Do We Still Need Aspirin in Coronary Artery Disease?
Abstract
:1. Introduction
1.1. Role of Aspirin for Primary Prevention
1.2. Loading for NSTEMI, STEMI, or Elective PCI
2. Secondary Prevention
2.1. Long Term Treatment after STEMI and NSTE-ACS
2.2. Long-Term Aspirin Use after PCI
Author (Year) Trial | HOST-EXAM (2021) [18] | TICO (2020) [50] | TWILIGHT (2019) [51] | SMART-CHOICE (2019) [46] | STOP-DAPT-2 (2019) [47] | GLOBAL LEADERS (2018) [17] | |
---|---|---|---|---|---|---|---|
Geographical location | South Korea | Korea | International | Korea | Japan | International | |
No. of patients | 5438 | 3056 | 7119 | 2993 | 3045 | 15,968 | |
Male (%) | 74.5 | 80 | 76.1 | 73.4 | 76.7 | 76.7 | |
Age (yrs) | 63.5 | 61 | 65.2 | 64.5 | 68.6 | 64.5 | |
Diabetes (%) | 34.2 | 27.3 | 36.8 | 37.5 | 38.1 | 25.3 | |
Smoker (%) | 20.7 | 37.4 | 21.8 | 26.4 | 23.3 | 26.1 | |
Dyslipidemia (%) | 69.3 | 60.4 | 60.4 | 45.2 | 73.7 | 67.4 | |
Chronic Kidney Disease/impaired renal function (%) | 12.7 | 20.3 | 16.8 | 3.24 | 5.5 | 13.6 | |
Previous myocardial infarction (%) | 16.0 | 3.70 | 28.7 | 4.24 | 13.3 | 23.2 | |
Previous cerebrovascular accident (%) | 4.7 | 4.12 | NR | 6.7 | 6.1 | 2.6 | |
Indications for PCI | Stable angina/stable CAD | 25.5 | 0 | 35.2 | 41.8 | 61.1 | 53.1 |
Unstable angina | 35.6 | 30.3 | 35.0 | 32.0 | 13.4 | 12.7 | |
NSTEMI | 19.4 | 33.6 | 29.8 | 15.7 | 5.9 | 21.1 | |
STEMI | 17.2 | 36.1 | 0 | 10.5 | 18.4 | 13.1 | |
Follow up time (years) | 2 | 1 | 1 | 1 | 1 | 2 | |
DAPT duration | 6–18 months in both arms | 3-month DAPT followed by ticagrelor monotherapy vs. 12-month DAPT | 3-month DAPT followed by P2Y12 inhibitors monotherapy vs. 12-month DAPT | 3-month DAPT followed by P2Y12 inhibitors monotherapy vs. 12-month DAPT | 1-month DAPT followed by clopidogrel o compared withstandard 12-month DAPT | Ticagrelor plus aspirin for 1 month, followed by ticagrelor monotherapy for 23 months vs. aspirin plus clopidogrel or ticagrelor for 12 months, followed by aspirin monotherapy for 12 months | |
Secondary prevention type | Dual antiplatelet therapy without clinical events for 6–18 months after percutaneous coronary intervention with DES | Acute coronary syndrome patients treated with drug-eluting stents | Dual antiplatelet therapy after percutaneous coronary intervention (PCI) | P2Y12 inhibitor monotherapy short-duration dual antiplatelettherapy (DAPT) vs. standard DAPT in patients undergoing percutaneous coronary intervention (PCI) | 1 month of DAPT compared withstandard 12 months of DAPT | Percutaneous coronary intervention using DES for stable coronary artery disease or acute coronary syndromes | |
P2Y12 vs. Aspirin dose | Clopidogrel 75 mg vs. aspirin 100 mg | Aspirin 300 mg loading followed by 100 mg daily. Ticagrelor 180 mg loading followed by 90 mg daily | Aspirin 81 to 100 mg daily, ticagrelor 90 mg twice daily | Aspirin 100 mg once daily plus clopidogrel 75 mg once daily or prasugrel 10 mg once daily or ticagrelor 90 mg twice daily for 3 months in both groups | 81 to 200mg/d, and clopidogrel,75 mg/d, or aspirin, 81 to 200 mg/d, and prasugrel 3.75 mg/d | Ticagrelor 90 mg twice daily vs. aspirin 75–100 mg daily | |
Outcomes | Myocardial infarction | HR = 0.65 (0.36 to 1.17) | HR = 0.55 (0.20 to 1.48) | HR = 1.0 (0.75 to 1.33) | HR = 0.66 (0.31 to 1.40) | HR = 1.19 (0.54 to 2.67) | RR = 1.0 (0.84 to 1.19) |
Stroke | HR = 0.42 (0.24 to 0.73) | HR = 0.73 (0.29 to 1.81) | HR = 2.0 (0.86 to 4.67) | HR = (2.23 (0.78 to 6.43) | HR = 0.50 (0.22 to 1.18) | RR = 0.98 (0.72 to 1.33) | |
CV mortality | HR = 1.37 (0.69 to 2.73) | NR | HR = 0.70 (0.43 to 1.16) | HR = 0.86 (0.38 to 1.91) | HR = 0.83 (0.34 to 1.99) | NR | |
