Recommended Aspirin Doses in Patients with Coronary Artery Disease

Aspirin is indicated for prevention and/or treatment of a wide variety of cardiovascular conditions, including primary and secondary prevention, percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) surgery, peripheral arterial disease (PAD), extra-cranial arterial disease, mechanical heart valve replacement and pericarditis. Although there is general consensus that lower doses of aspirin are usually as effective as, and safer than, higher doses for most indications, there is much variability in prescribing patterns in part related to the lack of a robust evidence base for certain disease states. An example of an effort to close this knowledge gap is the anticipated launch of the Patient Centered Outcomes Research Institute’s (PCORI) Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness (ADAPTABLE) Trial, a study that will compare aspirin doses of 81 mg versus 325 mg for secondary prevention among 20,000 patients with stable cardiovascular disease (CVD) (NCT02697916).

The table summarizes current recommendations for aspirin dosing across several coronary artery disease indications. Recommendations regarding duration of dual anti-platelet therapy are not included. Links to current guidelines are provided.

Indication	Aspirin dose (mg)	Guideline References
Primary Prevention*	75-100 mg daily+	2012 ACCP; 2014 ESC Working Group on Thrombosis
Secondary Prevention (SIHD)	75-162 mg daily	2012 ACCF/AHA SIHD
NSTE-ACS Medical Therapy	LD: 162-325 mg non-enteric; MD: 75-100 mg daily with a P2Y12 inhibitor as part of DAPT	2014 AHA/ACCF NSTE ACS 2016 ACCF/AHA DAPT
NSTE-ACS PCI	LD: 162-325 mg non-enteric; MD: 75-100 mg daily with a P2Y12 inhibitor as part of DAPT	2014 AHA/ACCF NSTE ACS 2016 ACCF/AHA DAPT
STEMI PCI	LD: 162-325 mg non-enteric; MD: 75-100 mg daily with a P2Y12 inhibitor as part of DAPT	2013 ACCF/AHA STEMI 2016 ACCF/AHA DAPT
STEMI Fibrinolysis	LD: 162-325 mg non-enteric; MD: 75-100 mg daily with clopidogrel as part of DAPT	2013 ACCF/AHA STEMI 2016 ACCF/AHA DAPT
PCI (SIHD)	LD: 81-325 mg if already taking aspirin or 325 mg non-enteric aspirin if not taking aspirin; MD: 75-100 mg daily with a P2Y12 inhibitor as part of DAPT	2011 ACCF/AHA PCI 2016 ACCF/AHA DAPT
CABG	Pre-op dose: 100-325 mg; Post-op MD in patients with SIHD: 100-325 mg daily; Post-op MD with a P2Y12 inhibitor as part of DAPT in patients with ACS:75-100 mg daily	2011 ACCF/AHA CABG 2014 AHA/ACCF NSTE ACS 2016 ACCF/AHA DAPT
As part of triple therapy regimen (with an anticoagulant + P2Y12 inhibitor) or in patients with mechanical heart valves receiving warfarin	MD: 75-100 mg daily	2016 ACCF/AHA DAPT 2014 AHA/ACCF Valve Disease

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Abbreviations: ACCF, American College of Cardiology Foundation; ACCP, American College of Chest Physicians; ACS, acute coronary syndrome; AHA, American Heart Association; CABG, coronary artery bypass; DAPT, dual anti-platelet therapy; ESC, European Society of Cardiology; LD, loading dose; MD, maintenance dose; NSTE, non-ST-elevation; PCI, percutaneous coronary intervention; SIHD, stable ischemic heart disease; STEMI, ST-elevation MI.

* Initiation of aspirin for primary prevention should only be done after risk-benefit analysis and patient engagement in shared decision-making, as is the case for statin therapy in this context. Considerations for healthy women differ from those for healthy men (Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. J Am Coll Cardiol 2011; 57:1404 –23). Diabetes alone is not a sufficient indication for aspirin for primary prevention (Pignone M et al. Aspirin for primary prevention of cardiovascular events in people with diabetes. a position statement of the American Diabetes Association, a Scientific Statement of the American Heart Association, and an Expert Consensus Document of the American College of Cardiology Foundation. J Am Coll Cardiol 2010; 55:2878-86).

+ 2002 AHA Primary Prevention Update recommended aspirin 75-160 mg daily. A non-enteric preparation of aspirin should be used in acute circumstances (e.g., immediately prior to PCI or with ACS) to facilitate bioavailability. Aspirin allergy can be a significant problem and consideration to desensitization should be given. Clopidogrel is recommended as an aspirin substitute for patients with aspirin allergy when anti-platelet therapy is indicated. In patients receiving low-dose aspirin in combination with other anti-thrombotic agents, use of a proton pump inhibitor or H2-blocker may need to be considered.

Keywords: Aspirin, Consensus, Coronary Artery Bypass, Heart Valves, Patient Outcome Assessment, Percutaneous Coronary Intervention, Pericarditis, Peripheral Arterial Disease, Secondary Prevention, Platelet Aggregation Inhibitors

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