Coronary syndromes following aspirin withdrawal
Key result
Aspirin withdrawal linked to ~2-fold higher rate of ST-elevation ACS vs continued use.
- P=0.001
- n=1,236
Why the study?
Although aspirin is sometimes stopped in coronary disease patients due to bleeding risk or poor compliance, it was not known whether aspirin withdrawal can be harmful or how often it precedes a relapse.
Does aspirin withdrawal increase the risk of acute coronary syndrome and ST-segment elevation ACS in patients with coronary disease?
Key Points
- To determine whether aspirin withdrawal is associated with recurrent acute coronary syndromes in patients with coronary disease.
- Between September 1999 and April 2002, 1,236 patients hospitalized for acute coronary syndrome (ACS) were interviewed to identify recent interruption of aspirin intake.
- Fifty-one ACS events occurred within 1 month of aspirin withdrawal (mean delay 10 ± 1.9 days), representing 4.1% of all coronary events and 13.3% of recurrent cases.
- Among relapsing patients, ST-segment elevation ACS was significantly higher in those who stopped aspirin compared to the 332 patients who continued therapy (39% vs. 18%; p = 0.001).
- Ten cases (20%) involved thrombosis of an uncoated stent placed on average 15.5 ± 6.5 months earlier, with common withdrawal reasons being non-compliance (20 cases), dental treatment (13 cases), and endoscopy (8 cases).
Study Design
Type
Observational (n=1,236)
Structured PICO
Does aspirin withdrawal increase the risk of acute coronary syndrome and ST-segment elevation ACS in patients with coronary disease?
P
Population
1,236 patients hospitalized for acute coronary syndrome between September 1999 and April 2002, including 383 with recurrent coronary events.
E
Exposure
Aspirin withdrawal within 1 month prior to the acute coronary syndrome event (due to minor surgery, fibroscopy, dental treatment, bleeding, or non-compliance)
C
Comparator
Continuous aspirin intake (patients with recurrent ACS who did not stop aspirin, n=332)
O
Outcome
Occurrence of acute coronary syndrome (ACS) within 1 month after aspirin withdrawal, including incidence of ST-segment elevation ACShard clinical
Main Result
Absolute Event Rate: 39% vs 18%
p-value: p=0.001
Aspirin withdrawal in patients with coronary artery disease is associated with a significant risk of recurrent acute coronary events, particularly ST-segment elevation ACS and late bare-metal stent thrombosis, typically occurring around 10 days after discontinuation.
Limitations
- Assessment of the exact incidence of coronary recurrences after aspirin withdrawal will need prospective studies.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Coronary patients preparing for dental work or surgery are often advised to stop taking aspirin to avoid increased bleeding. Our study serves as a reminder for all medical professionals who treat coronary patients that aspirin withdrawal should not be advised and that alternative recommendations should be considered.”
RSRichard S. IrwinPresident, American College of Chest Physicians
“[This study] sends a message to all medical professionals that the decision to discontinue aspirin therapy should not be taken lightly.”
Implication
Aspirin withdrawal warrants caution in CAD patients; observational data leaves open causal confirmation in randomized trials.
Abstract
Objectives We sought to determine whether aspirin withdrawal is an encountered situation in coronary disease patients who relapsed. Background Despite the recognized benefits of aspirin in coronary disease, and because of the threat of bleeding or poor compliance, aspirin intake is sometimes stopped. It is not known whether withdrawal of aspirin can be harmful in coronary-disease patients. Methods Between September 1999 and April 2002, a total of 1,236 patients hospitalized for acute coronary syndrome (ACS) were questioned in order to determine whether aspirin intake had been interrupted. Results Fifty-one of these ACSs occurred within 1 month after aspirin withdrawal. This represents 4.1% of all coronary events but 13.3% of recurrences. Among those patients who relapsed, the incidence of ST-segment elevation ACS was higher in those who stopped aspirin when compared to the 332 patients who did not stop aspirin (39% vs. 18%; p = 0.001). Ten (20%) cases involved a thrombosis of an uncoated stent implanted on average 15.5 +/- 6.5 months previously. Mean delay between aspirin withdrawal and the acute coronary event was 10 +/- 1.9 days. Reasons for aspirin withdrawal included minor surgery in 7 cases, fibroscopy in 8 cases, dental treatment in 13 cases, bleeding in 3 cases, and patient non-compliance in 20 cases. Conclusions Our results support the hypothesis that aspirin withdrawal in coronary patients may represent a real risk for the occurrence of a new coronary event. Many cases involved late uncoated-stent thrombosis. Assessment of the exact incidence of coronary recurrences after aspirin withdrawal will need prospective studies.
Discussion
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Cite This Study
Ferrari et al. (2005) conducted an observational in Acute coronary syndrome (ACS) (n=1,236). Aspirin withdrawal within 1 month prior to event vs. No aspirin interruption among relapsed patients was evaluated on ST-segment elevation acute coronary syndrome among patients with recurrent coronary events (p=0.001). Aspirin withdrawal preceded 13.3% of recurrent ACS cases and was associated with a higher rate of ST-elevation ACS compared with continued aspirin (39% vs. 18%; p = 0.001).