Aspirin in Acute Stroke
http://www.aspirin-foundation.com/edin_4.htm

Aspirin is part of the emergency treatment of acute myocardial infarction. There is now good evidence that it should be part of the routine treatment of patients with acute ischaemic stroke. This was the main theme of Peter Sandercock, Professor of Medical Neurology at the University of Edinburgh.  

The first need for a person with acute stroke is a brain scan: if it shows a haemorrhage, aspirin should not be given. Most strokes, however, are ischaemic and soon after the onset of symptoms of ischaemic stroke, the brain can appear normal on X-ray CT scanning. Magnetic resonance scanning is more sensitive than CT and can detect changes in the brain within the first hour. MR can even show the blocked artery which caused the ischaemic stroke. However, aspirin will not unblock an artery: this needs a thrombolytic drug. But, if an artery has unblocked itself, aspirin may help to keep it open and keep the arteries supplying blood to the damaged brain, minimising ischaemic damage. 

Two large trials have studied the effects of aspirin started within the first 48 hours of stroke onset. Patients in the Chinese Acute Stroke Trial and the International Stroke Trial (about 20,000 patients in each study) were seen within 48 hours and randomised to aspirin or control. All patients were started on long term aspirin at hospital discharge. In the International Stroke Trial, two thirds of patients had a CT scan before treatment started; the remainder had a CT scan soon after trial entry. In the Chinese Acute Stroke Trial 87% had CT scans before treatment.

The benefit of aspirin in both trials was a reduction in the risk of recurrent ischaemic stroke. Although there was a small increase in the risk of haemorrhagic stroke (of about 1 or 2 per 1000 patients treated with aspirin) there was clear net benefit: for every 1000 patients with acute stroke treated with aspirin 9 avoid death or non fatal stroke. Furthermore, in the longer term, aspirin reduced the number of patients who were dead or needed help in everyday activities of daily living and, in addition, increased the chances of making a complete recovery from the stroke.

Professor Sandercock concluded that aspirin is beneficial, for a wide variety of patients with acute ischaemic stroke. If CT scanning is not immediately available, treatment may be started while a scan is being arranged (of course if a subsequent scan shows that the stroke was due to haemorrhage, the aspirin should be stopped). About a third of patients with acute stroke have difficulty swallowing safely. For such patients, the aspirin may conveniently be given as a suppository.   

At a rough estimate, about five million patients each year world-wide have an acute ischaemic stroke. If just one million get to medical attention within the first 48 hours of onset and receive aspirin then 10,000 patients would avoid a poor outcome after stroke, and in addition about the same number would make a complete recovery. Aspirin should therefore become part of the routine treatment of patients with acute ischaemic stroke, not just in the developed world but also in the developing world.

The results of the survey, which didn't specifically mention bioterrorism, point to a need for a national database for physicians to look up what the most appropriate care is for certain ailments. The survey's nonprofit sponsor, the Kanter Family Foundation, is developing a national database with the Agency for Healthcare Research and Quality, which is part of the U.S. Department of Health and Human Services.

Though plans for a database were in progress well before the anthrax attacks, the results highlight a major shortcoming of the decentralized U.S. health-care system. The survey's finding that doctors might treat one common illness in a variety of ways -- when only one treatment has shown the most success -- also suggests the challenges a widespread bioterrorism attack could pose for the U.S.

In the online survey, which was conducted by research firm Harris Interactive, about 300 internal-medicine and family physicians were asked what they would do when patients showed up with certain problems such as a suspected stroke or chronic, high cholesterol. The respondents were drawn from an online panel of physicians maintained by Harris, and the margin of polling error is estimated to be plus or minus six percentage points.

In one example, despite the availability of evidence showing that the best treatment for the onset of a stroke is aspirin, only about 19% of the doctors surveyed chose aspirin as the initial treatment. {Skyaid comments - this appears to be incorrect - should NOT have aspirin after stroke onset} Instead, about half of the physicians opted for t-PA, a clot-busting drug therapy, and about 27% of the doctors recommended the drug heparin, a blood thinner. The survey's researchers said the best clinical evidence indicates that heparin actually is the second best choice and t-PA is third, because its benefits are outweighed by its potential risks.

In some cases, physicians chose treatments that actually weren't advised at all. For instance, 10% of the doctors chose not to treat high cholesterol with medication for a patient who failed to lower their cholesterol in other ways.

The researchers said many of the doctors surveyed said they wished they had more information that was easily accessible. But some doctors also have criticized national guidelines as "cookbook medicine." Some fear that if there are set-in-stone guidelines for every disease, managed-care companies could refuse to cover care that might not follow the rules but that a doctor deems necessary.

Health insurers, however, say following accepted guidelines in a majority of cases protects patients. "The shameful truth is that not all doctors adhere to evidence-based medical guidelines," said Alan Muney, the chief medical officer at Oxford Health Plans Inc., a Trumbull, Conn., regional health insurer. "Therefore, patients will undoubtedly continue to receive expensive, sometimes risky, treatment despite its proven failure."

Write to Barbara Martinez at barbara.martinez@wsj.com

A new factsheet - Aspirin and Stroke - just published by The Stroke Association, provides information on how aspirin works and how it is used in many areas of medicine, in particular, in the prevention of strokes. For those who have already had an ischaemic stroke¹ or a transient ischaemic attack², aspirin helps reduce the risk of a further stroke by as much as one third. It may also help to prevent a heart attack. This new publication explains how aspirin works to reduce the risk of blood clotting which can cause a stroke. It also clarifies who should take aspirin and when. Aspects of dosage, together with the benefits and safety issues are also discussed. "Aspirin, like any medication, has potential side effects - anyone thinking of routinely taking it to reduce the risk of a stroke should first of all talk to their GP," says Eoin Redahan of The Stroke Association. "Hopefully, this fact-sheet will help those worried about stroke and want to know more about the benefits of taking aspirin." For a free copy of the factsheet contact; The Stroke Association, Northampton Resource Centre, 61-69 Derngate, Northampton NN1 1HD or call 01604 623 934.

