Curriculum in CardiologyIs there an association between aspirin dosing and cardiac and bleeding events after treatment of acute coronary syndrome? A systematic review of the literature
Section snippets
Background
Acetylsalicylic acid (ASA) maintenance therapy is recommended in combination with adenosine diphosphate (ADP) inhibitors for the prevention of secondary thrombotic events in patients with acute coronary syndrome (ACS). Patients with a higher risk of future cardiac events are frequently prescribed high-dose ASA (325 mg/d) regimens, whereas patients with a lower risk or those with an increased risk of bleeding receive lower doses.1 The higher ASA doses are prescribed with the hope that they will
Objective
The objective of this systematic review and meta-analysis was to examine the literature on clinical trials and observational studies to better understand the evidence supporting the efficacy and safety of ASA dosing (with or without ADP inhibitors) in patients with ACS who underwent stent insertion (SI), coronary artery bypass grafting (CABG), or medical treatment (MT).
Search strategy
We performed 3 separate literature searches that included both electronic and manual components. Each search was designed to identify publications that evaluated patients with ACS who received treatment with SI, CABG, or MT. The electronic searches were performed in MEDLINE (via PubMed), EMBASE, and Current Contents; and all duplicate abstracts were removed before screening. Based on the availability of publications on the therapies of interest, the searches were restricted to January 1, 1985,
Search yields
The literature search for the SI group yielded 4,605 citations. Of these, 981 citations passed abstract screening and underwent full article screening; 93 passed the screening and were accepted for review. The review identified 25 publications that reported on previously reported patient populations (“related publications”), leaving 68 primary publications for analysis.
The literature search for the CABG group yielded 2,058 citations. Of these, 353 citations passed abstract screening and
Discussion
This is the first meta-analysis to our knowledge that investigates the role of maintenance aspirin dose in patients with ACS and the occurrence of thrombotic or bleeding events following SI or MT. We analyzed data from 136 primary publications and 289,330 patients; and the results suggest that there was no difference in the rate of thrombotic events between the ASA doses studied, even after adjusting for select confounders.
There were only 2 randomized clinical trials that directly addressed
Conclusion
In conclusion, our analyses suggest that there are no differences in clinical outcomes between low- and high-dose ASA after SI or during MT. In addition, high-dose ASA may be associated with higher rates of major bleeding in patients during MT.
Acknowledgement
We thank John Tumas, MS, ELS, of AstraZeneca for providing editorial assistance.
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Cited by (25)
2018 Guidelines of the Taiwan Society of Cardiology, Taiwan Society of Emergency Medicine and Taiwan Society of Cardiovascular Interventions for the management of non ST-segment elevation acute coronary syndrome
2018, Journal of the Formosan Medical AssociationCitation Excerpt :A maintenance daily dose of 100 mg should be continued indefinitely. Aspirin maintenance dose higher than 100 mg/day does not gain more benefit82 and the gastrointestinal side effects increase significantly if the dose is higher than 160 mg/day.83 The therapeutic benefits were uncertain if the maintenance dose is lower than 75 mg/day.81
Non–ST-Segment Acute Coronary Syndromes
2018, Cardiology ClinicsCitation Excerpt :The subsequent maintenance dose should be 81 mg per day. The lower dose is favored, as higher doses (≥160 mg) are associated with increased bleeding risk (especially gastrointestinal tract bleeding) in the absence of improved outcomes.52 NSAIDs, especially ibuprofen, naproxen, and indomethacin, should be avoided in patients with NSTEMI, as they are associated with increased risk of bleeding and excess thrombotic events, even after short-term treatment.1
Investigating therapeutic usage of combined Ticagrelor and Aspirin through solid-state and analytical studies
2017, European Journal of Pharmaceutical SciencesCitation Excerpt :The dosage quantities of TIC are rather well defined at 90 mg per tablet (James et al., 2009). In the case of ASA, it is well known that high doses are associated with higher rates of major bleeding in patients (Berger et al., 2012). A large systematic review on the efficacy of ASA to avoid blood clots has demonstrated that there are no differences in clinical outcome between low or high doses of ASA in the medical treatment following surgical stent insertions (Berger et al., 2012), thus for a combination therapy an effective ASA dosage quantity can be kept at a relatively low concentration.
Aspirin treatment and outcomes after percutaneous coronary intervention: Results of the ISAR-ASPI registry
2014, Journal of the American College of CardiologyThe year in acute coronary syndrome
2014, Journal of the American College of CardiologyCitation Excerpt :One hundred sixteen years after aspirin was first synthesized, a consensus on the use of lower dose aspirin for patients with ACS appears to have developed (6–8). A systematic review of the literature including 136 studies with 289,330 patients concluded that there was no improvement in clinical outcomes with higher (>160 mg/day) maintenance doses of aspirin compared with lower doses in patients with ACS receiving coronary stents or being medically managed (51). However, there was an excess of major bleeding of 23 per 1,000 with these higher doses of aspirin in medically treated patients.
James A. de Lemos, MD, served as guest editor for this article.