Aspirin desensitization procedures in aspirin intolerant patients: a neglected topic in the ESC 2019 Chronic Coronary Syndrome guidelines

This commentary refers to ‘2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes’, by J. Knuuti et al., on page 407. In the recently released Guidelines of the European Society of Cardiology on Chronic Coronary Syndromes (CCS), Knuuti et al.1 addressed the issue of aspirin intolerance in patients with CCS. The recommendation provided as Class I level of evidence B is to use clopidogrel instead of aspirin in patients with CCS intolerant to aspirin. Prasugrel or ticagrelor monotherapy may be considered after percutaneous coronary intervention (PCI) if dual antiplatelet therapy cannot be used because of aspirin intolerance (Class IIb recommendation, level of evidence C). Notably, aspirin desensitization procedures are not mentioned as a therapeutic option. Previous studies, however, demonstrated that several aspirin desensitization protocols are available and safe, with a rate of success over 90%.2–4 These procedures have been performed both in unstable and in stable patients, undergoing PCI. In contrast, to the best of our knowledge, only one published study with limited number of patients addressed safety and efficacy of prasugrel and ticagrelor monotherapy in patients with aspirin intolerance.5 On the basis of the available data, aspirin desensitization might be considered a valid therapeutic alternative to P2Y12 inhibitor monotherapy in patients with CCS and aspirin intolerance. Conflict of interest: none declared.