Aspirin Should Be Added to the Treatment Regimen for Patients with a History of Stroke and Elevated LDL Levels
All patients with a history of stroke and elevated LDL levels should receive aspirin (ASA) therapy at a dose of 75-325 mg daily as part of their secondary stroke prevention regimen, unless contraindicated. 1
Antiplatelet Therapy Recommendations
Aspirin Dosing and Administration
- For patients with a history of stroke not already on an antiplatelet agent, administer at least 160 mg of ASA immediately as a one-time loading dose, followed by 81-325 mg daily maintenance dose 1
- For long-term maintenance:
Special Considerations
- If the patient is already on ASA prior to the recurrent stroke, consider switching to clopidogrel 75 mg daily 1
- For patients who cannot tolerate ASA due to allergies or gastrointestinal issues, clopidogrel 75 mg daily is an appropriate alternative 1
- In patients with recent minor stroke (NIHSS ≤3) or high-risk TIA (ABCD2 score ≥4), consider dual antiplatelet therapy (ASA plus clopidogrel) for 21-90 days, then continue with single antiplatelet therapy 1
Comprehensive Management Approach
Lipid Management
- All patients with ischemic stroke and LDL >100 mg/dL should receive high-intensity statin therapy (atorvastatin 80 mg daily) 1, 3
- Target LDL-C should be <70 mg/dL for patients with stroke and atherosclerotic disease 1, 3
- If LDL-C remains >70 mg/dL despite maximum tolerated statin therapy, add ezetimibe 1, 3
Blood Pressure Management
- Target BP <130/80 mmHg for most patients with a history of stroke 1
- Use individualized antihypertensive regimens considering comorbidities and patient preferences 1
Clinical Evidence and Rationale
The recommendation to add aspirin is supported by strong evidence from multiple guidelines. The Canadian Stroke Best Practice Recommendations explicitly state that ASA reduces the risk of early recurrent ischemic stroke and provides long-term reduction in the risk of ischemic stroke, myocardial infarction, and vascular death 1. The 2021 AHA/ASA guidelines also recommend antiplatelet therapy for secondary stroke prevention 1.
Studies have demonstrated that acute-phase aspirin therapy reduces the risk of early recurrent ischemic stroke, and long-term aspirin therapy reduces the risk of ischemic stroke, myocardial infarction, and vascular death 1, 4. The CAPRIE trial showed that antiplatelet therapy is effective in reducing vascular events in patients with a history of stroke 5.
Common Pitfalls and Caveats
Bleeding risk assessment: Always evaluate bleeding risk before initiating aspirin therapy. Patients with a history of gastrointestinal bleeding, peptic ulcer disease, or intracranial hemorrhage may require alternative approaches.
Timing after thrombolysis: If the patient received tPA, delay aspirin administration until after the 24-hour post-thrombolysis scan has excluded intracranial hemorrhage 1.
Aspirin resistance: Approximately 10-20% of patients taking ASA may experience recurrent cardiovascular events due to aspirin resistance 4. Consider platelet function testing in patients with recurrent events despite compliance.
Dual antiplatelet therapy: Long-term use (>90 days) of aspirin plus clopidogrel is not recommended for secondary stroke prevention due to increased bleeding risk, unless there is another indication such as a coronary drug-eluting stent 1.
Dysphagia considerations: In patients with dysphagia, ASA may be administered via enteral tube (80 mg daily) or rectal suppository (325 mg daily) 1.
By adding aspirin to the treatment regimen of patients with a history of stroke and elevated LDL levels, you can significantly reduce their risk of recurrent stroke and other cardiovascular events, while simultaneously managing their lipid profile with appropriate statin therapy.