Is aspirin contraindicated in a dialysis (renal replacement therapy) patient presenting to the Emergency Department (ED) with chest pain?

Aspirin in Dialysis Patients with Chest Pain in the Emergency Department

Aspirin is not contraindicated in dialysis patients presenting to the ED with chest pain and should be administered promptly unless there are specific contraindications such as aspirin allergy or active gastrointestinal bleeding. 1

Rationale for Aspirin Use in Dialysis Patients

• Aspirin (162-325 mg) is a cornerstone of early management for suspected acute coronary syndromes, regardless of dialysis status, as it significantly decreases mortality when administered early after symptom onset 1
• The 2015 AHA guidelines specifically state that "unless the patient has a known aspirin allergy or active gastrointestinal hemorrhage, nonenteric aspirin should be given as soon as possible to all patients with suspected ACS" (Class I, LOE A) 1
• Early administration of aspirin (median 1.6 hours from pain onset) has been associated with higher survival compared to late administration (median 3.5 hours) 1

Administration Guidelines

• The recommended dose is 160-325 mg of non-enteric aspirin, chewed and swallowed 1
• EMS providers should administer nonenteric aspirin (160-325 mg) to patients with suspected ACS (Class I, LOE B to C) 1
• For patients unable to take aspirin due to hypersensitivity or major gastrointestinal intolerance, clopidogrel 300 mg can be administered as an alternative (Class IIa, LOE B) 1

Special Considerations for Dialysis Patients

• Despite being at high risk for cardiovascular disease, dialysis patients are often undertreated with aspirin for both primary and secondary prevention 2
• Research suggests that only about 51% of dialysis patients with a history of cardiovascular disease receive aspirin therapy, indicating significant underutilization 2
• While there are theoretical concerns about bleeding risk in dialysis patients, the benefit of aspirin in the acute setting of suspected myocardial infarction outweighs this risk 3
• A 2016 cohort study found that long-term low-dose aspirin use in hemodialysis patients was not associated with a significant increase in fatal cerebral hemorrhage (HR = 1.795,95% CI 0.666-4.841, P = 0.174) 4

Common Pitfalls to Avoid

• Withholding aspirin due to unfounded concerns about bleeding risk in dialysis patients 2
• Delaying aspirin administration until confirmation of ACS, which reduces its mortality benefit 3, 5
• Failing to consider aspirin because the chest pain is incorrectly judged as non-cardiac (a common reason for non-administration by EMS) 6
• Waiting for laboratory results before administering aspirin in a patient with suspected ACS 1

Decision Algorithm for Aspirin Administration in Dialysis Patients with Chest Pain

1. Assess for signs/symptoms suggestive of ACS (chest pain/pressure, shortness of breath, nausea, sweating, pain in jaw/arms/back) 1
2. Check for absolute contraindications:
   • Known aspirin allergy 1
   • Active gastrointestinal bleeding 1
   • Recent significant bleeding event 1
3. If no contraindications exist, administer 162-325 mg non-enteric aspirin to be chewed and swallowed 1
4. If aspirin is contraindicated, consider clopidogrel 300 mg as an alternative 1
5. Continue with other standard ACS management protocols including cardiac monitoring, oxygen if hypoxemic, and preparation for possible reperfusion therapy 1

In summary, dialysis status alone is not a contraindication to aspirin administration in patients presenting with chest pain suspicious for ACS. The mortality benefit of early aspirin administration in suspected ACS outweighs potential bleeding risks in this high-risk population.