Aspirin Therapy in Uncontrolled Hypertension with Suspected CKD
In a patient with uncontrolled hypertension and suspected CKD, aspirin should NOT be initiated for primary prevention until blood pressure is adequately controlled (target <130/80 mmHg), and the decision should then be based on cardiovascular risk stratification and CKD stage. 1, 2
Blood Pressure Control is the First Priority
- Uncontrolled hypertension is an absolute contraindication to initiating aspirin therapy due to substantially increased risk of hemorrhagic stroke and major bleeding events. 2
- Blood pressure must be controlled to <130/80 mmHg in patients with CKD before considering aspirin therapy. 1, 3
- The bleeding risk with aspirin approximately doubles (RR 2.04) in patients with uncontrolled hypertension, particularly when blood pressure exceeds 150/90 mmHg. 1
After Blood Pressure Control: Risk Stratification for Aspirin
When Aspirin is NOT Recommended (Primary Prevention)
Current evidence does NOT support routine aspirin use for primary prevention in CKD patients without established cardiovascular disease. 1
- Multiple meta-analyses show no statistically significant reduction in major cardiovascular events (RR 0.92,95% CI 0.49-1.73) or all-cause mortality in CKD patients without prior cardiovascular disease. 1, 4
- Aspirin significantly increases major bleeding risk (RR 1.98,95% CI 1.11-3.52) in CKD patients. 4
- The 2020 KDIGO guidelines explicitly state that aspirin is indicated for secondary prevention but NOT for primary prevention in CKD. 1
When Aspirin SHOULD Be Considered
Aspirin 75-100 mg daily is strongly recommended ONLY if the patient has:
- Established cardiovascular disease (prior MI, stroke, coronary revascularization, or documented significant obstructive CAD on imaging). 1, 2
- 10-year cardiovascular risk ≥10% with controlled blood pressure and eGFR 30-45 ml/min/1.73 m². 1
Emerging Evidence for Advanced CKD
- Recent data from the TIPS-3 trial suggests aspirin may reduce cardiovascular events specifically in patients with eGFR <60 ml/min/1.73 m² (HR 0.57,95% CI 0.34-0.94), with greater benefit at lower eGFR levels. 5
- However, this finding requires confirmation in the ongoing ATTACK trial (expected completion 2025) before changing practice guidelines. 1, 6
Dosing When Aspirin is Indicated
If aspirin is appropriate after blood pressure control and risk assessment, use 75-100 mg daily (81 mg is the standard U.S. formulation). 1, 2
- Doses of 75-162 mg daily are as effective as higher doses with lower bleeding risk. 1
- Higher doses provide no additional cardiovascular benefit but significantly increase bleeding complications. 2
Critical Monitoring and Safety Considerations
Before Initiating Aspirin:
- Confirm eGFR and stage of CKD (avoid if eGFR <15 ml/min or dialysis-dependent). 1
- Screen for bleeding risk factors: history of GI bleeding, peptic ulcer disease, concurrent anticoagulation, or thrombocytopenia. 1
- Assess for aspirin allergy or intolerance. 1
During Aspirin Therapy:
- Monitor for signs of bleeding (GI symptoms, unexplained anemia, bruising). 1
- Consider proton pump inhibitor co-prescription in patients at increased GI bleeding risk. 1
- Reassess cardiovascular risk and bleeding risk annually. 2
Common Pitfalls to Avoid
- Never initiate aspirin with uncontrolled hypertension - the bleeding risk far outweighs any potential cardiovascular benefit. 2
- Do not use aspirin for primary prevention in low-risk CKD patients (age <50 years without additional cardiovascular risk factors) - bleeding risks exceed benefits. 2
- Avoid combining aspirin with NSAIDs (including over-the-counter ibuprofen) as this dramatically increases bleeding risk. 2
- Do not assume all CKD patients need aspirin - only those with established cardiovascular disease have clear benefit. 1