All-cause mortality | HR = 1.43 (0.93 to 2.19) | HR = 0.70 (0.37 to 1.32) | HR = 0.75 (0.48 to 1.18) | HR = 1.18 (0.63 to 2.21) | HR = 1.18 (0.63 to 2.21) | RR = 0.88 (0.74 to 1.06) | |
Bleeding | HR = 0.63 (0.41 to 0.97) | HR = 0.56 (0.34 to 0.91) | HR = 0.56 (0.45 to 0.68) | HR = 0.87 (0.40 to 1.88) | HR = 0.19 (0.05 to 0.65) | RR = 0.95 (0.76 to 1.18) |
2.3. DAPT Duration
2.4. Aspirin Use in Patients Undergoing CABG
2.5. Contribution of P2Y12 Inhibitor Use
2.5.1. Primary Prevention
2.5.2. Secondary Prevention
Loading for STEMI, NSTEMI or Elective PCI
Long-Term Treatment for Secondary Prevention
Long-Term P2Y12 Use after CABG
3. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Abbreviations and Acronyms
ACS | acute coronary syndromes |
CABG | coronary artery bypass grafting surgery |
CAD | coronary artery disease |
COR | class of recommendation |
LOE | level of evidence |
NSTEMI | non-ST elevation myocardial infarction |
PCI | percutaneous coronary intervention |
STEMI | ST-elevation myocardial infarction |
References
- O’Gara, P.T.; Kushner, F.G.; Ascheim, D.D.; Casey, D.E., Jr.; Chung, M.K.; de Lemos, J.A.; Ettinger, S.M.; Fang, J.C.; Fesmire, F.M.; Franklin, B.A.; et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013, 127, e362–e425. [Google Scholar] [CrossRef] [PubMed]
- Amsterdam, E.A.; Wenger, N.K.; Brindis, R.G.; Casey, D.E., Jr.; Ganiats, T.G.; Holmes, D.R., Jr.; Jaffe, A.S.; Jneid, H.; Kelly, R.F.; Kontos, M.C.; et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J. Am. Coll. Cardiol. 2014, 64, e139–e228. [Google Scholar] [CrossRef] [PubMed]
- Arnett, D.K.; Blumenthal, R.S.; Albert, M.A.; Buroker, A.B.; Goldberger, Z.D.; Hahn, E.J.; Himmelfarb, C.D.; Khera, A.; Lloyd-Jones, D.; McEvoy, J.W.; et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019, 140, e596–e646. [Google Scholar] [CrossRef] [PubMed]
- Collet, J.P.; Thiele, H.; Barbato, E.; Barthélémy, O.; Bauersachs, J.; Bhatt, D.L.; Dendale, P.; Dorobantu, M.; Edvardsen, T.; Folliguet, T.; et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur. Heart J. 2021, 42, 1289–1367. [Google Scholar] [CrossRef] [PubMed]
- Davidson, K.W.; Barry, M.J.; Mangione, C.M.; Cabana, M.; Chelmow, D.; Coker, T.R.; Davis, E.M.; Donahue, K.E.; Jaén, C.R.; Krist, A.H.; et al. Aspirin Use to Prevent Cardiovascular Disease: US Preventive Services Task Force Recommendation Statement. JAMA 2022, 327, 1577–1584. [Google Scholar] [CrossRef] [PubMed]
- Ye, R.; Jneid, H.; Alam, M.; Uretsky, B.F.; Atar, D.; Kitakaze, M.; Davidson, S.M.; Yellon, D.M.; Birnbaum, Y. Do We Really Need Aspirin Loading for STEMI? Cardiovasc. Drugs Ther. 2022, 36, 1221–1238. [Google Scholar] [CrossRef]
- Gaziano, J.M.; Brotons, C.; Coppolecchia, R.; Cricelli, C.; Darius, H.; Gorelick, P.B.; Howard, G.; Pearson, T.A.; Rothwell, P.M.; Ruilope, L.M.; et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): A randomised, double-blind, placebo-controlled trial. Lancet 2018, 392, 1036–1046. [Google Scholar] [CrossRef]
- Bowman, L.; Mafham, M.; Wallendszus, K.; Stevens, W.; Buck, G.; Barton, J.; Murphy, K.; Aung, T.; Haynes, R.; Cox, J.; et al. Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus. N. Engl. J. Med. 2018, 379, 1529–1539. [Google Scholar] [CrossRef]
- McNeil, J.J.; Wolfe, R.; Woods, R.L.; Tonkin, A.M.; Donnan, G.A.; Nelson, M.R.; Reid, C.M.; Lockery, J.E.; Kirpach, B.; Storey, E.; et al. Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly. N. Engl. J. Med. 2018, 379, 1509–1518. [Google Scholar] [CrossRef]
- CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996, 348, 1329–1339. [Google Scholar] [CrossRef]
- Pettersen, A.; Seljeflot, I.; Abdelnoor, M.; Arnesen, H. High On-Aspirin Platelet Reactivity and Clinical Outcome in Patients With Stable Coronary Artery Disease: Results From ASCET (Aspirin Nonresponsiveness and Clopidogrel Endpoint Trial). J. Am. Heart Assoc. 2012, 1, e000703. [Google Scholar] [CrossRef]
