Do We Still Need Aspirin in Coronary Artery Disease?
Abstract
:1. Introduction
1.1. Role of Aspirin for Primary Prevention
1.2. Loading for NSTEMI, STEMI, or Elective PCI
2. Secondary Prevention
2.1. Long Term Treatment after STEMI and NSTE-ACS
2.2. Long-Term Aspirin Use after PCI
Author (Year) Trial | HOST-EXAM (2021) [18] | TICO (2020) [50] | TWILIGHT (2019) [51] | SMART-CHOICE (2019) [46] | STOP-DAPT-2 (2019) [47] | GLOBAL LEADERS (2018) [17] | |
---|---|---|---|---|---|---|---|
Geographical location | South Korea | Korea | International | Korea | Japan | International | |
No. of patients | 5438 | 3056 | 7119 | 2993 | 3045 | 15,968 | |
Male (%) | 74.5 | 80 | 76.1 | 73.4 | 76.7 | 76.7 | |
Age (yrs) | 63.5 | 61 | 65.2 | 64.5 | 68.6 | 64.5 | |
Diabetes (%) | 34.2 | 27.3 | 36.8 | 37.5 | 38.1 | 25.3 | |
Smoker (%) | 20.7 | 37.4 | 21.8 | 26.4 | 23.3 | 26.1 | |
Dyslipidemia (%) | 69.3 | 60.4 | 60.4 | 45.2 | 73.7 | 67.4 | |
Chronic Kidney Disease/impaired renal function (%) | 12.7 | 20.3 | 16.8 | 3.24 | 5.5 | 13.6 | |
Previous myocardial infarction (%) | 16.0 | 3.70 | 28.7 | 4.24 | 13.3 | 23.2 | |
Previous cerebrovascular accident (%) | 4.7 | 4.12 | NR | 6.7 | 6.1 | 2.6 | |
Indications for PCI | Stable angina/stable CAD | 25.5 | 0 | 35.2 | 41.8 | 61.1 | 53.1 |
Unstable angina | 35.6 | 30.3 | 35.0 | 32.0 | 13.4 | 12.7 | |
NSTEMI | 19.4 | 33.6 | 29.8 | 15.7 | 5.9 | 21.1 | |
STEMI | 17.2 | 36.1 | 0 | 10.5 | 18.4 | 13.1 | |
Follow up time (years) | 2 | 1 | 1 | 1 | 1 | 2 | |
DAPT duration | 6–18 months in both arms | 3-month DAPT followed by ticagrelor monotherapy vs. 12-month DAPT | 3-month DAPT followed by P2Y12 inhibitors monotherapy vs. 12-month DAPT | 3-month DAPT followed by P2Y12 inhibitors monotherapy vs. 12-month DAPT | 1-month DAPT followed by clopidogrel o compared withstandard 12-month DAPT | Ticagrelor plus aspirin for 1 month, followed by ticagrelor monotherapy for 23 months vs. aspirin plus clopidogrel or ticagrelor for 12 months, followed by aspirin monotherapy for 12 months | |
Secondary prevention type | Dual antiplatelet therapy without clinical events for 6–18 months after percutaneous coronary intervention with DES | Acute coronary syndrome patients treated with drug-eluting stents | Dual antiplatelet therapy after percutaneous coronary intervention (PCI) | P2Y12 inhibitor monotherapy short-duration dual antiplatelettherapy (DAPT) vs. standard DAPT in patients undergoing percutaneous coronary intervention (PCI) | 1 month of DAPT compared withstandard 12 months of DAPT | Percutaneous coronary intervention using DES for stable coronary artery disease or acute coronary syndromes | |
P2Y12 vs. Aspirin dose | Clopidogrel 75 mg vs. aspirin 100 mg | Aspirin 300 mg loading followed by 100 mg daily. Ticagrelor 180 mg loading followed by 90 mg daily | Aspirin 81 to 100 mg daily, ticagrelor 90 mg twice daily | Aspirin 100 mg once daily plus clopidogrel 75 mg once daily or prasugrel 10 mg once daily or ticagrelor 90 mg twice daily for 3 months in both groups | 81 to 200mg/d, and clopidogrel,75 mg/d, or aspirin, 81 to 200 mg/d, and prasugrel 3.75 mg/d | Ticagrelor 90 mg twice daily vs. aspirin 75–100 mg daily | |
