Aspirin or heparin immediately after a stroke?

Abstract

The International Stroke Trial (IST) published in this issue of The Lancet is the largest trial conducted of the acute treatment of ischaemic stroke. It included about 20 000 patients. It is a randomised open trial with four treatment groups equal in size: (1) aspirin 300 mg a day, (2) heparin at two doses (5000 or 12 500 IU twice a day), (3) aspirin plus heparin, and (4) no aspirin and no heparin. Treatment was started within 48 hours of the onset of a suspected acute ischaemic stroke and continued until discharge or for up to 14 days. The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19 435 patients with acute ischaemic strokeNeither heparin regimen offered any clinical advantage at 6 months. The results suggest that if heparin is given in routine clinical practice, the dose should not exceed 5000 IU subcutaneously twice daily. For aspirin, the IST suggests a small but worthwhile improvement at 6 months. Taking the IST together with the comparably large Chinese Acute Stroke Trial, aspirin produces a small but real reduction of about 10 deaths or recurrent strokes per 1000 during the first few weeks. Both trials suggest that aspirin should be started as soon as possible after the onset of ischaemic stroke; previous trials have already shown that continuation of low-dose aspirin gives protection in the longer term. Full-Text PDF