- Woodward, M.; Lowe, G.D.; Francis, L.M.; Rumley, A.; Cobbe, S.M. A randomized comparison of the effects of aspirin and clopidogrel on thrombotic risk factors and C-reactive protein following myocardial infarction: The CADET trial. J. Thromb. Haemost. 2004, 2, 1934–1940. [Google Scholar] [CrossRef]
- Schunkert, H.; Boening, A.; von Scheidt, M.; Lanig, C.; Gusmini, F.; de Waha, A.; Kuna, C.; Fach, A.; Grothusen, C.; Oberhoffer, M.; et al. Randomized trial of ticagrelor vs. aspirin in patients after coronary artery bypass grafting: The TiCAB trial. Eur. Heart J. 2019, 40, 2432–2440. [Google Scholar] [CrossRef]
- Zhao, Q.; Zhu, Y.; Xu, Z.; Cheng, Z.; Mei, J.; Chen, X.; Wang, X. Effect of Ticagrelor Plus Aspirin, Ticagrelor Alone, or Aspirin Alone on Saphenous Vein Graft Patency 1 Year After Coronary Artery Bypass Grafting: A Randomized Clinical Trial. JAMA 2018, 319, 1677–1686. [Google Scholar] [CrossRef]
- Johnston, S.C.; Amarenco, P.; Albers, G.W.; Denison, H.; Easton, J.D.; Evans, S.R.; Held, P.; Jonasson, J.; Minematsu, K.; Molina, C.A.; et al. Ticagrelor versus Aspirin in Acute Stroke or Transient Ischemic Attack. N. Engl. J. Med. 2016, 375, 35–43. [Google Scholar] [CrossRef]
- Wang, Y.; Wang, Y.; Zhao, X.; Liu, L.; Wang, D.; Wang, C.; Wang, C.; Li, H.; Meng, X.; Cui, L.; et al. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N. Engl. J. Med. 2013, 369, 11–19. [Google Scholar] [CrossRef]
- Vranckx, P.; Valgimigli, M.; Jüni, P.; Hamm, C.; Steg, P.G.; Heg, D.; van Es, G.A.; McFadden, E.P.; Onuma, Y.; van Meijeren, C.; et al. Ticagrelor plus aspirin for 1 month, followed by ticagrelor monotherapy for 23 months vs aspirin plus clopidogrel or ticagrelor for 12 months, followed by aspirin monotherapy for 12 months after implantation of a drug-eluting stent: A multicentre, open-label, randomised superiority trial. Lancet 2018, 392, 940–949. [Google Scholar] [CrossRef]
- Koo, B.K.; Kang, J.; Park, K.W.; Rhee, T.M.; Yang, H.M.; Won, K.B.; Rha, S.W.; Bae, J.W.; Lee, N.H.; Hur, S.H.; et al. Aspirin versus clopidogrel for chronic maintenance monotherapy after percutaneous coronary intervention (HOST-EXAM): An investigator-initiated, prospective, randomised, open-label, multicentre trial. Lancet 2021, 397, 2487–2496. [Google Scholar] [CrossRef] [PubMed]
- Byrne, R.A.; Rossello, X.; Coughlan, J.J.; Barbato, E.; Berry, C.; Chieffo, A.; Claeys, M.J.; Dan, G.A.; Dweck, M.R.; Galbraith, M.; et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. Acute Cardiovasc. Care 2023, 12, zuad107. [Google Scholar] [CrossRef] [PubMed]
- Peto, R.; Gray, R.; Collins, R.; Wheatley, K.; Hennekens, C.; Jamrozik, K.; Warlow, C.; Hafner, B.; Thompson, E.; Norton, S.; et al. Randomised trial of prophylactic daily aspirin in British male doctors. Br. Med. J. Clin. Res. Ed. 1988, 296, 313–316. [Google Scholar] [CrossRef] [PubMed]
- Steering Committee of the Physicians’ Health Study Research Group. Final report on the aspirin component of the ongoing Physicians’ Health Study. N. Engl. J. Med. 1989, 321, 129–135. [Google Scholar] [CrossRef] [PubMed]
- Hansson, L.; Zanchetti, A.; Carruthers, S.G.; Dahlöf, B.; Elmfeldt, D.; Julius, S.; Ménard, J.; Rahn, K.H.; Wedel, H.; Westerling, S. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: Principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet 1998, 351, 1755–1762. [Google Scholar] [CrossRef]
- Thrombosis prevention trial: Randomised trial of low-intensity oral anticoagulation with warfarin and low-dose aspirin in the primary prevention of ischaemic heart disease in men at increased risk. The Medical Research Council’s General Practice Research Framework. Lancet 1998, 351, 233–241.
