From the Guidelines
Patients with lacunar infarcts should be treated with Acetylsalicylic Acid (ASA) as it has been shown to be beneficial in preventing recurrent strokes. The use of antithrombotic agents, including ASA, has been studied in patients with intracranial atherosclerosis (ICAS) and has been found to be effective in reducing the risk of stroke and vascular events 1. Although the specific study does not directly address lacunar infarcts, the underlying mechanism of ASA in preventing platelet aggregation and reducing thromboxane A2 production is applicable to all types of ischemic strokes, including lacunar infarcts.
Some key points to consider when prescribing ASA for patients with lacunar infarcts include:
- The recommended dose is typically 81-325 mg daily, with many clinicians preferring 81 mg daily for long-term secondary prevention
- Treatment should be initiated as soon as possible after diagnosis and continued indefinitely unless contraindicated
- For patients who have just experienced a lacunar infarct, a loading dose of 160-325 mg may be given initially
- ASA should be taken with food to minimize gastrointestinal side effects, and those with a history of peptic ulcer disease may benefit from concurrent proton pump inhibitor therapy
It is essential to weigh the benefits of ASA therapy against the potential risks, particularly bleeding complications, and to closely monitor patients for any adverse effects. However, the benefit of ASA in preventing recurrent strokes in patients with lacunar infarcts generally outweighs the risk of bleeding complications.
The use of ASA in patients with lacunar infarcts is supported by the general principles of stroke prevention, which emphasize the importance of antiplatelet therapy in reducing the risk of recurrent strokes 1. While the specific study cited does not provide direct evidence for the use of ASA in lacunar infarcts, the underlying mechanism of action and the general principles of stroke prevention support its use in this patient population.
From the Research
Benefits of Acetylsalicylic Acid (ASA) in Patients with Lacunar Infarcts
- The effectiveness of ASA in patients with lacunar infarcts has been studied in several trials 2, 3, 4, 5.
- A study published in 2019 found that ASA significantly reduced the risk of recurrent stroke in patients with lacunar stroke (HR = 0.67,95% CI 0.45-0.99) 4.
- Another study published in 2015 found that any single antiplatelet agent, including ASA, was associated with a significant reduction in recurrence of any stroke (RR 0.77,0.62-0.97) and ischemic stroke (RR 0.48,0.30-0.78) compared to placebo 3.
- However, the addition of clopidogrel to ASA did not significantly reduce the risk of recurrent stroke in patients with lacunar infarcts, and increased the risk of bleeding and death 2, 5.
Comparison of ASA with Other Antiplatelet Agents
- A study published in 2015 found that there was no consistent reduction in stroke recurrence when other antiplatelet agents (ticlodipine, cilostazol, and dipyridamole) were compared to ASA (RR 0.91,0.75-1.10) 3.
- Dual antiplatelet therapy did not confer clear benefit over monotherapy in reducing the risk of recurrent stroke (RR 0.83,0.68-1.00) or ischemic stroke (RR 0.80,0.62-1.02) 3.
Other Factors Influencing the Effectiveness of ASA
- A study published in 2018 found that antihypertensive therapy, including calcium channel blockers, angiotensin-converting enzyme inhibitors, and beta-blockers, was beneficial in reducing neurological progression and improving clinical outcomes in patients with lacunar infarcts 6.
- However, this study did not specifically examine the effect of ASA on lacunar infarcts.