Can a patient with coronary artery disease (CAD), hypertension (HTN), and hyperlipidemia (HLD) stop taking aspirin due to tinnitus?

Should This Patient Stop Aspirin Due to Tinnitus?

No, this patient should NOT stop aspirin due to tinnitus—the cardiovascular risks of discontinuation in a patient with established coronary artery disease and prior stenting far outweigh the burden of tinnitus. 1, 2, 3

Rationale for Continuing Aspirin

Established CAD with Prior Stenting

• This patient has documented coronary artery disease with stents placed in 2009 (LAD) and 2020 (LCx), making aspirin a Class 1 recommendation for secondary prevention 1, 2
• Aspirin 75-100 mg daily is recommended lifelong in patients with prior myocardial infarction or remote percutaneous coronary intervention after an initial period of dual antiplatelet therapy 2, 3
• The patient is currently on aspirin 81 mg daily, which is the appropriate maintenance dose for secondary prevention 1, 3

Catastrophic Risks of Aspirin Discontinuation

• Aspirin withdrawal in patients with coronary stents carries an 89-fold increased risk of major adverse cardiac events (OR=89.78 [29.90-269.60]) 4
• In patients with established CAD, aspirin discontinuation is associated with a three-fold higher risk of major adverse cardiac events overall (OR=3.14 [1.75-5.61]) 4
• Non-compliance or withdrawal of aspirin has ominous prognostic implications and should only be advocated when bleeding risk clearly overwhelms atherothrombotic risk 4

Benefits Clearly Outweigh Risks

• For patients with established cardiovascular disease, the benefits of aspirin therapy far outweigh bleeding risks 1, 2
• Aspirin reduces vascular death after myocardial infarction and reduces the occurrence of vascular and coronary events including MI and stroke in secondary prevention 1
• Combination therapy with aspirin, statin, and blood pressure-lowering agents (all of which this patient is taking) is associated with lower risk of myocardial infarction (HR 0.68), ischemic stroke (HR 0.37), and all-cause mortality (HR 0.69) 5

Management of Tinnitus While Continuing Aspirin

Investigate Alternative Causes

• Tinnitus has multiple potential etiologies beyond aspirin, including age-related hearing loss, noise exposure, hypertension, and other medications 2
• The patient's blood pressure is well-controlled (120/68 mmHg), but hypertension itself can contribute to tinnitus 6
• Review all medications for ototoxic potential beyond aspirin

Dose Considerations

• The patient is already on the lowest effective dose (81 mg daily) recommended for secondary prevention 1, 3
• Further dose reduction below 75 mg is not supported by evidence and may compromise cardiovascular protection 2, 3
• Aspirin-related tinnitus is typically dose-dependent, but at 81 mg daily, this is less likely to be the primary cause 2

If Aspirin Truly Cannot Be Tolerated

• Clopidogrel 75 mg daily is the only acceptable alternative for patients with documented aspirin allergy or true intolerance 2, 3
• Clopidogrel is equally effective as aspirin for secondary prevention in patients with established CAD 2, 3
• However, simple discontinuation without replacement antiplatelet therapy is absolutely contraindicated 4

Common Pitfalls to Avoid

• Never discontinue aspirin in a patient with prior coronary stenting without replacing it with clopidogrel 4
• Do not assume tinnitus is aspirin-related without investigating other causes 2
• Recognize that the 89-fold increased risk of adverse events with aspirin discontinuation in stented patients makes this one of the highest-risk medication changes in cardiology 4
• Understand that even years after stent placement (2009 and 2020 in this case), aspirin remains essential for secondary prevention 2, 3

Recommended Action Plan

1. Continue aspirin 81 mg daily without interruption 1, 2, 3
2. Refer to ENT or audiology for comprehensive tinnitus evaluation to identify alternative causes 2
3. Ensure the patient understands the life-threatening risks of aspirin discontinuation in his specific situation 4
4. If tinnitus is definitively attributed to aspirin after thorough evaluation and becomes intolerable, transition to clopidogrel 75 mg daily as the only acceptable alternative 2, 3
5. Document this discussion and the decision-making process clearly in the medical record 4