ASPIRING Introduction

Why ASPIRING?

Spontaneous (non-traumatic) intracerebral haemorrhage (ICH) accounts for about one quarter of all strokes. Among the many causes of ICH, the most common is cerebral small vessel disease (e.g. hypertensive arteriopathy, amyloid angiopathy), which predisposes survivors of ICH to an annual risk of a recurrent ICH or major ischaemic vascular event (non-fatal ischaemic stroke, non-fatal myocardial infarction, or vascular death) of about 5-20%.

Strategies to reduce the risk of recurrent ICH and other major vascular events include identification and treatment of the underlying cause of the ICH, lowering blood pressure, and perhaps, antiplatelet therapy.

In 2019, the RESTART (REstart or STop Antithrombotics Randomised Trial) collaborators reported that among 537 adults (≥18 years) in the UK with prior occlusive vascular disease who experienced and survived an ICH, starting oral antiplatelet drug therapy was associated with less recurrent ICH (adjusted hazard ratio [HR] 0.51, 95%CI 0.25-1.03) and fewer major vascular events (non-fatal stroke, non-fatal myocardial infarction, or death of a vascular cause; adjusted HR 0.65, 95%CI 0.44-0.95) compared to avoiding antiplatelet therapy over two years follow-up.

However..

1. As the unexpected reduction in risk of recurrent ICH and expected reduction in risk of major vascular events with antiplatelet therapy in RESTART could be a chance finding, the results need to be replicated in another large clinical trial before they are considered robust.

2. As the RESTART trial was only conducted in the UK, the results need to be replicated in other high-middle income countries and in low-middle income countries before they can be considered generalisable to other populations.

3. As the RESTART trial only included participants with known prior vascular disease, the results need to be replicated in all survivors of ICH before they can be considered generalisable to ICH survivors with and without known prior vascular disease.

What is ASPIRING?

ASPIRING (Antiplatelet Secondary Prevention International Randomised trial after INtracerebral haemorrhage) is an investigator-led, multicentre, prospective, randomised, open-label, blinded outcome (PROBE), parallel-group clinical trial which aims to determine if antiplatelet monotherapy is of overall net benefit in reducing the incidence of serious vascular events compared to avoiding antiplatelet therapy for adults with a history of spontaneous ICH.

Where is ASPIRING?

ASPIRING will recruit patients from hospital sites, stroke units, rehabilitation wards, and outpatient clinics in Australia and China, and selected other countries.

Who is running ASPIRING?

ASPIRING in an International collaboration led by Professor Rustam Al Shahi Salman, The University of Edinburgh, and coordinated by International Coordinating Centres at the Sir Charles Gairdner Hospital, Perth, Australia (led by Professor Graeme Hankey) and The George Institute for Global Health, China (led by Professor Craig Anderson).