2026 | Which patient characteristics should guide antithrombotic selection after non-cardioembolic stroke?

So, you know, that’s a very interesting question. So initially, when you see someone with a non-cardioembolic stroke, the first branch point is the decision between dual antiplatelet therapy or single therapy. For dual therapy, we have evidence for the combination of aspirin and clopidogrel or aspirin and ticagrelor. Both of those combinations are superior to aspirin for the initial phase of treatment, 21 to 30 days in most cases. Now, the limitation there is on stroke severity. So the NIHSS, depending on the combination of trial, is less than four or less than five. So really more minor strokes for dual antiplatelet therapy. The other thing that plays into it is the timeline. Most of the data we have is in the first 24 hours. So from the INSPIRES trial, you can go out to 72 hours, particularly in patients who have atherosclerosis underlying their stroke. So minor strokes treated early with dual antiplatelet therapy. Otherwise, the choice is monotherapy. The other thing that has complicated the picture is the realization that there are patients who do not metabolize clopidogrel into its active form. The prevalence in most areas of the world is 30%, but in East Asia, it can be as high as 60%. There is evidence that using genetic testing to identify those with loss of function alleles for clopidogrel and substituting ticagrelor is a benefit. So those are the characteristics we use to choose antiplatelets. Now, when we think about asundexian, which is the only factor XIa inhibitor we have evidence for at the moment, and we look at the subgroup analysis, the very pleasing thing was we didn’t find subgroups where the agent was not effective. So it worked across age ranges, worked across stroke severity up to an NIHSS of 15, likewise across regions of the world and with or without dual antiplatelet therapy. In that trial, we allowed randomization up to 72 hours. Therefore, we could include patients who had been treated with IV thrombolysis or mechanical thrombectomy, which had not been the case in the previous dual antiplatelet trials. These patients benefited as well. So whether you had it or not, we saw benefit. In that subgroup analysis, it certainly looks like benefit is widespread. So we won’t have to be as choosy as we did with dual antiplatelet choices.

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