Q: Stroke prevention

[IM05]

Could somebody clarify this for me please ?

For stroke prevention which is the currently recommended dose of asprin - 80mg/ 325 mg or more a day ?

Do you recommend warfarin in anyone who had a small stroke or TIA but no AF ?
Thanks.

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[neurologist]

Could somebody clarify this for me please ?

For stroke prevention which is the currently recommended dose of asprin - 80mg/ 325 mg or more a day ?

Do you recommend warfarin in anyone who had a small stroke or TIA but no AF ?
Thanks.

The aspirin question is a vast quagmire. There have been many studies on this issue (and countless more editorializing, pro and con) regarding high/low dose ASA. Some studies have gone as low as 30 mg and demonstrated efficacy. Others argue that "if some is good, then more is better." There is also felt to be a category of "aspirin nonresponders" who many need higher doses or something other than ASA (Plavix, Aggrenox, etc). In most patients the bottom line seems to be that the difference between 81 and 325 mg is negligible. Always beware of GI bleeds. I myself usually start people on 325 because its cheaper than baby ASA and most people already have it in their house. I am not a "more is better" kind of guy, so I never go higher than 325 and if the person continues to have events I will switch them to a different antiplatelet med.

Warfarin is clearly indicated in the following situations: Stroke/tia with Afib; PFO with atrial septal aneurysm; severely lowered cardiac ejection fraction (<25%); mechanical heart valves.

It is almost always used in hypercoagulable conditions (anticardiolipin antibodies, protein C&S deficiency, Factor V mutation, etc) but it is somewhat arguable if it is really necessary in those conditions (vs using ASA). It is also often used for people with intracranial stenosis, but probably has no real efficacy in that situation.

It should NOT be used in small vessel (lacunar) disease or in stroke of unclear etiololgy.

Hope that helps.

 

[IM05]

Neurologist, Thanks for your input. My literature search confirms your views, I am trying to get the large clinical study that compared incidence of gastric adverse event with different dosage of Asprin, the name just got out of my mind, my attending told me ' HOT/HOST' or something like that.

There is one report that suggests higher doses may be helpful ( cf: IHD prevention) since with stroke the blood vessels are blocked at a distance compared to coronary vessels where the small vessel itself is blocked at the site that has the plaque.

Also there is one report from Mount Sinai, NY where they recommend warfarin to hypertensives ( > 160 systolic) even if there is no AF, valve problems etc.

Finally, Dipyridamole is recommended for prevention of stroke with associated co-morbidities such as type II DM etc in preference to Asprin, because of it's vascular tone effects eventhough in clinical practice how often people consider Dipyridamole is a question, when I spoke to an Australian physician she said over there Dipyridamole is very very commonly prescribed in stroke prevention.