Most cardiologist’s misstep on aspirin in ACS

Print

 Most cardiologist’s misstep
on aspirin in ACS

SNOWMASS, COLO: U.S. cardiologists are glaringly out of touch with the guidelines on maintenance aspirin dosing in patients with acute coronary syndrome, American College of Cardiology President Dr. Patrick T. O’Gara said at the Annual Cardiovascular Conference at Snowmass. The latest AHA/ACC guidelines state that maintenance aspirin therapy at 81 mg/day to be continued indefinitely is preferred over 325 mg/day in patients with ACS, regardless of whether they have received a coronary stent or noninvasive medical management (Circulation 2014 Dec 23;130(25):e344-426).

“This statement has been out there in the guidelines for several years now. Yet the last time we interrogated the NCDR [National Cardiovascular Data Registry], 70% of patients with ACS were discharged on 325 mg/day of aspirin in the U.S.,” said Dr. O’Gara, professor of medicine at Harvard Medical School and director of clinical cardiology at Brigham and Women’s Hospital, Boston.

The recommendation in the guidelines is based on several solid studies, including OASIS 7, which in more than 25,000 randomized patients showed no difference in outcomes when aspirin at 75-100 mg/day was compared with 300-325 mg/day, but an increased incidence of bleeding at the higher dose (N. Engl. J. Med. 2010;363:930-42).

“Aspirin at 81 mg/day is not inferior with respect to clinical efficacy and it’s superior with respect to its safety outcome. But here in the United States we are still very much wedded to using 325 mg of aspirin. I’m not exactly sure of the reasons for that. Maybe it’s a catch up phenomenon,” Dr. O’Gara commented.

In the setting of percutaneous coronary intervention with a bare metal or drug-eluting stent for patients with either non–ST-elevation ACS or ST-elevation MI, the AHA/ACC guidelines give a class I recommendation for at least 12 months of dual-antiplatelet therapy (DAPT) with aspirin and a P2Y inhibitor. Either ticagrelor (Brilinta) at 90 mg twice daily or prasugrel (Effient) once daily at 10 mg is recommended over clopidogrel at 75 mg/day in patients who can take those medications safely; this guidance is based on ticagrelor’s superior efficacy compared with clopidogrel as shown in TRITON TIMI-38 (N. Engl. J. Med. 2007;357:2001-15) and prasugrel’s superiority in the PLATO trial (N. Engl. J. Med. 2009;361:1045-57).

Recommended Readings

  1. New ACC/AHA guidelines will curb DAPT duration for some By: Bruce Jancin, Pediatric News Digital Network, Pediatric News, 2016
  2. Long-term DAPT offers ongoing post-MI benefit. Mitchel L. Zoler, Diabetes Hub
  3. Stent Thrombosis: A Disease for All Clinicians. Del RíOVj, Jeon C, RodríGuez O, Pneumonia Hub
  4. Long-term DAPT offers ongoing post-MI benefit. By: Mitchel L. Zoler, Rheumatology News Digital Network, Rheumatology News , 2015
  5. TRILOGY: Prasugrel, Clopidogrel Look Similar in ACS Patients. The Journal of Family Practice.
  6. Long-term antiplatelet therapy following myocardial infarction: implications of PEGASUS-TIMI 54William A E Parker et al., Heart, 2016.
  7. Outcomes with increased length of dual antiplatelet therapy after PCI  alindsay, HJS blog, 2014
  8. Dual antiplatelet therapy after acute coronary syndrome: a cardiologist-based optimal decision. Denis Angoulvant et al., Heart, 2015
  9. Current Status of Antiplatelet Therapy in Acute Coronary Syndrome Debabrata Dash, Cardiovasc Hematol Agents Med Chem, 2015
  10. Optimal doses for aspirin and clopidogrelrdeguzman, HJS blog, 2010