Would a patient with mild coronary artery disease benefit from prophylactic Aspirin (acetylsalicylic acid)?

From the Guidelines

Patients with mild coronary artery disease should be considered for prophylactic aspirin therapy, with a recommended dose of 75-100 mg daily, as the reduction of ischemic events outweighs the risk of serious bleeding events, according to the most recent guidelines 1. The use of aspirin in patients with mild coronary artery disease is a topic of ongoing debate, with some studies suggesting a benefit in reducing cardiovascular events, while others highlight the increased risk of bleeding complications. However, the 2024 ESC guidelines for the management of chronic coronary syndromes provide clear guidance on this issue, recommending low-dose aspirin monotherapy for patients with coronary artery disease, including those with mild disease 1. The benefits of aspirin therapy in this population include a significant reduction in the combined risk of non-fatal MI, non-fatal ischemic stroke, or death from vascular causes, with a relative risk reduction of 31%, 22%, and 9%, respectively 1. Additionally, aspirin therapy has been shown to reduce the risk of total stroke and coronary events by about a fifth 1. However, it is essential to weigh these benefits against the potential risks, including an increased risk of major gastrointestinal and extracranial bleeds, as well as a non-significant increase in hemorrhagic stroke 1. To minimize these risks, patients should be advised to take aspirin with food and be aware of potential drug interactions, particularly with other blood thinners or NSAIDs. In terms of specific patient populations, the guidelines suggest that daily aspirin doses of 75-100 mg are as effective as higher doses for long-term treatment, and that there is no evidence of different aspirin effects in women and men 1. Overall, the decision to initiate aspirin therapy in patients with mild coronary artery disease should be made on an individual basis, taking into account the patient's underlying risk factors, bleeding risk, and other comorbidities. However, based on the most recent guidelines, prophylactic aspirin therapy is a recommended treatment option for patients with mild coronary artery disease, with a focus on minimizing bleeding risks and maximizing cardiovascular benefits 1. Some patients may also benefit from additional preventive measures, such as:

• Statins to reduce cholesterol levels and prevent progression of atherosclerotic plaques
• Blood pressure management to reduce the risk of cardiovascular events
• Lifestyle modifications, including smoking cessation, regular exercise, and a heart-healthy diet, to reduce cardiovascular risk factors.

From the Research

Benefits of Prophylactic Aspirin in Mild Coronary Artery Disease

• Aspirin is the prophylactic antiplatelet drug of choice for people with cardiovascular disease, including those with mild coronary artery disease 2, 3, 4, 5.
• The use of aspirin has been shown to reduce the risk of cardiovascular events, including myocardial infarction and ischemic stroke, in patients with established cardiovascular disease 2, 6, 4.
• Aspirin therapy is also recommended for primary prevention of cardiovascular events in selected population groups, including those with moderate risk for a coronary event 3, 4, 5.

Risks and Considerations

• The use of aspirin is associated with an increased risk of major bleeding, particularly when combined with other antiplatelet agents such as clopidogrel 2, 6.
• The benefits of aspirin therapy must be weighed against the risks of bleeding and other adverse events, particularly in patients with a history of gastrointestinal bleeding or other bleeding disorders 2, 6, 4.
• Patients with mild coronary artery disease should be carefully evaluated to determine the potential benefits and risks of aspirin therapy, and alternative treatments should be considered in patients with contraindications to aspirin 4.

Dosage and Duration of Therapy

• The recommended dose of aspirin for cardiovascular disease prevention is 75-100 mg per day, although higher doses may be used in certain situations such as acute coronary syndrome 4, 5.
• Aspirin therapy should be continued indefinitely in patients with established cardiovascular disease, unless contraindicated or discontinued due to adverse events 4.