From the Guidelines
Aspirin is not routinely indicated for patients with microangiopathic changes on brain MRI alone, and its use should be based on the patient's overall cardiovascular risk profile. These changes, also known as small vessel disease or white matter hyperintensities, typically represent chronic ischemic damage to small blood vessels and are common findings, especially in older adults and those with vascular risk factors. According to the 2024 ESC guidelines for the management of chronic coronary syndromes 1, low-dose aspirin (75–100 mg once daily) is recommended for patients with chronic coronary syndromes, with or without prior MI, as it significantly reduces the combined risk of non-fatal MI, non-fatal ischemic stroke, or death from vascular causes. However, this recommendation is not specific to patients with microangiopathic changes on brain MRI.
Key considerations in deciding whether to prescribe aspirin include:
- The patient's overall cardiovascular risk profile
- The presence of additional risk factors such as hypertension, diabetes, hyperlipidemia, or a history of stroke or transient ischemic attack
- The potential benefits of aspirin in reducing ischemic events, as evidenced by a reduction of about a fifth in total stroke and in coronary events 1
- The bleeding risks associated with aspirin, including major gastrointestinal and extracranial bleeds 1
Management of patients with microangiopathic changes on brain MRI should focus on controlling underlying vascular risk factors through:
- Blood pressure management
- Lipid control
- Diabetes management if applicable
- Smoking cessation
- Lifestyle modifications including regular exercise and a heart-healthy diet Any decision regarding aspirin therapy should be individualized based on the patient's complete clinical picture and risk-benefit assessment, taking into account the latest guidelines and evidence, such as the 2024 ESC guidelines 1.
From the Research
Aspirin Indication in Patients with Microangiopathic Changes in Brain MRI
- There are no direct research papers that address the use of aspirin in patients with microangiopathic changes in brain MRI 2, 3, 4, 5, 6.
- However, studies have investigated the efficacy and safety of aspirin in patients with ischemic stroke or transient ischemic attack, which may be relevant to microangiopathic changes in the brain 2, 3, 4.
- A systematic review and meta-analysis found that adding or switching to another antiplatelet agent, such as clopidogrel, was associated with reduced risks of major adverse cardiovascular events and recurrent stroke compared to aspirin monotherapy 2.
- Another study found that clopidogrel plus aspirin was more effective than aspirin alone in reducing the risk of recurrent stroke, but increased the risk of major bleeding events 3.
- A study on thrombotic microangiopathy (TMA) discussed the importance of rapid assessment, diagnosis, and treatment, but did not specifically address the use of aspirin in patients with microangiopathic changes in brain MRI 5.
- A review of the contemporary clinical use of aspirin discussed its mechanisms of action, current concepts, and unresolved questions, but did not address its use in patients with microangiopathic changes in brain MRI 6.