Is it safe to give a 160 mg oral aspirin loading dose to a 60‑year‑old man with asthma and intermittent low‑grade fevers in the days before the event, who has no known aspirin‑exacerbated respiratory disease or NSAID hypersensitivity?

Aspirin Administration in Asthma with Recent Fever

Yes, it is safe to administer 160 mg oral aspirin to this patient, provided he has no known history of aspirin-exacerbated respiratory disease (AERD) or prior NSAID hypersensitivity reactions. 1

Key Clinical Context

The presence of intermittent low-grade fevers in the days prior does not contraindicate aspirin administration for acute coronary syndrome. 1 The critical distinction is between:

• Simple asthma (aspirin is safe) versus
• Aspirin-exacerbated respiratory disease (AERD) (aspirin is contraindicated) 1, 2

Guideline-Based Recommendations for Aspirin in Acute Coronary Events

For suspected acute myocardial infarction or acute coronary syndrome:

• Non-enteric-coated, chewable aspirin 162-325 mg should be given immediately to all patients without contraindications 1
• The loading dose should be chewed for faster absorption, particularly important in acute presentations 1
• Maintenance dosing of 75-100 mg daily should continue indefinitely thereafter 1, 3

Asthma as a Relative—Not Absolute—Contraindication

The European Society of Cardiology explicitly states that aspirin may occasionally trigger bronchospasm in asthmatic patients, but this is not an absolute contraindication. 1 The key differentiating factors are:

• AERD patients (5-15% of asthmatics) have chronic rhinosinusitis with nasal polyps, adult-onset asthma, and documented hypersensitivity to COX-1 inhibiting NSAIDs 2, 4
• Non-AERD asthmatics can safely receive aspirin for cardiovascular indications 1, 5
• Your patient has no known aspirin-exacerbated respiratory disease or NSAID hypersensitivity, making aspirin administration appropriate 1

Absolute Contraindications to Aspirin (None Present in This Case)

The following would preclude aspirin use: 1, 6

• Known hypersensitivity to salicylates 1
• Active gastrointestinal bleeding 1, 6
• Known bleeding disorders or severe hepatic disease 1
• Recent hemorrhagic stroke 1

Intermittent fever is not listed as a contraindication in any major guideline. 1

Clinical Pitfalls to Avoid

Do not use enteric-coated aspirin for acute presentations, as it has delayed and reduced absorption. 1 Non-enteric-coated, chewable formulations achieve rapid platelet inhibition within minutes. 1

Do not withhold aspirin based solely on asthma diagnosis without documented AERD or prior NSAID reactions. 1, 2 The mortality benefit of aspirin in acute MI (23% reduction with aspirin alone, 42% when combined with fibrinolysis) far outweighs the small risk of bronchospasm in non-AERD asthmatics. 1

Monitor for bronchospasm after administration in any asthmatic patient, but this should not delay initial dosing in the setting of suspected acute coronary syndrome. 1

Evidence Strength

The recommendation to give aspirin 160-325 mg immediately in acute coronary syndromes is a Class I, Level A recommendation from both the American College of Cardiology/American Heart Association and the European Society of Cardiology. 1 The ISIS-2 trial demonstrated conclusive efficacy with 35-day mortality reduction of 23% with aspirin alone. 1