Lifelong Aspirin for All in the Secondary Prevention of Chronic Coronary Syndrome: Still Sacrosanct or is Reappraisal Warranted?

Alan P Jacobsen, Inbar Raber, Cian P McCarthy, Roger S Blumenthal, Deepak L Bhatt, Ronan W Cusack, Patrick Wjc Serruys, William Wijns, John W McEvoy
Circulation 2020 September 4
Four decades have passed since the first trial suggesting aspirin's efficacy in the secondary prevention of myocardial infarction. Further trials, summarized in the Antithrombotic Trialists' Collaboration, solidified the historical role of aspirin in secondary prevention. Although the benefit of aspirin in the immediate phase following a myocardial infarction remains incontrovertible, a number of emerging lines of evidence - discussed in this narrative review - now raise some uncertainty as to the primacy of aspirin for the lifelong management of all patients with chronic coronary syndrome (CCS). For example, data challenging the previously unquestioned role of aspirin in CCS have come from recent trials where aspirin was discontinued in specific clinical scenarios; including early discontinuation of the aspirin component of dual-antiplatelet therapy following percutaneous coronary intervention and the withholding of aspirin among CCS patients with atrial fibrillation who require anticoagulation. Added to this, recent primary prevention trials have failed to consistently demonstrate net benefit for aspirin in patients treated to optimal contemporary cardiovascular risk-factor targets, indicating that the efficacy of aspirin for secondary prevention of CCS may similarly have changed with the addition of more modern secondary prevention therapies. Therefore, the totality of recent evidence supports further study of the universal need for lifelong aspirin in the modern secondary prevention of all adults with CCS, particularly in stable older patients who are at highest risk for aspirin-induced bleeding.

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