According to the American Heart Association, when should low‑dose aspirin be restarted after an intracerebral hemorrhage?

When to Restart Aspirin After Intracerebral Hemorrhage

According to the American Heart Association 2023 guidelines, resuming antiplatelet therapy beyond 24 hours after ICH symptom onset may be reasonable in patients with spontaneous ICH who have an indication for antiplatelet therapy, though the optimal timing remains uncertain and evidence is graded as level B. 1

Guideline Recommendations

The AHA-affiliated Stroke journal published comprehensive guidance in 2023 indicating that:

• Antiplatelet therapy resumption may be reasonable for prevention of thromboembolic events in patients with spontaneous ICH who have a clear indication for antiplatelet therapy 1
• Timing beyond 24 hours after ICH symptom onset is when restarting antiplatelet treatment may be considered 1
• The UK and Ireland guidelines specifically state patients may be considered for restarting antiplatelet treatment beyond 24 hours after ICH symptom onset 1

Evidence Supporting This Approach

The RESTART trial (2019) provided the foundational evidence that changed clinical practice:

• Counterintuitively, antiplatelet agents did not increase recurrent ICH risk compared to avoidance over 2 years (4% vs 9%; adjusted HR 0.51,95% CI 0.25-1.03) 1
• The trial included 537 ICH survivors associated with antithrombotic drug use 1
• Participants were recruited at a median of 76 days after ICH onset, though no difference in effects was found for earlier versus later timing 1
• Antiplatelet agents showed consistent effects on major adverse cardiovascular events (MACE) prevention similar to their use in patients without ICH 1

Clinical Decision Framework

For patients WITH prior indication for antiplatelet therapy (history of MACE, atrial fibrillation, or prior antithrombotic use):

• Consider restarting antiplatelet monotherapy after 24 hours from ICH symptom onset 1
• Chinese guidelines suggest aspirin monotherapy can be restored within a few days from ICH onset 1
• Balance the patient's baseline risks of recurrent ICH versus occlusive vascular events 1

For patients WITHOUT prior antithrombotic indication:

• The evidence is less clear, as RESTART focused on high-risk patients with prior MACE or antithrombotic use 1
• Future trials (ASPIRING) are recruiting broader ICH survivors to address this gap 1

Important Caveats and Pitfalls

Age considerations: Aspirin use in individuals older than 65 years may be correlated with increased ICH risk, requiring more careful risk-benefit assessment 2

Concurrent anticoagulation: Aspirin use with concurrent anticoagulant treatment may increase ICH risk and requires heightened caution 2

Mortality benefit: Observational data suggests low-dose aspirin after HS is associated with 32% improved survival (HR 0.68,95% CI 0.53-0.88), particularly in patients who were on antithrombotic therapy before the ICH episode 3

Discontinuation risks: Stopping aspirin after initiating it post-ICH was associated with decreased survival (HR 1.54,95% CI 1.21-1.97) in observational studies 3

Strength of Evidence Limitations

The AHA guidelines grade this evidence as Level B because 1:

• RESTART was a relatively small pilot phase RCT with imprecise effect estimates
• Uncertainty remains about net MACE reduction and effects in various subgroups
• The optimal timing strategy is not definitively established
• Most participants were from the UK, limiting generalizability to other populations

The definitive answer awaits the ASPIRING trial, which aims to recruit 4,148 ICH survivors to establish effects more conclusively 1