Antiplatelet Therapy After Hemorrhagic Stroke: Aspirin vs. Clopidogrel
In patients with a history of hemorrhagic stroke, antiplatelet therapy should generally be avoided as the risk of recurrent bleeding typically outweighs the benefit of stroke prevention. 1
Understanding the Risk-Benefit Balance
Hemorrhagic stroke fundamentally differs from ischemic stroke in terms of antiplatelet management. The American College of Chest Physicians (ACCP) provides clear guidance on this matter:
- For patients with a history of symptomatic primary intracerebral hemorrhage (ICH), antiplatelet therapy for ischemic stroke prevention is generally not recommended (Grade 2C) 1
- The risk of recurrent hemorrhagic stroke typically outweighs the potential benefits of antithrombotic therapy
When Antiplatelet Therapy Might Be Considered
In rare circumstances where antiplatelet therapy must be considered after hemorrhagic stroke:
- Limited to patients at relatively low risk of recurrent ICH (e.g., those with deep hemorrhages)
- Reserved for those at high risk (>7% per year) of thromboembolic events 1
- The decision should be made after sufficient time has passed since the hemorrhagic event
Choosing Between Antiplatelet Agents
If antiplatelet therapy is deemed necessary despite the history of hemorrhagic stroke:
Clopidogrel Considerations:
- In the CAPRIE trial, clopidogrel showed a slight superiority over aspirin in reducing serious vascular events (5.32% vs. 5.83% per year) 1, 2
- Clopidogrel was associated with a lower risk of gastrointestinal hemorrhage compared to aspirin (2.0% vs. 2.7%) 2
- The incidence of intracranial hemorrhage was slightly lower with clopidogrel (0.4%) compared to aspirin (0.5%) 2
Aspirin Considerations:
- Long-established efficacy in secondary stroke prevention
- May have additional benefits beyond stroke prevention, including potential reduction in cancer-related mortality with long-term use 1
- Generally less expensive and more accessible than clopidogrel
Monitoring and Safety Considerations
If antiplatelet therapy is initiated:
- Regular neurological assessments to monitor for signs of recurrent bleeding
- Brain imaging follow-up to assess for microbleeds or other signs of hemorrhagic risk
- Blood pressure control is crucial as hypertension significantly increases the risk of recurrent hemorrhage
- Patient education regarding warning signs of bleeding that require immediate medical attention
Conclusion
The primary recommendation remains avoidance of antiplatelet therapy after hemorrhagic stroke unless exceptional circumstances exist. If therapy is deemed necessary, clopidogrel may offer a marginally better safety profile than aspirin with respect to bleeding risk, though the difference is small. The decision should be made with extreme caution, weighing individual patient factors including the location and cause of the original hemorrhage, time since the event, and competing thromboembolic risks.