- de Gaetano, G. Low-dose aspirin and vitamin E in people at cardiovascular risk: A randomised trial in general practice. Collaborative Group of the Primary Prevention Project. Lancet 2001, 357, 89–95. [Google Scholar] [CrossRef]
- Ridker, P.M.; Cook, N.R.; Lee, I.M.; Gordon, D.; Gaziano, J.M.; Manson, J.E.; Hennekens, C.H.; Buring, J.E. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N. Engl. J. Med. 2005, 352, 1293–1304. [Google Scholar] [CrossRef]
- Fowkes, F.G.; Price, J.F.; Stewart, M.C.; Butcher, I.; Leng, G.C.; Pell, A.C.; Sandercock, P.A.; Fox, K.A.; Lowe, G.D.; Murray, G.D. Aspirin for prevention of cardiovascular events in a general population screened for a low ankle brachial index: A randomized controlled trial. JAMA 2010, 303, 841–848. [Google Scholar] [CrossRef]
- Ikeda, Y.; Shimada, K.; Teramoto, T.; Uchiyama, S.; Yamazaki, T.; Oikawa, S.; Sugawara, M.; Ando, K.; Murata, M.; Yokoyama, K.; et al. Low-dose aspirin for primary prevention of cardiovascular events in Japanese patients 60 years or older with atherosclerotic risk factors: A randomized clinical trial. JAMA 2014, 312, 2510–2520. [Google Scholar] [CrossRef]
- Ogawa, H.; Nakayama, M.; Morimoto, T.; Uemura, S.; Kanauchi, M.; Doi, N.; Jinnouchi, H.; Sugiyama, S.; Saito, Y. Low-dose aspirin for primary prevention of atherosclerotic events in patients with type 2 diabetes: A randomized controlled trial. JAMA 2008, 300, 2134–2141. [Google Scholar] [CrossRef]
- Belch, J.; MacCuish, A.; Campbell, I.; Cobbe, S.; Taylor, R.; Prescott, R.; Lee, R.; Bancroft, J.; MacEwan, S.; Shepherd, J.; et al. The prevention of progression of arterial disease and diabetes (POPADAD) trial: Factorial randomised placebo controlled trial of aspirin and antioxidants in patients with diabetes and asymptomatic peripheral arterial disease. BMJ 2008, 337, a1840. [Google Scholar] [CrossRef]
- Cacciatore, S.; Spadafora, L.; Bernardi, M.; Galli, M.; Betti, M.; Perone, F.; Nicolaio, G.; Marzetti, E.; Martone, A.M.; Landi, F.; et al. Management of Coronary Artery Disease in Older Adults: Recent Advances and Gaps in Evidence. J. Clin. Med. 2023, 12, 5233. [Google Scholar] [CrossRef] [PubMed]
- Khan, S.U.; Lone, A.N.; Kleiman, N.S.; Arshad, A.; Jain, V.; Al Rifai, M.; Arshad, H.B.; Dani, S.S.; Khera, A.; Morris, P.B.; et al. Aspirin With or Without Statin in Individuals Without Atherosclerotic Cardiovascular Disease Across Risk Categories. JACC Adv. 2023, 2, 100197. [Google Scholar] [CrossRef]
- Kulik, A.; Ruel, M.; Jneid, H.; Ferguson, T.B.; Hiratzka, L.F.; Ikonomidis, J.S.; Lopez-Jimenez, F.; McNallan, S.M.; Patel, M.; Roger, V.L.; et al. Secondary prevention after coronary artery bypass graft surgery: A scientific statement from the American Heart Association. Circulation 2015, 131, 927–964. [Google Scholar] [CrossRef]
- Virani, S.S.; Newby, L.K.; Arnold, S.V.; Bittner, V.; Brewer, L.C.; Demeter, S.H.; Dixon, D.L.; Fearon, W.F.; Hess, B.; Johnson, H.M.; et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023, 148, e9–e119. [Google Scholar] [CrossRef] [PubMed]
- Théroux, P.; Ouimet, H.; McCans, J.; Latour, J.G.; Joly, P.; Lévy, G.; Pelletier, E.; Juneau, M.; Stasiak, J.; deGuise, P.; et al. Aspirin, heparin, or both to treat acute unstable angina. N. Engl. J. Med. 1988, 319, 1105–1111. [Google Scholar] [CrossRef]
- Ibánez, B.; James, S.; Agewall, S.; Antunes, M.J.; Bucciarelli-Ducci, C.; Bueno, H.; Caforio, A.L.P.; Crea, F.; Goudevenos, J.A.; Halvorsen, S.; et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Rev. Esp. Cardiol. Engl. Ed. 2017, 70, 1082. [Google Scholar] [CrossRef] [PubMed]
- Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Lancet 1988, 2, 349–360.
