CLINICAL PRACTICE GUIDELINES SUPPORT ASPIRIN USE IN SECONDARY CV EVENT PREVENTION

Practice guidelines recommend aspirin as a top-tier, first-line treatment option

Condition/
indication
Recommendation for Aspirin Use,
Including Dose and Time Frame
Supporting
Guidelines
Recurrent MI Non–enteric-coated, chewable aspirin (162-325 mg) should be given to all patients with NSTE ACS without contraindications as soon as possible after presentation; a maintenance dose of aspirin (81-325 mg/d) should be continued indefinitely (class I, level A). AHA/ACC 2014 Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes1
STEMI
  • Aspirin (162-325 mg) should be given before primary PCI (class I, level B)
  • After PCI, aspirin should be continued indefinitely (class I, level A)
    — 81 mg/d is the preferred maintenance dose (class IIa, level B)
2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction2
NSTEMI Non–enteric-coated, chewable aspirin (162-325 mg) should be given to all patients with NSTE ACS without contraindications as soon as possible after presentation; a maintenance dose of aspirin (81-325 mg/d) should be continued indefinitely (class I, level A). AHA/ACC 2014 Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes1
Chronic Stable Angina Pectoris Aspirin (75-162 mg/d) should be continued indefinitely in the absence of contraindications in patients with stable ischemic heart disease (class I, level A). 2012 ACCF/AHA/
ACP/AATS/
PCNA/SCAI/
STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease3
Unstable Angina Pectoris Non–enteric-coated, chewable aspirin (162-325 mg) should be given to all patients with NSTE ACS without contraindications as soon as possible after presentation; a maintenance dose of aspirin (81-325 mg/d) should be continued indefinitely (class I, level A). AHA/ACC 2014 Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes1
Post-CABG
  • Aspirin (81-325 mg/d) should be administered preoperatively and within 6 hours after CABG, then continued indefinitely to reduce graft occlusion and adverse cardiac events (class I, level A)
  • After off-pump CABG, dual antiplatelet therapy with aspirin (81-162 mg/d) plus clopidogrel (75 mg/d) should be administered for 1 year to reduce graft occlusion (class I, level A)
  • In patients who present with ACS, it is reasonable to administer combination antiplatelet therapy after CABG with aspirin plus either prasugrel or ticagrelor (preferred over clopidogrel); prospective clinical trial data from CABG populations are not yet available (class IIa, level B)
  • As sole antiplatelet therapy after CABG, it is reasonable to consider aspirin at a higher (325 mg/d) rather than a lower dose (81 mg/d), presumably to prevent aspirin resistance, but the benefits are not well established (class IIa, level A)
  • Combination therapy with aspirin plus clopidogrel for 1 year after on-pump CABG may be considered in patients without recent ACS, but the benefits are not well established (class IIb, level A)
AHA 2015 Statement on Secondary Prevention After Coronary Artery Bypass Graft Surgery4
Post-PCI
  • Dual antiplatelet therapy (in the form of aspirin plus a P2Y12 inhibitor) is indicated for ≥12 months in patients undergoing stent implantation (class I, level B)
  • Dual antiplatelet therapy in the form of aspirin plus either clopidogrel, ticagrelor, or prasugrel is recommended for >12 months after PCI, unless there are contraindications such as excessive risk of bleeding (class IIb, level A)
ACC/AHA 2016 Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease5
Carotid Endarterectomy (CEA) Aspirin (81-325 mg/d) is recommended before CEA and may be continued indefinitely postoperatively (class I, level A).

Beyond the first month after CEA, aspirin (75-325 mg/d), clopidogrel (75 mg/d), or the combination of low-dose aspirin (25 mg) plus extended-release dipyridamole (200 mg) twice daily should be administered for long-term prophylaxis against ischemic cardiovascular events (class I, level B).
ASA/ACCF/
AHA 2011 Guidelines6
In women who are to undergo CEA, aspirin is recommended unless contraindicated. NOTE: A specific aspirin dose is not given for this recommendation. (class I, level C) AHA/ASA 2014 Stroke Prevention Guidelines for Women7
Recurrent Ischemic Stroke and TIA Aspirin (50-325 mg/d) monotherapy, the combination of aspirin (25 mg) and extendedrelease dipyridamole (200 mg) twice daily, or clopidogrel (75 mg) is indicated as initial therapy after TIA or ischemic stroke for prevention of future stroke (class I, level A for monotherapy; class I, level B for combination with dipyridamole; class IIb, level B for clopidogrel). AHA/ASA 2014 Guidelines for Stroke Prevention After Stroke or TIA8
AATS=American Association for Thoracic Surgery; ACC=American College of Cardiology; ACCF=American College of Cardiology Foundation; ACP=American College of Physicians; ACS=acute coronary syndrome; AHA=American Heart Association; ASA=American Stroke Association; CABG=coronary artery bypass graft; MI=myocardial infarction; NSTE=non–ST-segment elevation; NSTEMI=non–ST-elevation myocardial infarction; PCI=percutaneous coronary intervention; PCNA=Preventive Cardiovascular Nurses Association; SCAI=Society for Cardiovascular Angiography and Interventions; STEMI=ST-elevation myocardial infarction; STS=Society of Thoracic Surgeons; TIA=transient ischemic attack.
References: 1. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes. J Am Coll Cardiol. 2014;64:e139-228. 2. O'Gara PT, Kushner FG, Ascheim DD, 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. J Am Coll Cardiol. 2013;61:e78-140. doi:10.1016/j.jacc.2012.11.019. 3. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease. J Am Coll Cardiol. 2012;60(24):e44-e164. 4. Kulik A, Ruel M, Jneid H, et al. Secondary prevention after coronary artery bypass graft surgery: a scientific statement from the American Heart Association. Circulation. 2015;131(10):927-964. doi:10.1161/CIR.0000000000000182. 5. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease. Circulation. 2016;134(10):e123-e155. doi:10.1161/CIR.0000000000000404. 6. Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/
SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. Stroke. 2011;42:e464-e540. 7. Bushnell C, McCullough LD, Awad IA, et al. Guidelines for the prevention of stroke in women. a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45:1545-1588. 8. Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(7):2160-2236.