From the Guidelines
Continuing aspirin therapy is recommended in this case, as the benefits of antiplatelet therapy in reducing the risk of recurrent stroke or cardiovascular events likely outweigh the bleeding risk associated with low-dose aspirin. A 55-year-old patient with a history of TIA in 2014, PFO closure in 2019, and controlled hypertension and hyperlipidemia should generally continue taking low-dose aspirin (81mg daily) 1. While PFO closure reduces stroke risk significantly, the presence of multiple vascular risk factors (age, history of TIA, hypertension, hyperlipidemia) suggests ongoing benefit from antiplatelet therapy.
Some key points to consider in this case include:
- The patient's history of TIA and PFO closure, which suggests a higher risk of recurrent stroke or cardiovascular events
- The presence of controlled hypertension and hyperlipidemia, which are also risk factors for cardiovascular disease
- The recommendation for long-term antiplatelet therapy in patients with non-cardioembolic ischemic stroke or TIA who do not require anticoagulation, as stated in the 2023 systematic review and synthesis of global stroke guidelines 1
- The potential benefits and risks of continuing aspirin therapy, including the reduction in risk of recurrent stroke or cardiovascular events and the potential for bleeding complications
It is essential to personalize this recommendation based on the patient's complete medical history, bleeding risk, and other medications. A discussion with the patient's neurologist or cardiologist would be appropriate to evaluate the specific risk-benefit profile in this case. Some physicians might consider discontinuing aspirin 3-5 years after PFO closure if there are no other significant risk factors, but given this patient's vascular risk profile, continued aspirin therapy is likely beneficial for secondary prevention. The 2024 ESC guidelines for the management of chronic coronary syndromes also support the use of aspirin in patients with a history of cardiovascular disease, including those with a history of TIA or stroke 1.
From the Research
Patient's Current Situation
The patient had a transient ischemic attack (TIA) in 2014 and underwent a patent foramen ovale (PFO) closure in 2019. The patient is currently on baby aspirin and has controlled hyperlipidemia (HLD) and hypertension (HTN) as other risk factors.
Aspirin Therapy
- The patient has been on aspirin therapy since the TIA in 2014, and the question is whether to stop aspirin therapy 2, 3, 4, 5.
- Studies have shown that dual antiplatelet therapy (DAPT) with clopidogrel and aspirin can reduce the risk of recurrent stroke, but it also increases the risk of bleeding events 2, 3, 4, 5.
- However, the patient is currently on monotherapy with aspirin, and the decision to stop aspirin therapy should be based on the individual patient's risk-benefit profile.
Risk-Benefit Profile
- The patient has controlled HLD and HTN, which reduces the risk of recurrent stroke 2, 3, 4, 5.
- The patient has undergone PFO closure, which may also reduce the risk of recurrent stroke 2, 3, 4, 5.
- However, the patient is still on aspirin therapy, which suggests that the patient is still at risk for recurrent stroke.
Decision to Stop Aspirin Therapy
- There is no clear evidence to suggest that the patient should stop aspirin therapy, as the patient is still at risk for recurrent stroke 2, 3, 4, 5.
- The decision to stop aspirin therapy should be based on the individual patient's risk-benefit profile and should be made in consultation with a healthcare professional.
Gastrointestinal Protection
- The patient may benefit from gastrointestinal protection with a proton pump inhibitor (PPI) while on aspirin therapy, as PPIs can reduce the risk of gastrointestinal bleeding 6.
- However, the decision to use a PPI should be based on the individual patient's risk-benefit profile and should be made in consultation with a healthcare professional.