Should a 72-year-old male with a history of Non-ST-Elevation Myocardial Infarction (NSTEMI) be on aspirin (acetylsalicylic acid) if there is currently no risk for falls?

Aspirin for Secondary Prevention in a 72-Year-Old Male with NSTEMI History

Yes, a 72-year-old male with a history of NSTEMI should be on aspirin indefinitely if there is no risk for falls, as aspirin is a Class I recommendation (Level of Evidence: A) for secondary prevention in patients with prior myocardial infarction.

Evidence Supporting Aspirin Use in Post-NSTEMI Patients

Guideline Recommendations

• Aspirin should be continued indefinitely in patients recovering from NSTEMI as a Class I recommendation (Level of Evidence: A) 1
• For patients with unstable angina/NSTEMI treated medically without stenting, aspirin should be prescribed indefinitely 1
• The American Heart Association and American College of Cardiology strongly recommend aspirin for secondary prevention in patients with prior MI regardless of age 2

Dosing Recommendations

• A maintenance dose of 81 mg daily is preferred to higher maintenance doses to minimize bleeding risk 1
• Following an initial loading dose of 162 to 325 mg of non-enteric-coated aspirin during the acute event, an 81 mg daily dose is recommended for long-term therapy 1, 2
• It is reasonable to use an aspirin maintenance dose of 81 mg per day in preference to higher maintenance doses in patients with NSTE-ACS treated either invasively or with coronary stent implantation (Class IIa, Level of Evidence: B) 1

Benefits of Aspirin in Secondary Prevention

• Aspirin therapy has been well documented to reduce risks of subsequent cardiovascular disease in secondary prevention 3
• The Antithrombotic Trialists' Collaboration demonstrated that in patients who have survived a prior occlusive vascular event (including MI), aspirin prevents about 25% of serious vascular events 3
• Meta-analyses have confirmed the benefits of long-term aspirin therapy in patients at high risk of occlusive vascular events, including those with prior MI 2
• A meta-analysis of 16 secondary prevention trials (n=17,000 patients) demonstrated that aspirin allocation was associated with a 1.5% significantly lower risk of serious vascular events per year 2

Special Considerations for Elderly Patients

• The patient's age (72 years) does not contraindicate aspirin use; in fact, guidelines specifically recommend aspirin for secondary prevention in patients with prior MI regardless of age 2
• While elderly patients have increased bleeding risk, the cardiovascular benefits of aspirin for secondary prevention outweigh this risk in patients with established cardiovascular disease 3
• The absence of fall risk in this patient further supports aspirin use, as fall risk would be a consideration for bleeding risk assessment 4

Potential Risks and Monitoring

• Aspirin may cause stomach bleeding, with higher risk in patients age 60 or older 4
• The risk of bleeding can be mitigated by:
  • Using the lowest effective dose (81 mg daily) 1
  • Considering proton pump inhibitor use in patients with history of gastrointestinal bleeding or those requiring triple antithrombotic therapy 1
  • Regular monitoring for bleeding complications 4

Conclusion for Clinical Practice

• For this 72-year-old male with NSTEMI history and no fall risk, aspirin 81 mg daily should be prescribed indefinitely 1
• Regular assessment for bleeding risk factors should be performed at follow-up visits 4
• Aspirin should be part of a comprehensive secondary prevention strategy that includes management of other cardiovascular risk factors 1