Chronic stable angina treatment aspirin

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [4]; John Fani Srour, M.D.; Jinhui Wu, M.D.; Lakshmi Gopalakrishnan. M.B.B.S.; Aysha Anwar, M.B.B.S[5]

## Overview

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In patients with ischemic heart disease, prophylactic low dose aspirin prevents arterial thrombosis by irreversible inactivation of platelet aggregation.[1][2][3][4]

## Aspirin

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### Mechanisms of Benefit

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* Aspirin is a potent anti-platelet agent.

* Aspirin induces an irreversible functional defect in platelets by inhibiting cyclo oxygenase (COX-1) and subsequently suppressing the activation of thromboxane A2 that is responsible for platelet aggregation.[5]

* In patients with chronic stable angina, prior MI and unstable angina, aspirin improves survival and prevents infarction.[4]

* Aspirin has shown to improve endothelial function and at high doses reduce acute phase reactants.

### Indication

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All patients with chronic stable angina, aspirin unless contraindicated should be started at 75 to 162 mg/day and continued indefinitely.[3]

### Contraindications

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* Gastrointestinal bleed
* Aspirin hypersensitivity (triad of rhinitis, asthma and polyposis)
* Coagulation disorder
* Uncontrolled hypertension[6]

### Dosage

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* A dose range of 75 to 162 mg/day of aspirin[4] appears to be effective and is associated with lower risk of gastrointestinal bleeding.

* In comparison to a dose range of 160-325 mg/day, a lower dose of aspirin (75-162 mg/day) has a higher efficacy for secondary prevention.

* Aspirin improves endothelial function and at higher doses (300 mg/day) reduce the circulating levels of C-reactive protein.[7]

### Drug Interactions

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Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with an increased risk of bleeding and therefore, close monitoring is required.

### Adverse Effects

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A higher dose of aspirin is associated with increased risk of gastrointestinal bleed.[3]

### Supportive Trial Data

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* Meta-analysis (2002) of 140,000 patients from the Antiplatelet Trialists’ Collaboration showed that aspirin (75-325 mg/day) reduced the rate of subsequent myocardial infarction, stroke, and death in patients with history of angina pectoris, myocardial infarction, CABG, and stroke.[4]

* Meta-analysis (2000) of 24 randomized controlled trials involving 66,000 patients showed significant increase in the incidence of gastrointestinal hemorrhage associated with long term aspirin therapy. There was no supportive evidence of lower dose or modified release formulations reducing the incidence of GI bleed.[8]

* In the Swedish Angina Pectoris Aspirin Trial (SAPAT) (1992), aspirin (75 mg/day) in conjunction with the beta blocker sotalol conferred an additional 34% reduction in  acute myocardial infarction and sudden cardiac death among men and women with chronic stable angina.[9]

## 2012 Chronic Angina Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)[10][11][12]

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### Aspirin (DO NOT EDIT))[10][11][12]

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Class I

"1. Treatment with aspirin 75 to 162 mg daily should be continued indefinitely in the absence of contraindications in patients with SIHD. (Level of Evidence: A) "
Class IIa

"1. Treatment with aspirin 75 to 162 mg daily and clopidogrel 75 mg daily might be reasonable in certain high-risk patients with SIHD (Level of Evidence: B) "

## ESC Guidelines- Pharmacological Therapy to Improve Prognosis in Patients with Stable Angina (DO NOT EDIT) [13]

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### Aspirin (DO NOT EDIT)[13]

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Class I

"1. Aspirin 75 mg daily in all patients without speciﬁc contraindications (i.e. active GI bleeding, aspirin allergy, or previous aspirin intolerance). (Level of Evidence: B) "

## References

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1. ↑ (1994) Collaborative overview of randomised trials of antiplatelet therapy--I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists' Collaboration. BMJ 308 (6921):81-106. PMID: 8298418
2. ↑ Patrono C, Bachmann F, Baigent C, Bode C, De Caterina R, Charbonnier B et al. (2004) Expert consensus document on the use of antiplatelet agents. The task force on the use of antiplatelet agents in patients with atherosclerotic cardiovascular disease of the European society of cardiology. Eur Heart J 25 (2):166-81. PMID: 14720534
3. ↑ 3.0 3.1 3.2 Patrono C, Coller B, FitzGerald GA, Hirsh J, Roth G (2004) Platelet-active drugs: the relationships among dose, effectiveness, and side effects: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 126 (3 Suppl):234S-264S. DOI:10.1378/chest.126.3_suppl.234S PMID: 15383474
4. ↑ 4.0 4.1 4.2 4.3 Antithrombotic Trialists' Collaboration (2002) Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 324 (7329):71-86. PMID: 11786451
5. ↑ Patrono C (1994) Aspirin as an antiplatelet drug. N Engl J Med 330 (18):1287-94. DOI:10.1056/NEJM199405053301808 PMID: 8145785
6. ↑ Hansson L, Zanchetti A, Carruthers SG, Dahlöf B, Elmfeldt D, Julius S et al. (1998) 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 351 (9118):1755-62. PMID: 9635947
7. ↑ Ridker PM, Cushman M, Stampfer MJ, Tracy RP, Hennekens CH (1997) Inflammation, aspirin, and the risk of cardiovascular disease in apparently healthy men. N Engl J Med 336 (14):973-9. DOI:10.1056/NEJM199704033361401 PMID: 9077376
8. ↑ Derry S, Loke YK (2000) Risk of gastrointestinal haemorrhage with long term use of aspirin: meta-analysis. BMJ 321 (7270):1183-7. PMID: 11073508
9. ↑ Juul-Möller S, Edvardsson N, Jahnmatz B, Rosén A, Sørensen S, Omblus R (1992) Double-blind trial of aspirin in primary prevention of myocardial infarction in patients with stable chronic angina pectoris. The Swedish Angina Pectoris Aspirin Trial (SAPAT) Group. Lancet 340 (8833):1421-5. PMID: 1360557
10. ↑ 10.0 10.1 Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP; et al. (2012). "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 126 (25): 3097–137. doi:10.1161/CIR.0b013e3182776f83. PMID 23166210.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
11. ↑ 11.0 11.1 Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation 116 (23):2762-72.[1] PMID: 17998462
12. ↑ 12.0 12.1 Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina). Circulation 99 (21):2829-48. [2] PMID: 10351980
13. ↑ 13.0 13.1 Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology". Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)

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