Aspirin Therapy Duration After Cerebral Infarction
Yes, aspirin therapy should be continued indefinitely (lifelong) in patients with a history of cerebral infarction, including those with stroke in the past 6 months, at a dose of 75-100 mg daily. 1
Evidence for Lifelong Aspirin Therapy
Long-term aspirin therapy confers conclusive net benefit on the risk of subsequent myocardial infarction, stroke, or vascular death among patients with a history of transient ischemic attack (TIA) or minor stroke. 1 The proportional reduction in vascular events with long-term aspirin therapy in patients with prior stroke or TIA ranges from 20% to 25%, translating into avoidance of a major vascular event in 36 of 1,000 patients treated with aspirin for 30 months. 1
Optimal Dosing Strategy
- The optimal dose of aspirin for prevention of myocardial infarction, stroke, or vascular death lies within the narrow range of 75 to 160 mg daily. 1
- For patients with various manifestations of ischemic neurologic disease, there is no convincing evidence that the dose requirement for the antithrombotic effect of aspirin varies in different clinical settings. 1
- Clopidogrel 75 mg daily is recommended as a safe and effective alternative to aspirin monotherapy if aspirin is not tolerated. 1
Acute Phase Considerations (First 6 Months)
For your patient who had a stroke within the past 6 months, the treatment approach depends on whether they underwent revascularization:
Without Revascularization
- Aspirin 75-100 mg daily should be continued lifelong as monotherapy after the acute phase. 1
- The acute phase typically involves aspirin 160-325 mg within 24-48 hours of stroke onset, then transition to maintenance dosing. 2, 3
With Percutaneous Coronary Intervention (if applicable)
- Dual antiplatelet therapy (DAPT) consisting of aspirin 75-100 mg and clopidogrel 75 mg daily for up to 6 months is recommended after PCI-stenting. 1
- After completing the DAPT period, transition to lifelong aspirin monotherapy. 1
Risk-Benefit Profile
The benefits of long-term aspirin substantially outweigh the hemorrhagic risks:
- Aspirin increases the risk of intracranial hemorrhage by approximately 1 additional event per 1,000 patients per year in high-risk cardiovascular populations. 4
- This small hemorrhagic risk (absolute excess risk less than 0.1% annually) is far outweighed by the prevention of recurrent ischemic events. 4, 5
- In secondary prevention of cardiovascular and cerebrovascular events, the evidence supports that the benefits of aspirin treatment significantly outweigh the risk of major hemorrhage. 5
Critical Pitfalls to Avoid
- Never discontinue aspirin in stroke patients without a compelling contraindication (such as major bleeding or documented aspirin allergy), as this eliminates proven secondary prevention benefits. 1
- Do not use doses lower than 75 mg daily, as efficacy has not been established below this threshold for stroke prevention. 1
- Consider adding a proton pump inhibitor in patients at increased risk of gastrointestinal bleeding for the duration of antiplatelet therapy. 1
- Monitor for bleeding complications, but recognize that the absolute risk remains low and should not routinely prompt discontinuation. 4, 5