Should an elderly patient with hypertension (HTN), systolic dysfunction, congestive heart failure (CHF), coronary artery bypass graft (CABG), and atherosclerosis take aspirin 81 mg daily?

Aspirin Therapy in Elderly Women with Cardiovascular Disease

Yes, this elderly woman with hypertension, systolic dysfunction, CHF, CABG, and atherosclerosis should take aspirin 81 mg daily. She has established atherosclerotic cardiovascular disease (ASCVD) with prior coronary revascularization, which represents a clear indication for long-term aspirin therapy for secondary prevention.

Rationale for Aspirin Use

Aspirin is indicated for secondary prevention in patients with established ASCVD, including those with prior CABG. 1 After coronary artery bypass surgery, aspirin therapy improves vein graft patency, particularly during the first postoperative year, and reduces major adverse cardiovascular events (MACE). 1

• Aspirin should be continued indefinitely in patients with established coronary artery disease who tolerate it. 1
• The American Heart Association recommends aspirin 81 mg once daily as the preferred maintenance dose for patients with stable ischemic heart disease, acute coronary syndromes, or following coronary stent placement. 2
• For patients treated with dual antiplatelet therapy (DAPT), a daily aspirin dose of 81 mg (range 75-100 mg) is recommended. 1, 2

Optimal Dosing

The recommended dose is 81 mg daily, not higher doses. 1, 2

• After percutaneous coronary intervention (PCI) or in patients with established cardiovascular disease, 81 mg per day of aspirin is preferred over higher maintenance doses. 1, 2
• In a large pragmatic trial (ADAPTABLE) involving 15,076 patients with established cardiovascular disease, there were no significant differences in cardiovascular events or major bleeding between 81 mg and 325 mg daily aspirin, but patients assigned to higher doses had substantially more dose switching. 3
• Lower doses (81 mg) minimize bleeding risk while maintaining cardiovascular benefit. 2, 3

Special Considerations in Heart Failure

The presence of CHF and systolic dysfunction requires careful consideration, but does not contraindicate aspirin in this patient with established coronary disease and prior CABG. 4, 5

• Some evidence suggests aspirin may worsen outcomes in CHF patients, possibly by inhibiting prostaglandins with resulting adverse hemodynamic and renal effects. 4, 5
• However, aspirin may be beneficial in patients with recent infarction or multiple vascular risk factors, which this patient has. 5
• The controversy primarily applies to patients with CHF without underlying coronary disease or those with refractory CHF. 5
• Given this patient's established coronary disease with prior CABG and atherosclerosis, the benefits of aspirin for secondary prevention outweigh potential concerns about CHF. 5

Monitoring and Contraindications

Aspirin should be avoided or discontinued if the patient develops:

• Active pathological bleeding 1
• Aspirin allergy or hypersensitivity 1
• Major gastrointestinal intolerance 1
• High bleeding risk that outweighs cardiovascular benefit 1

Common pitfalls to avoid:

• Using higher maintenance doses (>81 mg) without clear indication, which increases bleeding risk without additional cardiovascular benefit. 2, 3
• Discontinuing aspirin in patients with established ASCVD without a compelling contraindication. 1
• Failing to consider proton pump inhibitor (PPI) co-therapy in patients at increased risk for gastrointestinal bleeding. 6

Clinical Algorithm

For this patient, the decision pathway is:

1. Established ASCVD present? Yes (prior CABG, atherosclerosis) → Aspirin indicated for secondary prevention 1
2. Active bleeding or absolute contraindication? If no → Proceed with aspirin 1
3. Optimal dose selection: 81 mg daily (preferred maintenance dose) 1, 2
4. CHF consideration: Benefits outweigh risks given established coronary disease 5
5. Duration: Indefinite, unless contraindication develops 1