Summary: Aspirin and other antiplatelet medicines may lower the risk of further bleeding after a stroke caused by bleeding in the brain.
Source: University of Edinburgh
Key finding: A major randomized clinical trial has found that people who suffered an intracerebral haemorrhage (bleeding stroke) and who restarted antiplatelet therapy did not face an increased risk of recurrent brain bleeding; in this study they experienced fewer recurrences than those who avoided these medicines.
Antiplatelet drugs—commonly used agents such as aspirin and clopidogrel—are prescribed widely to reduce the risk of heart attack and ischaemic stroke by preventing blood clots. Until now, doctors have been cautious about restarting these medications in patients who have had a bleed in the brain, fearing they might raise the chance of another intracerebral haemorrhage.
To address this question, researchers at the University of Edinburgh led the RESTART trial, which followed 537 people across the UK who had experienced a brain haemorrhage while already taking drugs to prevent clotting. Participants were randomly assigned either to recommence antiplatelet therapy or to avoid it, and they were followed for up to five years.
The trial results showed fewer recurrent intracerebral haemorrhages among those who resumed antiplatelet medication: 12 of 268 patients taking antiplatelets had another brain bleed, compared with 23 of 268 who avoided these medicines. While the difference did not reach conventional statistical significance, the data suggest that antiplatelet therapy does not increase—and may even reduce—the risk of further intracerebral haemorrhage. The authors caution that further research is needed to confirm this potential protective effect.
About half of the participants had an MRI scan at study entry. MRI can reveal small deposits of blood in the brain, called microbleeds, which are sometimes considered a warning sign for future haemorrhage. In the RESTART trial, having microbleeds did not make antiplatelet treatment more hazardous: patients with microbleeds did not show an excess risk from restarting antiplatelet therapy.
These findings offer practical reassurance for survivors of brain haemorrhage who need antiplatelet drugs to prevent occlusive vascular events—such as heart attacks and ischaemic strokes. Importantly, the results also suggest that routine MRI to look for microbleeds is not essential before deciding to restart antiplatelet therapy, a relevant point given that many older patients cannot undergo MRI scans.
The RESTART study, funded by the British Heart Foundation, is published in The Lancet and The Lancet Neurology, and its results were presented at the European Stroke Organisation Conference in Milan.
Professor Rustam Salman, from the University of Edinburgh’s Centre for Clinical Brain Sciences, commented that the trial provides reassurance for brain haemorrhage survivors who require antiplatelet medicines to prevent future heart attacks or ischaemic strokes. He noted interest in further investigating whether these medicines might substantially reduce the risk of recurrent brain haemorrhage.
Professor Metin Avkiran, Associate Medical Director at the British Heart Foundation, said the findings are crucial for patients and clinicians. He noted that about one in three people who experience a brain haemorrhage were taking an antiplatelet drug at the time, and the study strongly indicates that many of these patients can safely continue potentially life-saving antiplatelet therapy without increasing the risk of another intracerebral bleed.
Source:
University of Edinburgh
Media contacts:
Jen Middleton – University of Edinburgh
Image source:
The image is in the public domain.
Original research: Open access
“Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial”, RESTART Collaboration. The Lancet. DOI: 10.1016/S0140-6736(19)30840-2
Abstract (summary)
Background:
Antiplatelet therapy reduces the risk of major vascular events in people with occlusive vascular disease but may raise concerns about bleeding. Survivors of intracerebral haemorrhage are at risk of both bleeding and occlusive events, and it has been unclear whether restarting antiplatelet therapy is safe and whether any increased bleeding risk outweighs the benefits for preventing occlusive events.
Methods:
RESTART was a prospective, randomized, open-label, blinded-endpoint trial across 122 UK hospitals. Adults who were taking antithrombotic therapy when they had an intracerebral haemorrhage, who stopped that therapy and survived at least 24 hours, were randomized 1:1 to start or avoid antiplatelet therapy and were followed for up to five years. The primary outcome was recurrent symptomatic intracerebral haemorrhage.
Findings:
Between May 2013 and May 2018, 537 participants were randomized a median of 76 days after haemorrhage onset. Median follow-up was two years with 99.3% completeness. Recurrent intracerebral haemorrhage occurred in 12 of 268 participants allocated to antiplatelet therapy and 23 of 268 allocated to avoid antiplatelet therapy (adjusted hazard ratio 0.51, 95% CI 0.25–1.03; p=0.060). Major haemorrhagic events and major occlusive vascular events were similar between groups. The results rule out all but a very small increase in risk of recurrent intracerebral haemorrhage from antiplatelet therapy and suggest that any such risk is unlikely to outweigh the established benefits of antiplatelet agents for secondary prevention.
Funding:
British Heart Foundation.