- Lawton, J.S.; Tamis-Holland, J.E.; Bangalore, S.; Bates, E.R.; Beckie, T.M.; Bischoff, J.M.; Bittl, J.A.; Cohen, M.G.; DiMaio, J.M.; Don, C.W.; et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022, 145, e18–e114. [Google Scholar] [CrossRef]
- Barnathan, E.S.; Schwartz, J.S.; Taylor, L.; Laskey, W.K.; Kleaveland, J.P.; Kussmaul, W.G.; Hirshfeld, J.W., Jr. Aspirin and dipyridamole in the prevention of acute coronary thrombosis complicating coronary angioplasty. Circulation 1987, 76, 125–134. [Google Scholar] [CrossRef]
- Schwartz, L.; Bourassa, M.G.; Lespérance, J.; Aldridge, H.E.; Kazim, F.; Salvatori, V.A.; Henderson, M.; Bonan, R.; David, P.R. Aspirin and dipyridamole in the prevention of restenosis after percutaneous transluminal coronary angioplasty. N. Engl. J. Med. 1988, 318, 1714–1719. [Google Scholar] [CrossRef]
- Birnbaum, Y.; Lin, Y.; Ye, Y.; Martinez, J.D.; Huang, M.H.; Lui, C.Y.; Perez-Polo, J.R.; Uretsky, B.F. Aspirin before reperfusion blunts the infarct size limiting effect of atorvastatin. Am. J. Physiol. Heart Circ. Physiol. 2007, 292, H2891–H2897. [Google Scholar] [CrossRef]
- Cairns, J.A.; Gent, M.; Singer, J.; Finnie, K.J.; Froggatt, G.M.; Holder, D.A.; Jablonsky, G.; Kostuk, W.J.; Melendez, L.J.; Myers, M.G.; et al. Aspirin, sulfinpyrazone, or both in unstable angina. Results of a Canadian multicenter trial. N. Engl. J. Med. 1985, 313, 1369–1375. [Google Scholar] [CrossRef] [PubMed]
- Lewis, H.D., Jr.; Davis, J.W.; Archibald, D.G.; Steinke, W.E.; Smitherman, T.C.; Doherty, J.E., 3rd; Schnaper, H.W.; LeWinter, M.M.; Linares, E.; Pouget, J.M.; et al. Protective effects of aspirin against acute myocardial infarction and death in men with unstable angina. Results of a Veterans Administration Cooperative Study. N. Engl. J. Med. 1983, 309, 396–403. [Google Scholar] [CrossRef] [PubMed]
- Baigent, C.; Blackwell, L.; Collins, R.; Emberson, J.; Godwin, J.; Peto, R.; Buring, J.; Hennekens, C.; Kearney, P.; Meade, T.; et al. Aspirin in the primary and secondary prevention of vascular disease: Collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009, 373, 1849–1860. [Google Scholar] [CrossRef] [PubMed]
- Valgimigli, M.; Bueno, H.; Byrne, R.A.; Collet, J.P.; Costa, F.; Jeppsson, A.; Jüni, P.; Kastrati, A.; Kolh, P.; Mauri, L.; et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Eur. J. Cardiothorac. Surg. 2018, 53, 34–78. [Google Scholar] [CrossRef]
- Levine, G.N.; Bates, E.R.; Bittl, J.A.; Brindis, R.G.; Fihn, S.D.; Fleisher, L.A.; Granger, C.B.; Lange, R.A.; Mack, M.J.; Mauri, L.; et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Circulation 2016, 134, e123–e155. [Google Scholar] [CrossRef]
- Hahn, J.Y.; Song, Y.B.; Oh, J.H.; Chun, W.J.; Park, Y.H.; Jang, W.J.; Im, E.S.; Jeong, J.O.; Cho, B.R.; Oh, S.K.; et al. Effect of P2Y12 Inhibitor Monotherapy vs Dual Antiplatelet Therapy on Cardiovascular Events in Patients Undergoing Percutaneous Coronary Intervention: The SMART-CHOICE Randomized Clinical Trial. JAMA 2019, 321, 2428–2437. [Google Scholar] [CrossRef]
- Watanabe, H.; Domei, T.; Morimoto, T.; Natsuaki, M.; Shiomi, H.; Toyota, T.; Ohya, M.; Suwa, S.; Takagi, K.; Nanasato, M.; et al. Effect of 1-Month Dual Antiplatelet Therapy Followed by Clopidogrel vs 12-Month Dual Antiplatelet Therapy on Cardiovascular and Bleeding Events in Patients Receiving PCI: The STOPDAPT-2 Randomized Clinical Trial. JAMA 2019, 321, 2414–2427. [Google Scholar] [CrossRef]
- Kang, J.; Kim, H.S. The Evolving Concept of Dual Antiplatelet Therapy after Percutaneous Coronary Intervention: Focus on Unique Feature of East Asian and “Asian Paradox”. Korean Circ. J. 2018, 48, 537–551. [Google Scholar] [CrossRef]
- Andò, G.; De Santis, G.A.; Greco, A.; Pistelli, L.; Francaviglia, B.; Capodanno, D.; De Caterina, R.; Capranzano, P. P2Y(12) Inhibitor or Aspirin Following Dual Antiplatelet Therapy After Percutaneous Coronary Intervention: A Network Meta-Analysis. JACC Cardiovasc. Interv. 2022, 15, 2239–2249. [Google Scholar] [CrossRef]
- Kim, B.-K.; Hong, S.-J.; Cho, Y.-H.; Yun, K.H.; Kim, Y.H.; Suh, Y.; Cho, J.Y.; Her, A.-Y.; Cho, S.; Jeon, D.W.; et al. Effect of Ticagrelor Monotherapy vs Ticagrelor With Aspirin on Major Bleeding and Cardiovascular Events in Patients With Acute Coronary Syndrome: The TICO Randomized Clinical Trial. JAMA 2020, 323, 2407–2416. [Google Scholar] [CrossRef]
