Abstract

Background

Aspirin is recommended in stable coronary artery disease based on myocardial infarction and
stroke studies. However, benefit among stable coronary artery disease patients who have not
suffered an acute ischemic event is uncertain. The objective of this study was to evaluate the
impact of aspirin in stable coronary artery disease. We hypothesized that aspirin's benefit
would be attenuated among individuals with stable coronary artery disease but no prior
ischemic event.
Methods

An observational study was conducted from the INternational VErapamil-SR/Trandolapril

STudy cohort. Ambulatory patients 50 years of age with clinically stable coronary artery
disease requiring antihypertensive drug therapy (n = 22,576) were classified ischemic if
they had a history of unstable angina, myocardial infarction, transient ischemic attack, or
stroke at the baseline visit. All others were classified non-ischemic. Aspirin use was
updated at each clinic visit and considered as a time-varying covariate in a Cox regression
model. The primary outcome was first occurrence of all-cause mortality, myocardial
infarction, or stroke.
Results

At baseline, 56.7% of all participants used aspirin, which increased to 69.3% at study close
out. Among the non-ischemic group (n = 13,091), aspirin was not associated with a
reduction in risk (hazard ratio [HR] 1.11; 95% confidence interval [CI], 0.97-1.28; P = .13);
however, among the ischemic group (n = 9485), aspirin was associated with a reduction in
risk (HR 0.87; 95% CI, 0.77-0.99; P = .033).

Conclusions

In patients with stable coronary artery disease and hypertension, aspirin use was associated
with reduced risk for adverse cardiovascular outcomes among those with prior ischemic
events. Among patients with no prior ischemic events, aspirin use was not associated with a
reduction in risk.
K
Impact of Aspirin According to Type of Stable Coronary Artery Disease: Insights
from a Large International Cohort
Anthony A. Bavry, MD, MPH
,
Yan Gong, PhD
,
Eileen M. Handberg, PhD
,
Rhonda M. Cooper-DeHof, PharmD, MS
,
Carl J. Pepine, MD
Published Online: October 14, 2014

Am Heart J. 2004 Jul;148(1):157-64

The Warfarin/Aspirin Study in Heart

failure (WASH): a randomized trial
comparing antithrombotic strategies for
patients with heart failure.
Cleland JG1, Findlay I, Jafri S, Sutton G, Falk R, Bulpitt C, Prentice C, Ford I, Trainer A,
Poole-Wilson PA.

Author information
Abstract
BACKGROUND:
Heart failure is commonly associated with vascular disease and a high rate of atherothrombotic events, but the risks and benefits of antithrombotic therapy are unknown.
METHODS:
The current study was an open-label, randomized, controlled trial comparing no
antithrombotic therapy, aspirin (300 mg/day), and warfarin (target international normalized
ratio 2.5) in patients with heart failure and left ventricular systolic dysfunction requiring
diuretic therapy. The primary objective was to demonstrate the feasibility and inform the
design of a larger outcome study. The primary clinical outcome was death, nonfatal
myocardial infarction, or nonfatal stroke.
RESULTS:
Two hundred seventy-nine patients were randomized and 627 patient-years exposure were
accumulated over a mean follow-up time of 27 +/- 1 months. Twenty-six (26%), 29 (32%),
and 23 (26%) patients randomized to no antithrombotic treatment, aspirin, and warfarin,
respectively, reached the primary outcome (ns). There were trends to a worse outcome among
those randomized to aspirin for a number of secondary outcomes. Significantly (P =.044)
more patients randomized to aspirin were hospitalized for cardiovascular reasons, especially
worsening heart failure.
CONCLUSIONS:
The Warfarin/Aspirin Study in Heart failure (WASH) provides no evidence that aspirin is
effective or safe in patients with heart failure. The benefits of warfarin for patients with heart
failure in sinus rhythm have not been established. Antithrombotic therapy in patients with
heart failure is not evidence based but commonly contributes to polypharmacy.
PMID:
15215806
[PubMed - indexed for MEDLINE]

J Intern Med. 2005 May;257(5):399-414.

