What are the management options for a diabetic patient with a history of Cerebrovascular Accident (CVA) currently on Aspirin (acetylsalicylic acid)?

From the Guidelines

For a diabetic patient with a history of cerebrovascular accident (CVA) who is currently only on aspirin, I strongly recommend continuing aspirin therapy (75–162 mg/day) as a secondary prevention strategy, as it has been shown to have a modest effect on ischemic vascular events, with the absolute decrease in events depending on the underlying atherosclerotic cardiovascular disease (ASCVD) risk 1.

Secondary Prevention Strategy

The patient's current aspirin therapy should be continued, as it is a recommended secondary prevention strategy in those with diabetes and a history of atherosclerotic cardiovascular disease, including CVA 1. The dose of aspirin should be between 75–162 mg/day, as this has been shown to be effective in reducing the risk of ischemic vascular events.

Comprehensive Risk Factor Management

In addition to aspirin therapy, comprehensive stroke prevention should include:

• Aggressive diabetes management targeting HbA1c <7%
• Blood pressure control aiming for <130/80 mmHg with an ACE inhibitor or ARB
• High-intensity statin therapy (such as atorvastatin 40-80mg or rosuvastatin 20-40mg daily)
• Lifestyle modifications including Mediterranean diet, regular exercise, smoking cessation, and limited alcohol intake This approach addresses multiple risk factors simultaneously and targets the pathophysiological mechanisms that contribute to recurrent stroke in diabetic patients.

Dual Antiplatelet Therapy

While dual antiplatelet therapy (with low-dose aspirin and a P2Y12 inhibitor) may be considered for a year after an acute coronary syndrome, it is not necessarily recommended for long-term management of CVA in diabetic patients 1. However, the decision to use dual antiplatelet therapy should be individualized based on the patient's specific risk factors and bleeding risk.

Bleeding Risk

The main adverse effect of aspirin therapy is an increased risk of gastrointestinal bleeding, with an excess risk of up to 5 per 1,000 per year in real-world settings 1. Therefore, the patient's bleeding risk should be carefully assessed and monitored, and the benefits of aspirin therapy should be weighed against the potential risks.

From the FDA Drug Label

1. 5 Increased Risk of Hemorrhagic Stroke in Patients on Atorvastatin Calcium Tablets 80 mg with Recent Hemorrhagic Stroke

In a post-hoc analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial where 2,365 adult patients, without CHD who had a stroke or TIA within the preceding 6 months, were treated with atorvastatin calcium 80 mg, a higher incidence of hemorrhagic stroke was seen in the atorvastatin calcium 80 mg group compared to placebo (55,2.3% atorvastatin calcium vs. 33,1.4% placebo; HR: 1.68,95% CI: 1.09,2.59; p=0. 0168).

The patient in question is a diabetic patient with a history of CVA (cerebrovascular accident) and is currently on aspirin.

• Key consideration: The patient has a history of CVA, which increases the risk of hemorrhagic stroke.
• Atorvastatin dosage: The SPARCL trial used atorvastatin calcium 80 mg, which is associated with a higher incidence of hemorrhagic stroke in patients with recent hemorrhagic stroke.
• Clinical decision: Given the patient's history of CVA and the increased risk of hemorrhagic stroke associated with atorvastatin calcium 80 mg, it is recommended to exercise caution when considering atorvastatin therapy in this patient. The FDA drug label does not provide direct guidance on the use of atorvastatin in diabetic patients with a history of CVA who are on aspirin. However, based on the available information, it is essential to weigh the potential benefits of atorvastatin therapy against the increased risk of hemorrhagic stroke in this patient population 2.

From the Research

Aspirin Therapy in Diabetic Patients with History of CVA

• Aspirin is commonly used for primary and secondary prevention of cardiovascular events in patients with diabetes, including those with a history of cerebrovascular accident (CVA) 3.
• However, the efficacy of aspirin in preventing cardiovascular events in diabetic patients is modest, and its use is associated with an increased risk of gastrointestinal bleeding 4, 5.
• The limited efficacy of aspirin in diabetic patients may be due to the rapid turnover of platelets and the short inhibitory window provided by once-daily aspirin, which may not provide 24-hour protection against cardiovascular events 3, 6.

Alternative Aspirin Regimens

• Alternative aspirin regimens, such as higher daily doses or twice-daily dosing, have been proposed to overcome the limited efficacy of conventional aspirin in diabetic patients 3, 6.
• However, these regimens may be associated with increased bleeding risks and require careful consideration of the benefits and risks 6, 5.
• Newer formulations of aspirin, such as extended-release formulations, may also be effective in providing longer-lasting protection against cardiovascular events 3.

Patient-Specific Factors

• The decision to use aspirin in diabetic patients with a history of CVA should be individualized, taking into account the patient's baseline risk of cardiovascular events and bleeding risk 4, 5.
• Patient-provider discussions are recommended to weigh the benefits and risks of aspirin therapy and to consider alternative treatments, such as statins or other antiplatelet agents 4, 7.
• Novel markers, such as coronary artery calcium scores and high-sensitivity C-reactive protein, may help refine cardiovascular risk prediction and guide the use of aspirin therapy in diabetic patients 4.