What are the considerations for using aspirin (acetylsalicylic acid) in patients with chronic myeloid leukemia (CML) and heart failure?

Aspirin Use in Patients with CML and Heart Failure

Low-dose aspirin (75-100 mg daily) should be used with caution in patients with CML and heart failure, with the decision based primarily on cardiovascular risk factors rather than CML status, as aspirin may worsen heart failure symptoms while providing thrombotic protection in high-risk patients. 1, 2

Cardiovascular Risk Assessment in CML Patients

• CML patients should be stratified according to cardiovascular risk using established tools like the Systematic Coronary Risk Evaluation (SCORE) chart 3
• High-risk features warranting aspirin consideration include:
  • Age ≥60 years 1
  • Prior history of thrombosis 1
  • JAK2 mutation (in essential thrombocythemia) 1
  • Presence of cardiovascular risk factors 1

Aspirin in Heart Failure Patients

• Aspirin may have detrimental effects in heart failure patients by:

  • Inhibiting prostaglandins that have beneficial hemodynamic effects 2
  • Potentially increasing hospitalizations for worsening heart failure 2
  • Counteracting some beneficial effects of ACE inhibitors 2

• Aspirin should be used selectively in heart failure patients based on:

  • Recent myocardial infarction (within 6-12 months) 2
  • Established coronary artery disease with high ischemic risk 1
  • Multiple vascular risk factors 2

Aspirin in CML Patients

• CML patients treated with tyrosine kinase inhibitors (TKIs) have increased risk of arterial occlusive events 3, 4
• Older CML patients (≥60 years) treated with ponatinib who received prophylactic aspirin showed lower incidence of arterial occlusive events (33.3% vs 61.8%) 3
• Aspirin prophylaxis should be considered for:
  • CML patients aged ≥60 years on TKI therapy 3
  • Patients with high to very high cardiovascular risk scores 3
  • Patients with vascular symptoms 1

Special Considerations for Combined CML and Heart Failure

• For patients with both CML and heart failure:
  • Avoid aspirin in patients with refractory/decompensated heart failure 2
  • Consider aspirin in patients with recent myocardial infarction despite heart failure 2
  • Monitor for worsening heart failure symptoms if aspirin is initiated 2
  • Consider alternative TKIs with lower cardiovascular toxicity profiles in heart failure patients 4

Practical Recommendations

• For CML patients with heart failure:
  • Use low-dose aspirin (75-100 mg daily) only if cardiovascular benefit clearly outweighs risk 1
  • Consider clopidogrel as an alternative antiplatelet agent in patients who cannot tolerate aspirin 1
  • Closely monitor heart failure symptoms when initiating aspirin therapy 2
  • Consider proton pump inhibitors in patients at increased risk of gastrointestinal bleeding 1

Common Pitfalls and Caveats

• Avoid aspirin in patients with:

  • Decompensated heart failure without compelling cardiovascular indications 2
  • Increased bleeding risk (thrombocytopenia, recent surgery) 1
  • Acquired von Willebrand disease 1

• Remember that aspirin is not universally effective:

  • It fails to prevent the majority of serious vascular events 5
  • Non-adherence and inadequate dosing can reduce effectiveness 5
  • Alternative pathways of platelet activation may bypass aspirin's effects 5

• When using aspirin in CML patients with heart failure:

  • Start with the lowest effective dose (75-100 mg daily) 1
  • Regularly reassess the risk-benefit balance 2
  • Consider discontinuation if heart failure symptoms worsen 2