The best drug for stroke patients is a relative concept and depends on the type of stroke (ischemic or hemorrhagic), the time of onset of symptoms and the patient's condition. For secondary prevention of recurrent stroke, antiplatelet drugs (such as aspirin or clopidogrel) and anticoagulants (such as apixaban or rivaroxaban) play a key role in selected patients. Credible sources emphasize that no single drug is "best" for everyone and that the choice is based on the physician's judgment. This doctor's article has been compiled with the aim of a detailed review of effective drugs in the acute phase and prevention, along with timing and possible side effects, so that patients and families can gain the necessary knowledge.

Drugs for the acute phase of ischemic stroke (first hours)

In the early hours of an ischemic stroke, the main goal is to restore blood flow to the brain and prevent the spread of nerve damage. After diagnosis by neurological examination and brain imaging, drug treatment should be started without delay. The most important success factor at this stage is time; The sooner treatment is started, the more likely it is that neurological function will improve. For this reason, emergency protocols in medical centers play an important role in controlling the patient's condition.

English text:
An IV injection of recombinant tissue plasminogen activator (TPA) is the gold standard treatment for ischemic stroke. The two types of TPA are alteplase (Activase) and tenecteplase (TNKase). An injection of TPA is usually given through a vein in the arm within the first three hours. Farsi translation: Intravenous injection of recombinant tissue plasminogen activator (TPA) is the gold standard treatment for ischemic stroke; Two types of TPA are Alteplase (Activase) and TNKase (TNKase). TPA injection is usually done through a vein in the arm in the first three hours.

3. Antiplatelets in the acute phase

In patients with mild ischemic stroke or high-risk TIA of non-cardiac origin, short-term dual antiplatelet therapy is recommended. This method reduces the risk of early re-stroke. The combination of clopidogrel and aspirin has been declared effective and safe for about 21 days, if the risk of bleeding is not high.

4. Medicines to prevent venous clots

Inpatient and immobile patients after stroke are prone to deep vein thrombosis. For prevention, anticoagulants are prescribed with a preventive dose. Low molecular weight heparin is more common in the inpatient phase, while new oral anticoagulants (DOACs) are usually used during treatment and based on the cause of stroke in some patients, as well as stroke severity and expert opinion.

Drug class	Examples	Mode of action (main mechanism)	Main clinical use
Thrombolytics (clot dissolver)	Alteplase, Tenecteplase	Activation of plasminogen and direct dissolution of the blood clot inside the cerebral artery	Acute phase of ischemic stroke (first hours, in eligible patients)
Antiplatelets	Clopidogrel, Clopidogrel	Inhibition of platelet aggregation and prevention of new clot formation	Mild acute phase, TIA and prevention Secondary
dual antiplatelet therapy (short-term)	aspirin + clopidogrel	simultaneous inhibition of different pathways of platelet activation	reducing the risk of early re-stroke in mild stroke or high-risk TIA
anticoagulants	heparin, Warfarin, DOACs	Inhibition of coagulation factors and prevention of thrombus formation	Stroke of cardiac origin (such as atrial fibrillation)
Statins	Atrovastatin, Rosuvastatin	Lowering of LDL, stabilization of atherosclerotic plaque and anti-inflammatory effect Vascular	Secondary stroke prevention
Blood pressure control drugs	ACE inhibitors, ARBs	Lowering blood pressure and chronic vascular damage	Recurrent stroke prevention (not acute treatment)
Glucose and fever control drugs	Insulin, Acetaminophen	Decreasing cerebral metabolism and preventing the exacerbation of nerve damage	Supportive care in the acute phase
Deep venous thrombosis (DVT) prevention drugs	Heparin with a preventive dose	Prevention of clots in the deep veins of the limbs	Inpatients and Immobility after stroke

Medications to prevent recurrent stroke after a stroke or TIA

After passing the acute stage, the focus of treatment is on secondary prevention. The main goal will be to reduce the risk of clot formation and control risk factors such as blood pressure, diabetes and blood lipids. The choice of medicine at this stage caring for a stroke patient at home depends on the cause of the stroke, the presence of heart diseases and the level of risk of bleeding, and is usually considered a long-term treatment.

1. Antiplatelet monotherapy

After the end of dual antiplatelet therapy, antiplatelet monotherapy continues as the main treatment. This method strikes a good balance between preventing blood clots and reducing the risk of bleeding. Aspirin, clopidogrel, or the aspirin-dipyridamole combination are common options, and the final choice is made based on the patient's tolerance and history of complications.

English text:
Tissue plasminogen activator (tPA) used as a common emergency treatment during a stroke. For this treatment, tPA is injected into a vein so it can get to the blood clot quickly. tPA is not used for everyone. People at high risk of bleeding into their brain aren't given tPA. Persian translation: Tissue plasminogen activator (tPA) is used as an emergency treatment for stroke. For this treatment, tPA is injected into a vein to quickly reach the blood clot. tPA is not for everyone. tPA is not given to people at high risk of brain bleeding.

Citation from healthline

2. Anticoagulants

In patients who have a stroke caused by atrial fibrillation or cardiac embolism, anticoagulants play a major role. These drugs significantly reduce the risk of recurrent stroke. DOACs and warfarin are selected based on the patient's condition.

3. Statins

Statins such as pravastatin and rosuvastatin are effective in the secondary prevention of stroke by reducing LDL cholesterol and stabilizing atherosclerotic plaques. Studies have shown that statin use reduces the risk of recurrent ischemic stroke. Despite concerns about the increased risk of hemorrhagic stroke, the benefits of statins outweigh their potential risks in most patients.

3. Medicines to control blood pressure and control diabetes

Accurate control of blood pressure is one of the most important factors in reducing stroke recurrence. ACEIs and ARBs are highly effective in diabetic and non-diabetic patients. If needed, diuretics or calcium channel blockers are added. Proper blood sugar control also prevents more vascular damage.

Choosing drugs based on the cause of stroke

The choice of medicine will be based on the cause of the stroke. Stroke caused by atherosclerosis, cardiac embolism or coagulation disorders each have different treatment. Also, some drugs such as opioids, anticholinergic drugs or antipsychotics increase the risk of stroke and should be used with caution in high-risk patients. Some observational studies have reported a possible connection, but a definite causal relationship has not been proven.

Conclusion

The best medicine for stroke patients does not exist, and drug treatment is determined based on the type of stroke (ischemic or hemorrhagic), the time of onset of symptoms, and the patient's condition. According to the 2026 AHA/ASA Guidelines for the Acute Management of Ischemic Stroke, alteplase or tenecteplase as intravenous thrombolytics are the most effective options for clot dissolution in eligible patients in an appropriate time frame (up to 4.5 hours or longer in selected cases with advanced imaging) and improve functional outcomes. Because of its faster and easier injection, tenectplase is considered a suitable alternative to alteplase. In secondary prevention, antiplatelet drugs such as aspirin or clopidogrel (or a short-term combination in certain cases), high-intensity statins (such as atorvastatin 80 mg) are necessary to reduce LDL-C below 70 mg/dL, and antihypertensive drugs to target <130.80 mmHg. If symptoms of stroke (eg, sudden paralysis, slurred speech, or blurred vision) occur, go to the emergency department immediately for rapid evaluation (CT/MRI) and appropriate treatment (thrombolysis, thrombectomy, or supportive management). This quick approach minimizes brain damage and increases the chance of recovery.

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