Aspirin’s Benefits Were Previously Underestimated and Are Primarily Accrued in the Acute Setting
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Urgent management of transient ischemic attack (TIA) or minor stroke within 24 hours of symptom onset can reduce the 3-month risk of stroke by ≤80%.1,2 This risk had been previously estimated at 10% to 12% or more based on data from the 1990s and early 2000s,3,4 but more recent data suggest that this risk may now be <3%.1,2,5 Guidelines recommend urgent assessment and treatment, including risk factor control, carotid endarterectomy or stenting, and immediate oral anticoagulation for documented atrial fibrillation or aspirin therapy for most other cases.6–9 Because the risk of recurrent stroke is highest in the first few days,3,4 urgent TIA clinics, such as those reported in the SOS-TIA (SOS-Transient Ischemic Attack) or EXPRESS studies (Early Use of Existing Preventive Strategies for Stroke),1,2 have used dual antiplatelet therapy in the acute setting based on meta-analyses of previous trials. In SOS-TIA,1 the referring physician was instructed by telephone to immediately initiate a 300 mg loading dose of aspirin even before the initial evaluation or hospital admission and before any brain imaging. Whether this immediate empirical antiplatelet regimen partly explains the low recurrence rates observed in the SOS-TIA and EXPRESS studies is not clear because no randomized trial has yet validated this approach for TIA and minor ischemic stroke.
In a recent issue of The Lancet, Rothwell et al10 report the results of a new meta-analysis of 12 randomized controlled trials of aspirin versus control for TIA or minor stroke that was focused on the time course of benefit from aspirin therapy. While the overall benefits of aspirin for secondary stroke prevention are well-established, …