- Mehran, R.; Baber, U.; Sharma, S.K.; Cohen, D.J.; Angiolillo, D.J.; Briguori, C.; Cha, J.Y.; Collier, T.; Dangas, G.; Dudek, D.; et al. Ticagrelor with or without Aspirin in High-Risk Patients after PCI. N. Engl. J. Med. 2019, 381, 2032–2042. [Google Scholar] [CrossRef]
- Hong, S.J.; Lee, S.J.; Suh, Y.; Yun, K.H.; Kang, T.S.; Shin, S.; Kwon, S.W.; Lee, J.W.; Cho, D.K.; Park, J.K.; et al. Stopping Aspirin Within 1 Month After Stenting for Ticagrelor Monotherapy in Acute Coronary Syndrome: The T-PASS Randomized Noninferiority Trial. Circulation, 2023; ahead of print. [Google Scholar] [CrossRef]
- Lee, S.Y.; Jeong, Y.H.; Yun, K.H.; Cho, J.Y.; Gorog, D.A.; Angiolillo, D.J.; Kim, J.W.; Jang, Y. P2Y(12) Inhibitor Monotherapy Combined With Colchicine Following PCI in ACS Patients: The MACT Pilot Study. JACC Cardiovasc. Interv. 2023, 16, 1845–1855. [Google Scholar] [CrossRef] [PubMed]
- Gragnano, F.; Mehran, R.; Branca, M.; Franzone, A.; Baber, U.; Jang, Y.; Kimura, T.; Hahn, J.Y.; Zhao, Q.; Windecker, S.; et al. P2Y(12) Inhibitor Monotherapy or Dual Antiplatelet Therapy After Complex Percutaneous Coronary Interventions. J. Am. Coll. Cardiol. 2023, 81, 537–552. [Google Scholar] [CrossRef] [PubMed]
- Lawton, J.S.; Tamis-Holland, J.E.; Bangalore, S.; Bates, E.R.; Beckie, T.M.; Bischoff, J.M.; Bittl, J.A.; Cohen, M.G.; DiMaio, J.M.; Don, C.W.; et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022, 145, e4–e17. [Google Scholar] [CrossRef] [PubMed]
- Chesebro, J.H.; Clements, I.P.; Fuster, V.; Elveback, L.R.; Smith, H.C.; Bardsley, W.T.; Frye, R.L.; Holmes, D.R., Jr.; Vlietstra, R.E.; Pluth, J.R.; et al. A platelet-inhibitor-drug trial in coronary-artery bypass operations: Benefit of perioperative dipyridamole and aspirin therapy on early postoperative vein-graft patency. N. Engl. J. Med. 1982, 307, 73–78. [Google Scholar] [CrossRef]
- Steinhubl, S.R.; Berger, P.B.; Mann, J.T., 3rd; Fry, E.T.; DeLago, A.; Wilmer, C.; Topol, E.J. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: A randomized controlled trial. JAMA 2002, 288, 2411–2420. [Google Scholar] [CrossRef]
- Sabatine, M.S.; Cannon, C.P.; Gibson, C.M.; López-Sendón, J.L.; Montalescot, G.; Theroux, P.; Lewis, B.S.; Murphy, S.A.; McCabe, C.H.; Braunwald, E. Effect of clopidogrel pretreatment before percutaneous coronary intervention in patients with ST-elevation myocardial infarction treated with fibrinolytics: The PCI-CLARITY study. JAMA 2005, 294, 1224–1232. [Google Scholar] [CrossRef]
- Patti, G.; Colonna, G.; Pasceri, V.; Pepe, L.L.; Montinaro, A.; Di Sciascio, G. Randomized trial of high loading dose of clopidogrel for reduction of periprocedural myocardial infarction in patients undergoing coronary intervention: Results from the ARMYDA-2 (Antiplatelet therapy for Reduction of MYocardial Damage during Angioplasty) study. Circulation 2005, 111, 2099–2106. [Google Scholar] [CrossRef]
- European Society of Cardiology. Dual-Antiplatelet Therapy Should Remain Standard Strategy after Stent Implantation. Available online: https://www.escardio.org/The-ESC/Press-Office/Press-releases/Dual-antiplatelet-therapy-should-remain-standard-strategy-after-stent-implantation (accessed on 26 August 2023).
- Montalescot, G.; van ‘t Hof, A.W.; Lapostolle, F.; Silvain, J.; Lassen, J.F.; Bolognese, L.; Cantor, W.J.; Cequier, A.; Chettibi, M.; Goodman, S.G.; et al. Prehospital ticagrelor in ST-segment elevation myocardial infarction. N. Engl. J. Med. 2014, 371, 1016–1027. [Google Scholar] [CrossRef]
- Montalescot, G.; Bolognese, L.; Dudek, D.; Goldstein, P.; Hamm, C.; Tanguay, J.F.; ten Berg, J.M.; Miller, D.L.; Costigan, T.M.; Goedicke, J.; et al. Pretreatment with prasugrel in non-ST-segment elevation acute coronary syndromes. N. Engl. J. Med. 2013, 369, 999–1010. [Google Scholar] [CrossRef] [PubMed]
- Harrington, R.A.; Stone, G.W.; McNulty, S.; White, H.D.; Lincoff, A.M.; Gibson, C.M.; Pollack, C.V., Jr.; Montalescot, G.; Mahaffey, K.W.; Kleiman, N.S.; et al. Platelet inhibition with cangrelor in patients undergoing PCI. N. Engl. J. Med. 2009, 361, 2318–2329. [Google Scholar] [CrossRef] [PubMed]
- Bhatt, D.L.; Stone, G.W.; Mahaffey, K.W.; Gibson, C.M.; Steg, P.G.; Hamm, C.W.; Price, M.J.; Leonardi, S.; Gallup, D.; Bramucci, E.; et al. Effect of platelet inhibition with cangrelor during PCI on ischemic events. N. Engl. J. Med. 2013, 368, 1303–1313. [Google Scholar] [CrossRef]
