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Aspirin in ischemic cerebrovascular disease. How strong is the case for a different dosing regimen?
1Department of Pharmacology, University of Chieti, "G. D'Annunzio" School of Medicine, Italy.
Insights
For stroke prevention, higher aspirin doses are not proven more effective than lower doses. Current evidence supports using the lowest effective aspirin dose, 75 mg daily, for cerebrovascular disease patients.
Area of Science:
- Cardiovascular Medicine
- Neurology
- Pharmacology
Background:
- Established consensus recommends 75-160 mg daily aspirin for coronary heart disease prevention.
- Significant uncertainty exists regarding optimal aspirin dosage for cerebrovascular disease, with recommendations varying widely (30-1300 mg).
Purpose of the Study:
- To review and dispute biological hypotheses supporting higher aspirin doses for stroke prevention.
- To assess the practical implications of using higher aspirin doses in cerebrovascular disease patients.
Main Methods:
- Critical review of indirect comparisons, mini-meta-analyses, and subgroup analyses.
- Theoretical calculations of absolute benefits and risks associated with higher aspirin doses.
Main Results:
- Claims of higher aspirin dose efficacy in stroke prevention lack definitive evidence from direct, adequately sized randomized trials.
- Biological hypotheses for increased efficacy of higher doses are disputed.
Conclusions:
- Until further trial data is available, clinical practice should favor the lowest effective aspirin dose for stroke and death prevention in ischemic cerebrovascular disease.
- The recommended lowest effective dose is 75 mg daily.
Background:
A vast consensus exists in defining a narrow range of recommended daily doses of aspirin, ie, 75 to 160 mg, for the prevention of myocardial infarction, stroke, and vascular death in patients with different manifestations of coronary hearth disease. In contrast, for patients with cerebrovascular disease, a much larger degree of uncertainty still exists, with recommendations ranging from 30 to 1300 mg daily.
Summary Of Comment:
The contention that higher doses of aspirin (650 to 1300 mg) are more effective than lower doses in stroke prevention is based on indirect and selective comparisons of different trial data, mini-meta-analyses, or subgroup analyses of individual trials. In the absence of definitive evidence from direct randomized comparisons of low-dose versus high-dose aspirin in trials of adequate size to detect a moderate difference between the two, the biological hypotheses that underpin the suggestion of greater efficacy of higher aspirin doses in cerebrovascular disease patients are reviewed and disputed. Practical implications of the use of higher doses of aspirin are also assessed on the basis of theoretical calculations of absolute benefits and risks.
Conclusions:
Until additional information from ongoing trials is available, good clinical practice should dictate the use of the lowest dose of aspirin shown effective in the prevention of stroke and death in patients with ischemic cerebrovascular disease, ie, 75 mg daily.