Aspirin and GI bleeding

In “Aspirin to prevent cardiovascular events,” (Medicine in Brief, Current Psychiatry, February 2010), the authors emphasize the risk of gastrointestinal (GI) bleeding. Because about 80% of strokes are ischemic but 20% represent a CNS bleed, shouldn’t the risk of hemorrhagic stroke be considered, especially in patients without known heart disease or those who have never had a heart attack before taking daily aspirin?

Bryan D. Spader, MD
Kinston, NC

The authors respond

We appreciate Dr. Spader’s question about the risk of hemorrhagic stroke in addition to GI bleeding with daily aspirin. The Women’s Health Study shows increases in hemorrhagic strokes in the aspirin group are not statistically significant (relative risk [RR] 1.24, confidence interval [CI] 0.82 to 1.87). This is confirmed by the meta-analysis that is the basis for the U.S. Preventive Services Task Force recommendations.¹ Hemorrhagic stroke was not significantly higher in women taking aspirin than controls, but was higher in men (odds ratio [OR] 1.69, [CI, 1.04 to 2.73]). However, the same study concluded, “Aspirin does not seem to affect CVD (cardiovascular disease) mortality or all-cause mortality in either men or women. Aspirin use for the primary prevention of CVD events probably provides more benefits than harms to men at increased risk for myocardial infarction and women at increased risk for ischemic stroke.”¹ Recent estimates indicate that the risk of hemorrhagic stroke is small, at about 0.2 per 1,000 patient-years of aspirin exposure. For every 1 hemorrhagic stroke over 5 years, approximately 14 myocardial infarctions are prevented in individuals with moderate cardiac risks.²

However, we found a dearth of follow-up studies showing individuals having hemorrhagic strokes when taking aspirin. One study examined 204 hemorrhagic stroke patients who were later placed on aspirin to reduce ischemic events and showed that aspirin use is not associated with intracerebral hemorrhage recurrence in survivors of either lobar hemorrhage or deep hemorrhage.³ Nevertheless, the median time to aspirin initiation is 5.4 months after index hemorrhagic stroke. Until more evidence emerges, use of aspirin for hemorrhagic stroke patients should be made on an individual basis after considering the benefits, controlling hypertension, and assessing other risk factors.

Glen L. Xiong, MD
Assistant clinical professor
University of California, Davis
Sacramento, CA

Christopher A. Kenedi, MD, MPH
Adjunct professor of psychiatry
Duke University Medical Center
Durham, NC

In “Aspirin to prevent cardiovascular events,” (Medicine in Brief, Current Psychiatry, February 2010), the authors emphasize the risk of gastrointestinal (GI) bleeding. Because about 80% of strokes are ischemic but 20% represent a CNS bleed, shouldn’t the risk of hemorrhagic stroke be considered, especially in patients without known heart disease or those who have never had a heart attack before taking daily aspirin?

Bryan D. Spader, MD
Kinston, NC

The authors respond

We appreciate Dr. Spader’s question about the risk of hemorrhagic stroke in addition to GI bleeding with daily aspirin. The Women’s Health Study shows increases in hemorrhagic strokes in the aspirin group are not statistically significant (relative risk [RR] 1.24, confidence interval [CI] 0.82 to 1.87). This is confirmed by the meta-analysis that is the basis for the U.S. Preventive Services Task Force recommendations.¹ Hemorrhagic stroke was not significantly higher in women taking aspirin than controls, but was higher in men (odds ratio [OR] 1.69, [CI, 1.04 to 2.73]). However, the same study concluded, “Aspirin does not seem to affect CVD (cardiovascular disease) mortality or all-cause mortality in either men or women. Aspirin use for the primary prevention of CVD events probably provides more benefits than harms to men at increased risk for myocardial infarction and women at increased risk for ischemic stroke.”¹ Recent estimates indicate that the risk of hemorrhagic stroke is small, at about 0.2 per 1,000 patient-years of aspirin exposure. For every 1 hemorrhagic stroke over 5 years, approximately 14 myocardial infarctions are prevented in individuals with moderate cardiac risks.²

However, we found a dearth of follow-up studies showing individuals having hemorrhagic strokes when taking aspirin. One study examined 204 hemorrhagic stroke patients who were later placed on aspirin to reduce ischemic events and showed that aspirin use is not associated with intracerebral hemorrhage recurrence in survivors of either lobar hemorrhage or deep hemorrhage.³ Nevertheless, the median time to aspirin initiation is 5.4 months after index hemorrhagic stroke. Until more evidence emerges, use of aspirin for hemorrhagic stroke patients should be made on an individual basis after considering the benefits, controlling hypertension, and assessing other risk factors.

Glen L. Xiong, MD
Assistant clinical professor
University of California, Davis
Sacramento, CA

Christopher A. Kenedi, MD, MPH
Adjunct professor of psychiatry
Duke University Medical Center
Durham, NC

In “Aspirin to prevent cardiovascular events,” (Medicine in Brief, Current Psychiatry, February 2010), the authors emphasize the risk of gastrointestinal (GI) bleeding. Because about 80% of strokes are ischemic but 20% represent a CNS bleed, shouldn’t the risk of hemorrhagic stroke be considered, especially in patients without known heart disease or those who have never had a heart attack before taking daily aspirin?

Bryan D. Spader, MD
Kinston, NC

The authors respond

We appreciate Dr. Spader’s question about the risk of hemorrhagic stroke in addition to GI bleeding with daily aspirin. The Women’s Health Study shows increases in hemorrhagic strokes in the aspirin group are not statistically significant (relative risk [RR] 1.24, confidence interval [CI] 0.82 to 1.87). This is confirmed by the meta-analysis that is the basis for the U.S. Preventive Services Task Force recommendations.¹ Hemorrhagic stroke was not significantly higher in women taking aspirin than controls, but was higher in men (odds ratio [OR] 1.69, [CI, 1.04 to 2.73]). However, the same study concluded, “Aspirin does not seem to affect CVD (cardiovascular disease) mortality or all-cause mortality in either men or women. Aspirin use for the primary prevention of CVD events probably provides more benefits than harms to men at increased risk for myocardial infarction and women at increased risk for ischemic stroke.”¹ Recent estimates indicate that the risk of hemorrhagic stroke is small, at about 0.2 per 1,000 patient-years of aspirin exposure. For every 1 hemorrhagic stroke over 5 years, approximately 14 myocardial infarctions are prevented in individuals with moderate cardiac risks.²

However, we found a dearth of follow-up studies showing individuals having hemorrhagic strokes when taking aspirin. One study examined 204 hemorrhagic stroke patients who were later placed on aspirin to reduce ischemic events and showed that aspirin use is not associated with intracerebral hemorrhage recurrence in survivors of either lobar hemorrhage or deep hemorrhage.³ Nevertheless, the median time to aspirin initiation is 5.4 months after index hemorrhagic stroke. Until more evidence emerges, use of aspirin for hemorrhagic stroke patients should be made on an individual basis after considering the benefits, controlling hypertension, and assessing other risk factors.

Glen L. Xiong, MD
Assistant clinical professor
University of California, Davis
Sacramento, CA

Christopher A. Kenedi, MD, MPH
Adjunct professor of psychiatry
Duke University Medical Center
Durham, NC