Outcomes | Myocardial infarction | HR = 0.65 (0.36 to 1.17) | HR = 0.55 (0.20 to 1.48) | HR = 1.0 (0.75 to 1.33) | HR = 0.66 (0.31 to 1.40) | HR = 1.19 (0.54 to 2.67) | RR = 1.0 (0.84 to 1.19) |
Stroke | HR = 0.42 (0.24 to 0.73) | HR = 0.73 (0.29 to 1.81) | HR = 2.0 (0.86 to 4.67) | HR = (2.23 (0.78 to 6.43) | HR = 0.50 (0.22 to 1.18) | RR = 0.98 (0.72 to 1.33) | |
CV mortality | HR = 1.37 (0.69 to 2.73) | NR | HR = 0.70 (0.43 to 1.16) | HR = 0.86 (0.38 to 1.91) | HR = 0.83 (0.34 to 1.99) | NR | |
All-cause mortality | HR = 1.43 (0.93 to 2.19) | HR = 0.70 (0.37 to 1.32) | HR = 0.75 (0.48 to 1.18) | HR = 1.18 (0.63 to 2.21) | HR = 1.18 (0.63 to 2.21) | RR = 0.88 (0.74 to 1.06) | |
Bleeding | HR = 0.63 (0.41 to 0.97) | HR = 0.56 (0.34 to 0.91) | HR = 0.56 (0.45 to 0.68) | HR = 0.87 (0.40 to 1.88) | HR = 0.19 (0.05 to 0.65) | RR = 0.95 (0.76 to 1.18) |
2.3. DAPT Duration
2.4. Aspirin Use in Patients Undergoing CABG
2.5. Contribution of P2Y12 Inhibitor Use
2.5.1. Primary Prevention
2.5.2. Secondary Prevention
Loading for STEMI, NSTEMI or Elective PCI
Long-Term Treatment for Secondary Prevention
Long-Term P2Y12 Use after CABG
3. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Abbreviations and Acronyms
ACS | acute coronary syndromes |
CABG | coronary artery bypass grafting surgery |
CAD | coronary artery disease |
COR | class of recommendation |
LOE | level of evidence |
NSTEMI | non-ST elevation myocardial infarction |
PCI | percutaneous coronary intervention |
STEMI | ST-elevation myocardial infarction |
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Author (Year) Trial | Study Period | No. of Patients | Male (%) | Age (yrs) | Diabetes (%) | Aspirin Dose/Day | Outcomes in RR or HR | |||
---|---|---|---|---|---|---|---|---|---|---|
Myocardial Infarction | Stroke | CV Mortality | All-Cause Mortality | |||||||
Non-diabetes | ||||||||||
Peto R (1988) [20] | 1978–1984 | 5139 | 100 | 61 | 2 | 500 mg | NR | NR | NR | NR |
Ongoing Physician Health Study (1989) [21] | 1982–1988 | 22,071 | NR | NR | 2 | 325 mg | RR = 0.56 (0.45–0.70) | RR = 1.22 (0.93–1.60) | RR = 0.96 (0.60–1.54) | RR = 0.96 (0.80–1.14) |
Hansson (1998) HOT trial [22] | 1992–1997 | 18,790 | 53 | 61 | 8 | 75 mg | RR = 0.85 (0.69–1.05) | RR = 0.98 (0.78–1.24) | RR = 0.95 (0.75–1.20) | RR = 0.93 (0.79–1.09) |
Thrombosis prevention trial (1998) [23] | 1984–1997 | 5499 | 100 | 57 | 2 | 75 mg | RR = 0.80 (0.64–0.99) | RR = 0.98 (0.65–1.47) | RR = 1.26 (0.93–1.69) | RR = 1.03 (0.80–1.32) |
Primary prevention project (2001) [24] | 1994–1998 | 4495 | 42 | 64 | 17 | 100 mg | RR = 0.69 (0.38–1.23) | RR = 0.67 (0.36–1.27) | RR = 0.56 (0.31–0.99) | RR = 0.81 (0.58–1.13) |
Ridker P (2005) Women’s health study [25] | 1992–2004 | 39,876 | 0 | 54 | 3 | 100 mg | RR = 1.02 (0.84–1.25) | RR = 0.83 (0.69–0.99) | RR = 0.95 (0.74–1.22) | RR = 0.95 (0.85–1.06) |
Fowkes (2010) Aspirin for Asymptomatic Atherosclerosis trial [26] | 1998–2008 | 3350 | 28 | 62 | 3 | 100 mg | NR | NR | NR | HR = 0.95 (0.77–1.16) |
Ikeda Y (2014) Japanese Primary Prevention Project (JPPP) [27] | 2002–2008 | 2539 | 55 | 65 | 34 | 100 mg | HR = 0.53 (0.31–0.91) | HR = 1.04 (0.80–1.34) | HR = 1.03 (0.71–1.48) | HR = 0.99 (0.85–1.17) |
