Can aspirin (acetylsalicylic acid) be given to patients?

Aspirin Therapy in Clinical Practice

Aspirin should be given to patients based on their cardiovascular risk profile, with low-dose aspirin (75-162 mg daily) recommended for secondary prevention in all patients with established cardiovascular disease, while primary prevention requires careful risk-benefit assessment based on individual cardiovascular risk factors.

Indications for Aspirin Therapy

Secondary Prevention (Established Cardiovascular Disease)

• Strong recommendation for aspirin use in patients with:
  • History of myocardial infarction 1
  • History of stroke or transient ischemic attack 1
  • Stable coronary artery disease 2
  • History of vascular bypass procedures 1
  • Peripheral vascular disease 1, 2
  • Angina 1

Acute Coronary Syndromes

• Initial loading dose of 162-325 mg (preferably non-enteric coated for faster absorption) 1
• Followed by daily maintenance dose of 75-100 mg 1
• Should be administered as soon as ACS is suspected or diagnosed 1

Primary Prevention

• Consider for adults with diabetes who are at increased ASCVD risk (especially those with 10-year risk of CHD ≥10%) 1
• May be considered for patients with multiple cardiovascular risk factors 1
• Not recommended for patients at low risk of ASCVD (such as men and women <50 years with diabetes with no other major risk factors) 1
• Generally not recommended for adults over 70 years due to increased bleeding risk 1

Dosing Recommendations

Optimal Dosing

• Secondary prevention: 75-162 mg daily 1, 2
• Acute coronary syndrome: Initial loading dose of 162-325 mg, followed by maintenance dose of 75-100 mg daily 1
• Primary prevention (when indicated): 75-162 mg daily 1

Dosing Considerations

• Lower doses (75-100 mg) are preferred for long-term therapy due to similar efficacy with reduced bleeding risk 1, 3
• Higher doses do not provide additional cardiovascular protection but increase bleeding risk 3
• The CURE trial showed that major bleeding increased with increasing aspirin dose: 1.9% with <100 mg, 2.8% with 101-199 mg, and 3.7% with ≥200 mg 3

Contraindications and Precautions

Absolute Contraindications

• Aspirin allergy 1
• Active bleeding 1
• Children under 21 years (risk of Reye's syndrome) 1

Relative Contraindications/Caution

• Recent gastrointestinal bleeding 1
• Concurrent anticoagulant therapy (increased bleeding risk) 1
• Clinically active hepatic disease 1
• History of peptic ulcer disease
• Severe uncontrolled hypertension

Special Populations

Diabetes Mellitus

• Secondary prevention: Aspirin 75-162 mg daily for all diabetic patients with history of cardiovascular events 1
• Primary prevention: Consider for diabetic patients >40 years of age or with additional risk factors (family history of CVD, hypertension, smoking, dyslipidemia, albuminuria) 1

Elderly Patients

• For patients over 70 years, the balance of aspirin for primary prevention appears to have greater risk than benefit 1
• Secondary prevention benefits outweigh risks even in elderly patients 1

Monitoring and Follow-up

• Monitor for signs of bleeding (gastrointestinal, intracranial)
• Assess for medication adherence at each visit
• Re-evaluate cardiovascular risk periodically

Common Pitfalls and Caveats

1. Overuse in primary prevention: Aspirin is not recommended for low-risk individuals where bleeding risks may outweigh cardiovascular benefits 1

2. Inappropriate dosing: Higher doses (>100 mg daily) for long-term therapy increase bleeding risk without providing additional cardiovascular protection 3

3. Enteric-coated vs. plain aspirin: For acute situations (like ACS), non-enteric coated formulations provide faster absorption 1

4. Discontinuation risk: Abrupt discontinuation of aspirin in patients with established cardiovascular disease can trigger rebound thrombotic events

5. Concurrent NSAID use: May interfere with aspirin's cardioprotective effects and increase bleeding risk

By following these evidence-based recommendations, clinicians can optimize the benefits of aspirin therapy while minimizing potential risks in patients requiring cardiovascular protection.