Can aspirin (ASA) be stopped in a patient with an intracranial bleed and a cardiac stent?

Management of Aspirin in Patients with Intracranial Bleeding and Cardiac Stent

In patients with intracranial bleeding and a cardiac stent, aspirin should be temporarily discontinued if the hemorrhagic risk is major, but should be resumed as soon as possible after bleeding is controlled. 1

Risk Assessment Framework

The decision to stop aspirin therapy requires careful consideration of two competing risks:

• Hemorrhagic risk: Continued bleeding or rebleeding with antiplatelet therapy
• Thrombotic risk: Stent thrombosis leading to myocardial infarction or death

Factors influencing decision:

Stent-related factors:

• Type of stent 1:

  • Drug-eluting stents (DES) have higher thrombotic risk than bare-metal stents
  • DES require longer duration of dual antiplatelet therapy (DAPT)

• Time since stent placement 1:

  • Major risk: <6 months to 1 year after placement
  • Moderate risk: >6 months to 1 year after placement

Bleeding-related factors:

• Severity of intracranial hemorrhage 1
• Location of bleeding 1
• Active vs. stabilized bleeding 1

Management Algorithm

1. For major intracranial bleeding with high stent thrombosis risk:

• Temporarily discontinue aspirin 1
• Consider temporary substitution with:
  • Low-molecular-weight heparin (85-100 IU aXa per kg for 12h) 1
  • Note: This carries substantial perioperative bleeding risk 1
• Resume aspirin as soon as possible after bleeding is controlled 1
• Consider multidisciplinary consultation (cardiologist, neurologist, and hematologist) 1

2. For intermediate bleeding risk with high stent thrombosis risk:

• If stent is <6 months to 1 year old (high risk of thrombosis):
  • Maintain aspirin if possible 1
  • Stop clopidogrel for 5 days if on dual therapy 1

3. For stabilized intracranial bleeding:

• Resume aspirin as soon as bleeding is controlled 1
• Consider resuming with a lower maintenance dose (75-100 mg daily) 1
• For drug-eluting stents, aspirin should be maintained for at least 1 year 1

Special Considerations

Drug-Eluting Stents:

• Higher risk of thrombosis if antiplatelet therapy is discontinued 1
• Maintaining aspirin during high bleeding risk periods is the preferred option 1
• If aspirin must be discontinued, resume as soon as possible 1

Dual Antiplatelet Therapy:

• If patient is on DAPT (aspirin plus clopidogrel), consider stopping only clopidogrel while maintaining aspirin if possible 1
• When resuming clopidogrel, consider loading dose of at least 300 mg 1

Common Pitfalls and Caveats

• Avoid prolonged discontinuation of all antiplatelet therapy in patients with recent stent placement (<1 year) due to high risk of stent thrombosis 1
• Balance bleeding vs. thrombotic risk - both conditions carry significant mortality risk 1
• Consider stent age - newer stents (especially DES <6 months old) have higher thrombotic risk when antiplatelet therapy is discontinued 1
• Involve multidisciplinary team in decision-making process 1
• The risk of major hemorrhage is significantly increased with dual antiplatelet therapy compared to single antiplatelet therapy 1

Follow-up Recommendations

• Close monitoring for signs of stent thrombosis or recurrent bleeding 1
• Resume aspirin at the earliest safe opportunity 1
• Consider lower maintenance dose of aspirin (75-100 mg) when resuming therapy 1
• For patients with drug-eluting stents, aspirin therapy should be maintained for at least 1 year after placement 1