Gaziano (2018) ARRIVE [7] | 2007–2016 | 12,546 | 70 | 64 | 0 | 100 mg | HR = 0.85 (0.64–1.11) | 1.12 (0.80–1.55) | HR = 0.97 (0.62–1.52) | HR = 0.99 (0.80–1.24) |
McNeil (2018) ASPREE [9] | 2010–2014 | 19,114 | 44 | 74 | 11 | 100 mg | HR = 0.93 (0.76–1.15) | HR = 0.95 (0.83–1.08) | NR | NR |
Diabetes | ||||||||||
Ogawa (2008) Japanese Primary Prevention of Atherosclerosis with Aspirin for diabetes [28] | 2002–2008 | 2539 | 55 | 65 | 100 | 81 or 100 mg | NR | HR = 0.84 (0.53–1.32) | NR | NR |
Belch (2008) Prevention of progression of arterial disease and diabetes (POPADAD) [29] | 1997–2006 | 1276 | 44 | 60 | 100 | 100 mg | HR = 0.98 (0.68–1.43) | HR = 0.71 (0.44–1.14) | HR = 1.35 (0.81–2.25) | HR = 0.93 (0.71–1.24) |
ASCEND (2018) [8] | 2005–2017 | 15,480 | 63 | 63 | 100 | 100 mg | HR = 0.98 (0.80–1.19) | 0.88 (0.73–1.06) | NR | NR |
Society | Guideline | Class of Recommendation | Level of Evidence |
---|---|---|---|
Primary prevention | |||
American College of Cardiology/American Heart Association guidelines for primary prevention of cardiovascular disease 2019 [3] | Low-dose aspirin 75–100 mg for primary prevention between ages 40 and 70 years with higher risk of atherosclerotic cardiovascular disease and not at increased risk of bleeding | IIb | A |
Preventive Services Task Force Recommendation Statement 2022 [5] | Aspirin as primary prevention for patient between 40 and 59 years who have a 10% or greater risk of cardiovascular disease who are not at increased risk of bleeding | - | C |
Secondary prevention | |||
2013 ACCF/AHA Guideline for the Management ofST-Elevation Myocardial Infarction [1] | Aspirin 162 to 325 mg should be given before primary PCI | I | B |
After PCI, aspirin should be continued indefinitely | I | A | |
2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation AcuteCoronary Syndromes [2] | Non–enteric-coated, chewable aspirin (162 mg to 325 mg) should be given to all patients with NSTE-ACS without contraindications as soon as possible after presentation, and a maintenance dose of aspirin (81 mg/d to 325 mg/d) should be continued indefinitely | I | A |
Aspirin maintenance dose continued indefinitely | I | A | |
Patients already taking daily aspirin before PCI should take 81 mg to 325 mg non–enteric-coated aspirin before PCI | I | B | |
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation [4] | Aspirin is recommended for all patients without contraindications at an initial oral loading dose of 150 to 300 mg (or 75 to 250 mg i.v.), and at a maintenance dose of 75 to 100 mg daily for long-term treatment. | I | A |
2015 Secondary prevention after coronary artery bypass graft surgery: a scientific statement from the American Heart Association [32] | Aspirin should be administered preoperatively and within 6 h after CABG in doses of 81 to 325 mg daily followed by indefinite maintenance therapy to reduce graft occlusion and adverse cardiac events | I | A |
2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guidelines for the management of patients with chronic coronary disease [33] | Dual antiplatelet therapy consisting of aspirin and clopidogrel for 6 months post PCI followed by single antiplatelet therapy is indicated to reduce MACE and bleeding events | I | A |
