From the Guidelines
Aspirin should be administered to ESRD patients with chest pain, provided there are no contraindications, as the benefits of aspirin in acute coronary syndrome outweigh the risks. When considering aspirin therapy in ESRD patients with chest pain, it is crucial to weigh the potential cardiovascular benefits against the increased bleeding risk due to uremic platelet dysfunction and impaired drug clearance 1. For suspected acute coronary syndrome in these patients, a loading dose of 162-325 mg of aspirin, followed by a maintenance dose of 81 mg daily, can be considered. However, it is essential to use aspirin cautiously and monitor these patients closely for signs of bleeding, as the antiplatelet effects of aspirin may be more pronounced and last longer between dialysis sessions.
- Key considerations include:
- Evaluating kidney function and adjusting medication regimens accordingly
- Regular reassessment of bleeding risk, especially in dialysis patients
- Balancing the cardiovascular benefits of aspirin against the potential for increased bleeding
- Considering alternative pain management strategies for non-cardiac chest pain Given the potential for aspirin to improve outcomes in acute coronary syndrome, as recommended by the American Heart Association 1, its use should not be withheld from ESRD patients with chest pain without careful consideration of the individual patient's risk factors and potential benefits.
From the Research
Aspirin Use in ESRD Patients with Chest Pain
- The use of aspirin in patients with end-stage renal disease (ESRD) is a topic of interest, as these patients are at high risk of cardiovascular events 2.
- A study published in 2018 proposed a randomized controlled trial to evaluate the safety and efficacy of aspirin in reducing the risk of thrombotic events in patients with ESRD on hemodialysis 2.
- Another study published in 2022 compared the effectiveness of different antithrombotic regimens, including aspirin, in patients with symptomatic peripheral arterial disease, and found that clopidogrel, ticagrelor, and ASA plus low-dose rivaroxaban were superior to ASA monotherapy in preventing major adverse cardiovascular events 3.
- A 2021 study compared the effectiveness of different aspirin dosing strategies in patients with established atherosclerotic cardiovascular disease, and found no significant differences in cardiovascular events or major bleeding between patients assigned to 81 mg and those assigned to 325 mg of aspirin daily 4.
- Early administration of aspirin (within two hours) following the onset of chest pain was associated with increased survival compared to late administration (median 3.5 hours or in-hospital) in a systematic review published in 2020 5.
- A 2021 study found that ticagrelor was not superior to clopidogrel in reducing ischemic events in patients with myocardial infarction with nonobstructive coronary arteries, and did not cause a significant increase in bleeding 6.
Considerations for Aspirin Use in ESRD Patients
- The decision to use aspirin in ESRD patients with chest pain should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 2, 3, 4, 5, 6.
- The optimal dose and timing of aspirin administration in ESRD patients with chest pain are not well established, and further research is needed to determine the best approach 2, 4, 5.