title: Aspirin for secondary prevention after stroke of unknown etiology in resource-limited settings.
abstract: OBJECTIVE
  To analyze the potential impact of aspirin therapy for long-term secondary prevention after stroke of undetermined etiology in resource-limited settings without access to neuroimaging to distinguish ischemic stroke from intracerebral hemorrhage (ICH).
  
  
  METHODS
  We conducted a decision analysis using a Markov state transition model. Sensitivity analyses were performed across the worldwide reported range of the proportion of strokes due to ICH and the 95% confidence intervals (CIs) of aspirin-associated relative risks in patients with ICH.
  
  
  RESULTS
  For patients with stroke of undetermined etiology, long-term aspirin was the preferred treatment strategy across the worldwide reported range of the proportion of strokes due to ICH. At 34% of strokes due to ICH (the highest proportion reported in a large epidemiologic study), the benefit of aspirin remained beyond the upper bounds of the 95% CIs of aspirin-associated post-ICH relative risks most concerning to clinicians (ICH recurrence risk and mortality risk if ICH recurs on aspirin). Based on the estimated 11,590,204 strokes in low- and middle-income countries in 2010, our model predicts that aspirin therapy for secondary stroke prevention in all patients with stroke in these countries could lead to an estimated yearly decrease of 84,492 recurrent strokes and 4,056 stroke-related mortalities.
  
  
  CONCLUSIONS
  The concern that the risks of aspirin in patients with stroke of unknown etiology could outweigh the benefits is not supported by our model, which predicts that aspirin for secondary prevention in patients with stroke of undetermined etiology in resource-limited settings could lead to decreased stroke-related mortality and stroke recurrence.
authors.affiliation: From the Department of Neurology (A.L.B., S.H.C.), Brigham and Women's Hospital, Harvard Medical School; and Department of Neurology (M.B.W., M.T.B.), Massachusetts General Hospital, Harvard Medical School, Boston. aberkowitz3@partners.org.
authors.forename: Aaron L
authors.initials: AL
authors.lastname: Berkowitz
authors.affiliation: From the Department of Neurology (A.L.B., S.H.C.), Brigham and Women's Hospital, Harvard Medical School; and Department of Neurology (M.B.W., M.T.B.), Massachusetts General Hospital, Harvard Medical School, Boston.
authors.forename: M Brandon
authors.initials: MB
authors.lastname: Westover
authors.affiliation: From the Department of Neurology (A.L.B., S.H.C.), Brigham and Women's Hospital, Harvard Medical School; and Department of Neurology (M.B.W., M.T.B.), Massachusetts General Hospital, Harvard Medical School, Boston.
authors.forename: Matt T
authors.initials: MT
authors.lastname: Bianchi
authors.affiliation: From the Department of Neurology (A.L.B., S.H.C.), Brigham and Women's Hospital, Harvard Medical School; and Department of Neurology (M.B.W., M.T.B.), Massachusetts General Hospital, Harvard Medical School, Boston.
authors.forename: Sherry H-Y
authors.initials: SH
authors.lastname: Chou
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001241:Aspirin / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use*; D002545:Brain Ischemia / Q000191:economics / Q000401:mortality / Q000517:prevention & control; D002543:Cerebral Hemorrhage / Q000191:economics / Q000401:mortality / Q000517:prevention & control; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D006801:Humans; D038622:Internationality; D008390:Markov Chains; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects / Q000191:economics / Q000627:therapeutic use*; D011204:Poverty Areas; D012307:Risk Factors; D055502:Secondary Prevention / Q000191:economics*; D012680:Sensitivity and Specificity; D020521:Stroke / Q000191:economics* / Q000401:mortality / Q000517:prevention & control*; D013997:Time Factors; D055815:Young Adult
chemical_list: D010975:Platelet Aggregation Inhibitors; D001241:Aspirin