Should I continue low‑dose aspirin (75 mg once daily) in an 80‑year‑old patient with hypertension and chronic coronary syndrome (stable angina)?

Should Aspirin 75 mg Daily Be Continued in This 80‑Year‑Old Patient with Hypertension and Chronic Coronary Syndrome?

Yes—continue aspirin 75 mg once daily indefinitely for lifelong secondary prevention in this patient with established chronic coronary syndrome (stable angina). 1

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Guideline‑Based Recommendation for Chronic Coronary Syndrome

• The 2024 European Society of Cardiology (ESC) guideline for chronic coronary syndromes gives a Class I, Level A recommendation for aspirin 75–100 mg daily lifelong in patients without prior myocardial infarction or revascularization but with evidence of significant obstructive coronary artery disease. 1 Your patient's history of angina treated as chronic coronary syndrome qualifies as established coronary disease, making aspirin a cornerstone of secondary prevention. 1

• The same ESC guideline states that in patients with a prior MI or remote percutaneous coronary intervention, aspirin 75–100 mg daily is recommended lifelong after an initial period of dual antiplatelet therapy. 1 Even though your patient has not undergone revascularization, the presence of symptomatic coronary disease (angina) places them in the chronic coronary syndrome category that warrants indefinite aspirin. 1

• Older ACC/AHA and ESC STEMI guidelines (2008–2009) consistently recommend aspirin 75–162 mg daily indefinitely in all patients with established coronary disease unless contraindicated. 1 These recommendations apply to both post‑MI and stable coronary patients. 1

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Evidence Supporting Low‑Dose Aspirin in Stable Coronary Disease

• A 2008 meta‑analysis of six randomized trials (9,853 patients with stable cardiovascular disease) demonstrated that low‑dose aspirin (50–325 mg/day) reduces cardiovascular events by 21 % (95 % CI 0.72–0.88), nonfatal MI by 26 % (95 % CI 0.60–0.91), stroke by 25 % (95 % CI 0.65–0.87), and all‑cause mortality by 13 % (95 % CI 0.76–0.98). 2 Treating 1,000 patients for 33 months prevented 33 cardiovascular events, 12 nonfatal MIs, 25 nonfatal strokes, and 14 deaths, while causing 9 major bleeding events. 2

• In patients with ischemic heart disease specifically, aspirin was most effective at reducing nonfatal MI and all‑cause mortality. 2 Your patient's chronic coronary syndrome (stable angina) falls squarely into this category. 2

• The optimal maintenance dose for chronic prevention is 75–100 mg daily, which provides equivalent efficacy to higher doses (up to 1,500 mg) while minimizing gastrointestinal bleeding risk. 1, 2 Doses below 75 mg have limited supporting data, and doses above 325 mg increase bleeding without proportional benefit. 1

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Age and Hypertension Are Not Contraindications

• Advanced age (80 years) is not a contraindication to aspirin in established coronary disease. 1 The 2024 ESC guideline does not list age as a reason to withhold aspirin in patients with chronic coronary syndrome. 1

• Hypertension should be controlled before and during aspirin therapy, but it is not a contraindication. 3 Your patient's underlying hypertension requires optimization, but this does not preclude aspirin use. 3

• The 2022 US Preventive Services Task Force (USPSTF) recommendation against initiating aspirin for primary prevention in adults ≥60 years does not apply to your patient, who has established coronary disease (secondary prevention). 4 The USPSTF statement explicitly excludes patients with known cardiovascular disease. 4

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Absolute Contraindications to Aspirin (None Present in Your Case)

• Aspirin is contraindicated only in the presence of:

  • Active pathological bleeding 1
  • Known hypersensitivity to aspirin 1
  • Severe thrombocytopenia 1
  • Intracranial hemorrhage not excluded on imaging (relevant only in acute stroke) 3

• Your patient has none of these contraindications. 1

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Practical Management Algorithm

1. Confirm the diagnosis of chronic coronary syndrome (stable angina with documented obstructive coronary disease on imaging or stress testing). 1
2. Continue aspirin 75 mg once daily indefinitely. 1
3. Optimize blood pressure control to target <130/80 mmHg. 1
4. Add a high‑intensity statin (e.g., atorvastatin 40–80 mg or rosuvastatin 20–40 mg) to achieve LDL‑C <1.4 mmol/L (55 mg/dL) and ≥50 % reduction from baseline. 1
5. Initiate a beta‑blocker and/or calcium channel blocker for symptom control and heart rate management. 1
6. Consider adding a second antiplatelet agent (clopidogrel 75 mg daily) only if the patient has had a recent acute coronary syndrome or high‑risk features; otherwise, aspirin monotherapy is the standard. 1
7. Prescribe a proton pump inhibitor if the patient has a history of gastrointestinal bleeding, peptic ulcer disease, or concomitant NSAID use. 1

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Common Pitfalls to Avoid

• Do not discontinue aspirin after the acute phase unless a clear contraindication develops. 1 Aspirin is a lifelong therapy in chronic coronary syndrome. 1

• Do not substitute aspirin with clopidogrel unless the patient is aspirin‑intolerant. 1 Clopidogrel 75 mg daily is an equally effective alternative, but aspirin remains first‑line. 1

• Do not use dual antiplatelet therapy (aspirin + clopidogrel) long‑term in stable coronary disease without a specific indication (e.g., recent stent, recent MI). 1 Prolonged dual therapy markedly increases bleeding risk without additional benefit in stable patients. 1

• Do not delay aspirin initiation while awaiting further testing or specialist consultation. 1 The benefit of aspirin is time‑dependent, and early initiation is critical. 1

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Summary

Continue aspirin 75 mg once daily indefinitely in this 80‑year‑old patient with hypertension and chronic coronary syndrome. 1 The 2024 ESC guideline provides Class I, Level A evidence for lifelong aspirin in patients with established coronary disease, regardless of age or hypertension status. 1 The absolute benefits of aspirin (preventing MI, stroke, and death) substantially outweigh the absolute risks of major bleeding in this secondary prevention population. 2