The American Heart Association recommends the use of aspirin in patients who have experienced a myocardial infarction (heart attack), unstable angina , ischemic stroke, or transient ischemic attacks (TIAs or "little strokes") if not contraindicated. This recommendation is based on sound clinical trial evidence showing that aspirin prevents the recurrence of clinical events such as heart attack, hospitalization for recurrent angina, second strokes, etc.

Taking aspirin after the onset of known heart or blood vessel disease is commonly referred to as "secondary prevention." Clinical trial evidence isn't available to demonstrate similar benefits in patients with other forms of diagnosed vascular disease, such as

*      peripheral vascular blockage
*      carotid artery narrowing  
*      aortic atherosclerosis  

However, the American Heart Association's secondary prevention panel believes that such benefits are likely, and that aspirin should be considered for use in all such patients. Since aspirin is not without risk in certain people, the decision to use it should be made by the patient and physician. Together they should evaluate that patient's risk and likelihood of benefit. The main factors to consider are the presence of

*      liver or kidney disease
*      peptic ulcer
*      other gastrointestinal disease or bleeding  
*      other bleeding problems  
*      allergy to aspirin  
*      use of alcohol

Using aspirin to prevent a first heart attack, stroke or other vascular event in healthy people is referred to as "primary prevention." In its 1997 scientific statement, entitled "Aspirin as a Therapeutic Agent in Cardiovascular Disease," the American Heart Association concluded that the clinical decision to use aspirin in primary prevention should be made on an individual basis by a physician. The American Heart Association cautions people not to start taking aspirin on a long-term basis without first consulting their doctors. When more data have been analyzed and published, these decisions may be made more objectively. Physicians will need to evaluate each patient individually. In particular they will have to weigh a person's risk of myocardial infarction and coronary heart disease and death against the potential for adverse reactions to prolonged aspirin therapy. Some of these possible side effects are now being explored.

Cautions

Overall, there are a number of cautions to exercise before one begins taking aspirin for life. These include risk of abnormal bleeding in the gastrointestinal tract.

AHA Recommendation

The American Heart Association makes these recommendations for using aspirin in primary prevention:

        All other major risk factors for coronary heart disease and stroke should be determined and a concerted program begun to reduce or modify those risk factors, which include smoking, high blood cholesterol, high blood pressure, physical inactivity, obesity and diabetes .

        The decision to start taking aspirin regularly should be made only after each person consults with his or her physician. Among the contraindications to regular aspirin therapy are liver or kidney disease, peptic ulcer, gastrointestinal bleeding or other bleeding problems, and allergy to aspirin. These must be ruled out by the physician to protect the individual.

        A person who chooses to start a regular aspirin regimen should be aware of its side effects . If they occur, they should be reported to his or her physician. If a person taking aspirin must undergo even a simple surgical procedure or dental extraction, the surgeon or dentist must be told of the aspirin dosage. That's because the tendency to bleed persists for up to 10 days after the drug is stopped.

What about aspirin and alcohol?

The U.S. Food and Drug Administration warns against drinking alcohol for people who regularly take aspirin. Patients who have heart disease should stop drinking and keep taking aspirin if their doctor prescribed aspirin as part of the treatment plan for their heart condition. Patients should not stop taking aspirin without talking to their doctor first. What about taking aspirin during a heart attack or stroke?  If any heart attack warning signs occur, call 9-1-1 immediately. After the call to 9-1-1, the American Heart Association recommends taking an aspirin as soon as the warning signs of a heart attack occur, unless you have an allergy to aspirin or a condition that makes using it too risky. Research shows that taking an aspirin when symptoms start significantly improves chances of survival for people having a heart attack.

Less may be more when it comes to using aspirin to prevent stroke in healthy women.  Some aspirin can reduce a woman's risk of ischemic stroke, which is caused by plaques blocking blood vessels. But researchers at Harvard Medical School found that taking 15 or more aspirin tablets a week doubles the risk of hemorrhagic stroke, a more rare but also more deadly stroke that occurs when a vessel ruptures and bleeds into the brain.  The study, which the researchers say is the largest of its kind to date of women, is published in a recent issue of Stroke: Journal of the American Heart Association.  "This is the first large-scale, detailed study of the relationship between aspirin use and the risk of principal types of stroke," says Dr. JoAnn Manson, lead author of the study and professor of medicine at Harvard Medical School and Brigham and Women's Hospital in Boston.  Earlier research has shown that aspirin taken regularly by survivors of stroke or heart attack helps prevent recurrences, but there still is debate about whether healthy people should routinely take aspirin to prevent a first heart attack or stroke, Manson says. 

She adds that one 81-milligram baby aspirin every other day may be enough to help prevent ischemic stroke. But she also found that heavy doses of 325-milligram adult aspirin, for example 15 or more tablets a week, can double the risk of hemorrhagic stroke. And older women with high blood pressure who took large doses of aspirin tripled their risk of hemorrhagic stroke.  "No one should begin taking aspirin regularly to prevent their first stroke without consulting their physician," Manson says. "Aspirin can cause gastrointestinal bleeding and it increases the risk of hemorrhagic stroke."  The researchers used data collected in the Nurses' Health Study to examine aspirin use and stroke risk in 79,319 healthy women aged 34 to 59.