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August 25, 1999

Aspirin and Risk of Hemorrhagic Stroke—Reply

Author Affiliations

Margaret A.WinkerMD, Deputy EditorIndividualAuthorPhil B.FontanarosaMD, Interim CoeditorIndividualAuthor

JAMA. 1999;282(8):731-733. doi:10-1001/pubs.JAMA-ISSN-0098-7484-282-8-jbk0825

In Reply: We appreciate Dr Colwell's comments on our work. We agree with Dr Boissel's1 editorial, that each individual patient should be evaluated regarding his or her risk and potential benefit from long-term aspirin therapy.Our meta-analysis has demonstrated that aspirin therapy reduces risk of myocardial infarction and ischemic stroke, but increases risk of hemorrhagic stroke. In patients with prior cardiovascular disease, including myocardial infarction, unstable angina, chronic stable angina, ischemic stroke, and transient ischemic attacks, the benefits of aspirin use outweigh the potential for adverse effects, and aspirin therapy should be recommended for all such patients.2 However, in patients without prior cardiovascular disease, the decision to start aspirin therapy should be individualized based on the risk-benefit ratio. Patients with diabetes are at increased risk of cardiovascular disease, mainly myocardial infarction. Therefore, the ADA has wisely recommended aspirin therapy as a primary prevention strategy in diabetic patients with additional risk factors for cardiovascular disease.3 Because most of the trials included in our meta-analysis were not conducted in diabetic patients, the risk of hemorrhagic stroke related to aspirin therapy in this population could not be estimated. However, based on the high absolute risk of myocardial infarction and ischemic stroke in diabetic patients, the benefit should outweigh the risk.

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