Low-dose aspirin for secondary

cardiovascular prevention - cardiovascular
risks after its perioperative withdrawal

versus bleeding risks with its continuation review and meta-analysis.

Burger W1, Chemnitius JM, Kneissl GD, Rcker G.

Author information
Abstract
OBJECTIVES:
Low-dose aspirin given for secondary prevention of cardiovascular disease is frequently
withdrawn prior to surgical or diagnostic procedures to reduce bleeding complications. This
may expose patients to increased cardiovascular morbidity and mortality. Aim of the study
was to review and quantify cardiovascular risks because of periprocedural aspirin withdrawal
and bleeding risks with the continuation of aspirin.
METHODS:
We screened MEDLINE (January 1970-October 2004) with additional manual crossreferencing for clinical studies, surveys on the opinions of doctors and guidelines.
RESULTS:
Studies reporting the relative risk of acute cardiovascular events after aspirin withdrawal
when compared with its continuation were not found. However, retrospective investigations
revealed that aspirin withdrawal precedes up to 10.2% of acute cardiovascular syndromes.
The time interval between discontinuation and acute cerebral events was 14.3 +/- 11.3 days,
8.5 +/- 3.6 days for acute coronary syndromes, and 25.8 +/- 18.1 days for acute peripheral
arterial syndromes (P < 0.02 versus acute coronary syndromes). On aspirin-related bleeding
risks, we obtained 41 (12 observational retrospective, 19 observational prospective, 10
randomized) studies, reporting on 49 590 patients (14 981 on aspirin). Baseline frequency of
bleeding complications varied between 0 (skin lesion excision, cataract surgery) and 75%
(transrectal prostate biopsy). Whilst aspirin increased the rate of bleeding complications by
factor 1.5 (median, interquartile range: 1.0-2.5), it did not lead to a higher level of the
severity of bleeding complications (exception: intracranial surgery, and possibly transurethral
prostatectomy). Surveys amongst doctors on the management of this problem demonstrate
wide variations. Available guidelines are scarce and in part contradictory.
CONCLUSIONS:
Only if low-dose aspirin may cause bleeding risks with increased mortality or sequels
comparable with the observed cardiovascular risks after aspirin withdrawal, it should be
discontinued prior to an intended operation or procedure. Controlled clinical studies are
urgently needed.

Comment in

There is no strong evidence that low-dose aspirin should be routinely discontinued

preoperatively. Commentary. [Evid Based Cardiovasc Med. 2005]

PMID:
15836656
[PubMed - indexed for MEDLINE]

Triple therapy for atrial fibrillation and

percutaneous coronary intervention.
Abstract

PURPOSE OF REVIEW
Patients with atrial fibrillation undergoing percutaneous coronary intervention (PCI)
require treatment with oral anticoagulation (OAC) and additional dual antiplatelet
therapy with aspirin and clopidogrel (DAPT), i.e. triple therapy. However, triple
therapy produces a high annual bleeding risk outweighing the benefits. To improve
safety of antithrombotic treatment in these patients, the risks and benefits of all
possible treatment options should be evaluated. This review provides an overview of
current guidelines and new evidence for optimizing treatment of atrial fibrillation
patients with an indication for combined treatment with OAC and DAPT.
RECENT FINDINGS
To reduce bleeding risks during PCI, new evidence suggests that uninterrupted
anticoagulation, radial access and the use of newer-generation drug eluting stent
(DES) should be preferred. The use of glycoprotein receptor inhibitors should be
avoided. After PCI, omitting aspirin seems to result in less bleeding compared with
triple therapy, and the use of proton pump inhibitors further reduces bleeding risk.
SUMMARY
These new strategies seem to further improve the safety of antithrombotic treatment in
patients with atrial fibrillation undergoing PCI.

Authors

Bennaghmouch N
aDepartment of Cardiology, St Antonius Hospital, Nieuwegein bDepartment of
Cardiology, Amphia Hospital Breda, the Netherlands.
Dewilde WJ
Ten Berg JM

Current opinion in cardiology : 2015 Sep 24 pg

Source
Pub Type(s)

JOURNAL ARTICLE

The Discovery of Aspirin's Antithrombotic Efects