- Leon, M.B.; Baim, D.S.; Popma, J.J.; Gordon, P.C.; Cutlip, D.E.; Ho, K.K.; Giambartolomei, A.; Diver, D.J.; Lasorda, D.M.; Williams, D.O.; et al. A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. N. Engl. J. Med. 1998, 339, 1665–1671. [Google Scholar] [CrossRef]
- Aggarwal, D.; Bhatia, K.; Chunawala, Z.S.; Furtado, R.H.M.; Mukherjee, D.; Dixon, S.R.; Jain, V.; Arora, S.; Zelniker, T.A.; Navarese, E.P.; et al. P2Y(12) inhibitor versus aspirin monotherapy for secondary prevention of cardiovascular events: Meta-analysis of randomized trials. Eur. Heart J. Open 2022, 2, oeac019. [Google Scholar] [CrossRef]
Author (Year) Trial | Study Period | No. of Patients | Male (%) | Age (yrs) | Diabetes (%) | Aspirin Dose/Day | Outcomes in RR or HR | |||
---|---|---|---|---|---|---|---|---|---|---|
Myocardial Infarction | Stroke | CV Mortality | All-Cause Mortality | |||||||
Non-diabetes | ||||||||||
Peto R (1988) [20] | 1978–1984 | 5139 | 100 | 61 | 2 | 500 mg | NR | NR | NR | NR |
Ongoing Physician Health Study (1989) [21] | 1982–1988 | 22,071 | NR | NR | 2 | 325 mg | RR = 0.56 (0.45–0.70) | RR = 1.22 (0.93–1.60) | RR = 0.96 (0.60–1.54) | RR = 0.96 (0.80–1.14) |
Hansson (1998) HOT trial [22] | 1992–1997 | 18,790 | 53 | 61 | 8 | 75 mg | RR = 0.85 (0.69–1.05) | RR = 0.98 (0.78–1.24) | RR = 0.95 (0.75–1.20) | RR = 0.93 (0.79–1.09) |
Thrombosis prevention trial (1998) [23] | 1984–1997 | 5499 | 100 | 57 | 2 | 75 mg | RR = 0.80 (0.64–0.99) | RR = 0.98 (0.65–1.47) | RR = 1.26 (0.93–1.69) | RR = 1.03 (0.80–1.32) |
Primary prevention project (2001) [24] | 1994–1998 | 4495 | 42 | 64 | 17 | 100 mg | RR = 0.69 (0.38–1.23) | RR = 0.67 (0.36–1.27) | RR = 0.56 (0.31–0.99) | RR = 0.81 (0.58–1.13) |
Ridker P (2005) Women’s health study [25] | 1992–2004 | 39,876 | 0 | 54 | 3 | 100 mg | RR = 1.02 (0.84–1.25) | RR = 0.83 (0.69–0.99) | RR = 0.95 (0.74–1.22) | RR = 0.95 (0.85–1.06) |
Fowkes (2010) Aspirin for Asymptomatic Atherosclerosis trial [26] | 1998–2008 | 3350 | 28 | 62 | 3 | 100 mg | NR | NR | NR | HR = 0.95 (0.77–1.16) |
Ikeda Y (2014) Japanese Primary Prevention Project (JPPP) [27] | 2002–2008 | 2539 | 55 | 65 | 34 | 100 mg | HR = 0.53 (0.31–0.91) | HR = 1.04 (0.80–1.34) | HR = 1.03 (0.71–1.48) | HR = 0.99 (0.85–1.17) |
Gaziano (2018) ARRIVE [7] | 2007–2016 | 12,546 | 70 | 64 | 0 | 100 mg | HR = 0.85 (0.64–1.11) | 1.12 (0.80–1.55) | HR = 0.97 (0.62–1.52) | HR = 0.99 (0.80–1.24) |
McNeil (2018) ASPREE [9] | 2010–2014 | 19,114 | 44 | 74 | 11 | 100 mg | HR = 0.93 (0.76–1.15) | HR = 0.95 (0.83–1.08) | NR | NR |
Diabetes | ||||||||||
Ogawa (2008) Japanese Primary Prevention of Atherosclerosis with Aspirin for diabetes [28] | 2002–2008 | 2539 | 55 | 65 | 100 | 81 or 100 mg | NR | HR = 0.84 (0.53–1.32) | NR | NR |
Belch (2008) Prevention of progression of arterial disease and diabetes (POPADAD) [29] | 1997–2006 | 1276 | 44 | 60 | 100 | 100 mg | HR = 0.98 (0.68–1.43) | HR = 0.71 (0.44–1.14) | HR = 1.35 (0.81–2.25) | HR = 0.93 (0.71–1.24) |
ASCEND (2018) [8] | 2005–2017 | 15,480 | 63 | 63 | 100 | 100 mg | HR = 0.98 (0.80–1.19) | 0.88 (0.73–1.06) | NR | NR |
Society | Guideline | Class of Recommendation | Level of Evidence |
---|---|---|---|
Primary prevention | |||
American College of Cardiology/American Heart Association guidelines for primary prevention of cardiovascular disease 2019 [3] | Low-dose aspirin 75–100 mg for primary prevention between ages 40 and 70 years with higher risk of atherosclerotic cardiovascular disease and not at increased risk of bleeding | IIb | A |
Preventive Services Task Force Recommendation Statement 2022 [5] | Aspirin as primary prevention for patient between 40 and 59 years who have a 10% or greater risk of cardiovascular disease who are not at increased risk of bleeding | - | C |
Secondary prevention | |||
2013 ACCF/AHA Guideline for the Management ofST-Elevation Myocardial Infarction [1] | Aspirin 162 to 325 mg should be given before primary PCI | I | B |
After PCI, aspirin should be continued indefinitely | I | A | |
2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation AcuteCoronary Syndromes [2] | Non–enteric-coated, chewable aspirin (162 mg to 325 mg) should be given to all patients with NSTE-ACS without contraindications as soon as possible after presentation, and a maintenance dose of aspirin (81 mg/d to 325 mg/d) should be continued indefinitely | I | A |
