Should an 82-year-old female with coronary artery disease, significant stenosis in the LAD and diagonal arteries, and heart failure with reduced LV ejection fraction be considered for aspirin therapy?

Should This Patient Be on Aspirin?

Yes, this 82-year-old female with documented coronary artery disease (70% LAD stenosis, 70% diagonal stenosis) and diabetes should be on aspirin therapy for secondary prevention, despite her age and heart failure with reduced ejection fraction.

Rationale for Aspirin Therapy

This patient has established atherosclerotic cardiovascular disease documented by coronary angiography showing significant stenoses in the LAD and diagonal arteries. This clearly qualifies her for aspirin as secondary prevention, which has far greater benefit than risk compared to primary prevention 1.

Key Supporting Evidence

• Aspirin 75-162 mg daily is strongly recommended as secondary prevention in patients with diabetes and documented atherosclerotic cardiovascular disease 1, 2.

• The American Diabetes Association guidelines explicitly state that for patients with documented ASCVD, aspirin for secondary prevention has far greater benefit than risk 1.

• Even in patients over age 70 years, where primary prevention with aspirin shows greater risk than benefit, secondary prevention remains strongly indicated when established cardiovascular disease is present 1.

Addressing Potential Concerns

Age Considerations

While this patient is 82 years old, the caution about aspirin in elderly patients applies primarily to primary prevention, not secondary prevention 1. The guidelines specifically note that for patients over 70 years without established cardiovascular disease, bleeding risks may outweigh benefits, but this patient has documented obstructive CAD 1.

Heart Failure with Reduced Ejection Fraction

• The presence of HFrEF (LVEF 20-30%) does not contraindicate aspirin therapy in the setting of documented CAD 3.

• Research demonstrates that CAD in HFpEF patients is associated with increased mortality and greater deterioration in ventricular function, and similar principles apply to HFrEF 3.

• The patient's heart failure should be managed with guideline-directed medical therapy, but this does not preclude aspirin for her documented coronary disease 1.

Bleeding Risk Assessment

Evaluate for contraindications before initiating aspirin 4:

• History of gastrointestinal bleeding - not mentioned in this case
• Active peptic ulcer disease - patient has GERD but no active ulcer documented
• Severe uncontrolled hypertension - her BP is 143/40 mmHg, which is acceptable
• Concurrent anticoagulation - none mentioned
• Thrombocytopenia or bleeding disorders - not mentioned
• Aspirin allergy - not mentioned

The patient's GERD is a relative consideration but not an absolute contraindication, and can be managed with proton pump inhibitors if needed 4.

Recommended Dosing

Aspirin 75-81 mg daily is the recommended dose for secondary prevention 1, 2.

• The most common formulation in the U.S. is 81 mg daily 1.

• Lower doses (75-81 mg) provide equivalent cardiovascular protection to higher doses while significantly reducing bleeding complications 2.

• The ADAPTABLE trial showed no difference in cardiovascular events between 81 mg and 325 mg daily, supporting use of the lower dose 1.

Additional Antiplatelet Considerations

• If the patient develops angina or requires PCI for her LAD/diagonal stenoses (as suggested in the catheterization report), dual antiplatelet therapy with aspirin plus a P2Y12 inhibitor would be indicated for at least one year 1.

• If aspirin allergy is documented, clopidogrel 75 mg daily should be substituted 1, 2.

Common Pitfalls to Avoid

• Do not withhold aspirin based solely on advanced age when documented ASCVD is present - the secondary prevention benefit clearly outweighs bleeding risk 1.

• Do not assume low-dose aspirin (81 mg) is insignificant - it still affects platelet function and provides cardiovascular protection 5, 2.

• Do not overlook the need for gastric protection if the patient has symptomatic GERD or develops gastrointestinal symptoms on aspirin 4.

• Do not use aspirin as a substitute for guideline-directed medical therapy for her heart failure - she needs comprehensive HFrEF management including ACE inhibitors/ARBs, beta-blockers, and consideration of SGLT2 inhibitors 1.

Monitoring and Follow-up

• Assess for bleeding symptoms at each follow-up visit, particularly gastrointestinal bleeding given her GERD history 4.

• Consider proton pump inhibitor co-therapy to reduce gastrointestinal bleeding risk, especially given her GERD 4.

• Ensure adherence to aspirin therapy as part of comprehensive cardiovascular risk reduction 1.