Patient with chronic coronary disease recommended PCI and a drug-eluting stent who completed a 1- to 3-month course of dual antiplatelet therapy, P2Y12 inhibitor monotherapy for at least 12 months is reasonable to reduce bleeding risk | IIa | A | |
2023 ESC Guidelines for the management of acute coronary syndromes [19] | P2Y12 inhibitor monotherapy may be considered as an alternative to aspirin monotherapy for long-term treatment | IIb | A |
In high bleeding risk patients, aspirin or P2Y12 receptor inhibitor monotherapy after 1 month of DAPT may be considered | IIb | A | |
In patients who are event free after 3–6 months of DAPT and who are not at high ischemic risk, single antiplatelet therapy (preferably with a P2Y12 receptor inhibitor) should be considered | IIa | A |
Author (Year) Trial | Geographical Location | N | Male (%) | Age (yrs) | Follow up Time (yrs) | Secondary Prevention Type | P2Y12 vs. Aspirin Dose | Outcomes in RR or HR | ||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
MI | Stroke | CV Mortality | All-Cause Mortality | Bleeding | ||||||||
Clopidogrel (C) | ||||||||||||
CAPRIE (1996) [10] | International | 19,185 | 71.9 | 62.5 | 3 | ASCVD (ischemic stroke, MI, or PAD) | ASA 325 mg vs. C 75 mg | NR | NR | NR | RRR = 2.2 (−9.9 to 12.9) | NR |
CADET (2004) [12] | United Kingdom | 184 | 80.9 | 62.6 | 0.5 | Acute MI within the previous 3–7° days | C 75 mg vs. ASA 75 mg | NR | NR | NR | NR | NR |
ASCET (2012) [11] | Norway | 1001 | 78.2 | 62.4 | 2 | SIHD | ASA 160 mg vs. C 75 mg | RR = 2.05 (0.62 to 6.80) | RR = 2.05 (0.37 to 11.17) | NR | NR | NR |
Ticagrelor (T) | ||||||||||||
SOCRATES (2016) [15] | International | 13,199 | 58.4 | 65.8 | 0.25 | Acute ischemic stroke or transient ischemic attack | T 90 mg twice daily vs. ASA 100 mg | HR = 1.20 (0.67 to 2.14) | HR = 0.86 (0.75 to 0.99) | HR = 1.18 (0.75 to 1.85) | HR = 1.18 (0.83 to 1.67) | HR = 0.83 (0.52 to 1.34) |
DACAB (2018) [14] | China | 332 | 82.8 | 63.6 | 1 | Post-coronary artery bypass grafting | T 90 mg twice daily vs. ASA 100 mg | NR | NR | NR | NR | NR |
TICAB (2019) [13] | International | 1859 | 84.9 | 66.7 | 1 | ACS or SIHD post- CABG | T90 mg twice daily vs. aspirin 100 mg | HR = 0.63 (0.36–1.12) | HR = 1.21 (0.70–2.08) | HR = 0.85 (0.38–1.89) | NR | HR = 1.02 (0.67–1.55) |
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Maqsood, M.H.; Levine, G.N.; Kleiman, N.D.; Hasdai, D.; Uretsky, B.F.; Birnbaum, Y. Do We Still Need Aspirin in Coronary Artery Disease? J. Clin. Med. 2023, 12, 7534. https://doi.org/10.3390/jcm12247534
Maqsood MH, Levine GN, Kleiman ND, Hasdai D, Uretsky BF, Birnbaum Y. Do We Still Need Aspirin in Coronary Artery Disease? Journal of Clinical Medicine. 2023; 12(24):7534. https://doi.org/10.3390/jcm12247534
Chicago/Turabian StyleMaqsood, Muhammad Haisum, Glenn N. Levine, Neal D. Kleiman, David Hasdai, Barry F. Uretsky, and Yochai Birnbaum. 2023. "Do We Still Need Aspirin in Coronary Artery Disease?" Journal of Clinical Medicine 12, no. 24: 7534. https://doi.org/10.3390/jcm12247534
APA StyleMaqsood, M. H., Levine, G. N., Kleiman, N. D., Hasdai, D., Uretsky, B. F., & Birnbaum, Y. (2023). Do We Still Need Aspirin in Coronary Artery Disease? Journal of Clinical Medicine, 12(24), 7534. https://doi.org/10.3390/jcm12247534