Should a 7-year-old child with coronary artery disease (CAD) and no history of myocardial infarction (MI) or cerebrovascular accident (CVA) be started on daily low-dose aspirin (acetylsalicylic acid)?

Aspirin Therapy in a Seven-Year-Old Child with Coronary Artery Disease

Low-dose aspirin should NOT be started in a seven-year-old child with coronary artery disease unless the CAD is specifically due to Kawasaki disease with coronary aneurysms or other specific cardiac indications. 1

Understanding Pediatric Coronary Artery Disease

Coronary artery disease in children is rare and fundamentally different from adult atherosclerotic disease. The most common cause of pediatric CAD is Kawasaki disease, which can lead to coronary aneurysms. The management approach depends entirely on the underlying etiology:

For Kawasaki Disease-Related CAD:

• If the child has Kawasaki disease with coronary involvement, aspirin therapy is indicated with dosing based on the size of coronary aneurysms:
  • For small coronary aneurysms: Low-dose aspirin (3-5 mg/kg/day) is recommended 1
  • For moderate-sized aneurysms (4-6 mm): Aspirin plus a second antiplatelet agent may be considered 1
  • For giant aneurysms (≥8 mm): Aspirin plus warfarin (INR 2.0-3.0) is reasonable 1

For Non-Kawasaki Disease CAD:

• There are no established guidelines recommending routine aspirin therapy for children with other forms of CAD without a history of MI or stroke 1
• The American College of Chest Physicians guidelines do not recommend prophylactic aspirin for children with CAD unless specific indications exist 1

Dosing Considerations if Aspirin is Indicated

If aspirin is indicated (e.g., for Kawasaki disease with coronary aneurysms):

• For children <2 years: Evidence suggests higher doses around 5 mg/kg/day may be needed for adequate platelet inhibition 2
• For children >2 years: 3 mg/kg/day appears to provide adequate platelet inhibition 2

Important Safety Considerations

1. Risk of Reye's syndrome: Children on aspirin therapy are at risk for Reye syndrome during viral illnesses, particularly influenza and varicella 1

   • Annual influenza vaccination is mandatory
   • Verify varicella vaccination status
   • Consider temporarily switching to alternative antiplatelet therapy during suspected influenza or varicella infection

2. Drug interactions: Ibuprofen should be avoided in children taking aspirin for antiplatelet effects as it antagonizes aspirin's irreversible platelet inhibition 3

3. Monitoring: If aspirin therapy is initiated, regular cardiac follow-up with echocardiography is essential to monitor coronary status 1

Special Considerations

• For children with mechanical heart valves or ventricular assist devices, different antithrombotic regimens are recommended, typically including aspirin plus additional agents 1
• For children with arterial ischemic stroke, aspirin may be indicated at 3-5 mg/kg/day for secondary prevention 1

Conclusion

The decision to use aspirin in pediatric CAD must be based on the specific etiology and severity of coronary involvement. Without a history of Kawasaki disease with coronary aneurysms, MI, stroke, or other specific indications, routine aspirin therapy is not recommended in a seven-year-old child with CAD.