Is low-dose aspirin (acetylsalicylic acid) recommended for patients with a history of coronary artery disease or stroke and stage three chronic kidney disease (CKD)?

Aspirin Use in Patients with History of Coronary Disease or Stroke and Stage 3 CKD

Low-dose aspirin (75-100 mg daily) is recommended for secondary prevention in patients with a history of coronary artery disease or stroke, even in those with stage 3 chronic kidney disease (CKD). 1

Secondary Prevention in CKD Patients

For patients with established cardiovascular disease (CVD) and CKD:

• The 2024 European Society of Cardiology (ESC) guidelines strongly recommend aspirin 75-100 mg daily for lifelong use in patients with prior myocardial infarction (MI), percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG) 1
• Clopidogrel 75 mg daily is recommended as a safe and effective alternative for patients with aspirin intolerance 1
• For patients with evidence of significant obstructive coronary artery disease (CAD) without prior MI or revascularization, aspirin 75-100 mg daily is also recommended lifelong 1

Risk-Benefit Assessment in CKD

The risk-benefit profile for aspirin differs between primary and secondary prevention in CKD patients:

• Secondary prevention: Benefits clearly outweigh risks for patients with established cardiovascular disease
• Primary prevention: Not recommended due to increased bleeding risk without significant cardiovascular benefit 1, 2

Stage 3 CKD specifically:

• Increases bleeding risk compared to patients with normal kidney function
• Does NOT contraindicate aspirin use when there is a clear indication for secondary prevention 1

Bleeding Risk Management

To mitigate bleeding risk in CKD patients on aspirin:

• Use the lowest effective dose (75-100 mg daily) 1, 2
• Consider adding a proton pump inhibitor for patients at increased risk of gastrointestinal bleeding 1
• Monitor regularly for bleeding complications, especially gastrointestinal bleeding 2

Special Considerations for CKD Patients

• CKD patients have inherently higher bleeding risk due to uremic platelet dysfunction 2
• Despite this increased risk, the benefit of aspirin for secondary prevention remains substantial 1, 2
• Patients with kidney disease who received aspirin following myocardial infarction had 43% lower odds of dying within 30 days 2

Algorithm for Decision-Making

1. Determine if secondary prevention indication exists:

   • History of MI, stroke, coronary revascularization, or established CAD? → Use aspirin
   • No history of cardiovascular events? → Avoid aspirin

2. Assess bleeding risk factors:

   • History of GI bleeding, concurrent anticoagulants, advanced age → Add PPI
   • No additional risk factors → Standard monitoring

3. Select appropriate antiplatelet:

   • No contraindications to aspirin → Aspirin 75-100 mg daily
   • Aspirin intolerance → Clopidogrel 75 mg daily

Conclusion

While CKD increases bleeding risk, this does not outweigh the benefits of aspirin for secondary prevention in patients with established cardiovascular disease. The current guidelines consistently support using low-dose aspirin (75-100 mg daily) for secondary prevention in patients with stage 3 CKD who have a history of coronary disease or stroke.