Aspirin maintenance dose continued indefinitely | I | A | |
Patients already taking daily aspirin before PCI should take 81 mg to 325 mg non–enteric-coated aspirin before PCI | I | B | |
2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation [4] | Aspirin is recommended for all patients without contraindications at an initial oral loading dose of 150 to 300 mg (or 75 to 250 mg i.v.), and at a maintenance dose of 75 to 100 mg daily for long-term treatment. | I | A |
2015 Secondary prevention after coronary artery bypass graft surgery: a scientific statement from the American Heart Association [32] | Aspirin should be administered preoperatively and within 6 h after CABG in doses of 81 to 325 mg daily followed by indefinite maintenance therapy to reduce graft occlusion and adverse cardiac events | I | A |
2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guidelines for the management of patients with chronic coronary disease [33] | Dual antiplatelet therapy consisting of aspirin and clopidogrel for 6 months post PCI followed by single antiplatelet therapy is indicated to reduce MACE and bleeding events | I | A |
Patient with chronic coronary disease recommended PCI and a drug-eluting stent who completed a 1- to 3-month course of dual antiplatelet therapy, P2Y12 inhibitor monotherapy for at least 12 months is reasonable to reduce bleeding risk | IIa | A | |
2023 ESC Guidelines for the management of acute coronary syndromes [19] | P2Y12 inhibitor monotherapy may be considered as an alternative to aspirin monotherapy for long-term treatment | IIb | A |
In high bleeding risk patients, aspirin or P2Y12 receptor inhibitor monotherapy after 1 month of DAPT may be considered | IIb | A | |
In patients who are event free after 3–6 months of DAPT and who are not at high ischemic risk, single antiplatelet therapy (preferably with a P2Y12 receptor inhibitor) should be considered | IIa | A |
Author (Year) Trial | Geographical Location | N | Male (%) | Age (yrs) | Follow up Time (yrs) | Secondary Prevention Type | P2Y12 vs. Aspirin Dose | Outcomes in RR or HR | ||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
MI | Stroke | CV Mortality | All-Cause Mortality | Bleeding | ||||||||
Clopidogrel (C) | ||||||||||||
CAPRIE (1996) [10] | International | 19,185 | 71.9 | 62.5 | 3 | ASCVD (ischemic stroke, MI, or PAD) | ASA 325 mg vs. C 75 mg | NR | NR | NR | RRR = 2.2 (−9.9 to 12.9) | NR |
CADET (2004) [12] | United Kingdom | 184 | 80.9 | 62.6 | 0.5 | Acute MI within the previous 3–7° days | C 75 mg vs. ASA 75 mg | NR | NR | NR | NR | NR |
ASCET (2012) [11] | Norway | 1001 | 78.2 | 62.4 | 2 | SIHD | ASA 160 mg vs. C 75 mg | RR = 2.05 (0.62 to 6.80) | RR = 2.05 (0.37 to 11.17) | NR | NR | NR |
Ticagrelor (T) | ||||||||||||
SOCRATES (2016) [15] | International | 13,199 | 58.4 | 65.8 | 0.25 | Acute ischemic stroke or transient ischemic attack | T 90 mg twice daily vs. ASA 100 mg | HR = 1.20 (0.67 to 2.14) | HR = 0.86 (0.75 to 0.99) | HR = 1.18 (0.75 to 1.85) | HR = 1.18 (0.83 to 1.67) | HR = 0.83 (0.52 to 1.34) |
DACAB (2018) [14] | China | 332 | 82.8 | 63.6 | 1 | Post-coronary artery bypass grafting | T 90 mg twice daily vs. ASA 100 mg | NR | NR | NR | NR | NR |
TICAB (2019) [13] | International | 1859 | 84.9 | 66.7 | 1 | ACS or SIHD post- CABG | T90 mg twice daily vs. aspirin 100 mg | HR = 0.63 (0.36–1.12) | HR = 1.21 (0.70–2.08) | HR = 0.85 (0.38–1.89) | NR | HR = 1.02 (0.67–1.55) |
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Maqsood, M.H.; Levine, G.N.; Kleiman, N.D.; Hasdai, D.; Uretsky, B.F.; Birnbaum, Y. Do We Still Need Aspirin in Coronary Artery Disease? J. Clin. Med. 2023, 12, 7534. https://doi.org/10.3390/jcm12247534
Maqsood MH, Levine GN, Kleiman ND, Hasdai D, Uretsky BF, Birnbaum Y. Do We Still Need Aspirin in Coronary Artery Disease? Journal of Clinical Medicine. 2023; 12(24):7534. https://doi.org/10.3390/jcm12247534
Chicago/Turabian StyleMaqsood, Muhammad Haisum, Glenn N. Levine, Neal D. Kleiman, David Hasdai, Barry F. Uretsky, and Yochai Birnbaum. 2023. "Do We Still Need Aspirin in Coronary Artery Disease?" Journal of Clinical Medicine 12, no. 24: 7534. https://doi.org/10.3390/jcm12247534