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__NOTOC__
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{{Chronic stable angina}}
{{Chronic stable angina}}
'''Editors-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:mgibson@perfuse.org] Phone:617-632-7753; {{CZ}}; '''Associate Editors-In-Chief:''' [[John Fani Srour, M.D.]]; Jinhui Wu, MD
 
'''Editor-In-Chief:''' [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; '''Associate Editor(s)-In-Chief:''' {{CZ}}; [[John Fani Srour, M.D.]]; [[WikiDoc Scholars#WikiDoc Scholars with Distinction|Jinhui Wu, M.D.]]; [[Lakshmi Gopalakrishnan|Lakshmi Gopalakrishnan. M.B.B.S.]]; {{AA}}


==Overview==
==Overview==
In patients with [[ischemic heart disease]], prophylactic low dose aspirin prevents arterial thrombosis by irreversible inactivation of platelet aggregation.<ref name="pmid8298418"> (1994) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8298418 Collaborative overview of randomised trials of antiplatelet therapy--I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists' Collaboration.] ''BMJ'' 308 (6921):81-106. PMID: [http://pubmed.gov/8298418 8298418]</ref><ref name="pmid14720534">Patrono C, Bachmann F, Baigent C, Bode C, De Caterina R, Charbonnier B et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14720534 Expert consensus document on the use of antiplatelet agents. The task force on the use of antiplatelet agents in patients with atherosclerotic cardiovascular disease of the European society of cardiology.] ''Eur Heart J'' 25 (2):166-81. PMID: [http://pubmed.gov/14720534 14720534]</ref><ref name="pmid15383474">Patrono C, Coller B, FitzGerald GA, Hirsh J, Roth G (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15383474 Platelet-active drugs: the relationships among dose, effectiveness, and side effects: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.] ''Chest'' 126 (3 Suppl):234S-264S. [http://dx.doi.org/10.1378/chest.126.3_suppl.234S DOI:10.1378/chest.126.3_suppl.234S] PMID: [http://pubmed.gov/15383474 15383474]</ref><ref name="pmid11786451">Antithrombotic Trialists' Collaboration (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11786451 Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients.] ''BMJ'' 324 (7329):71-86. PMID: [http://pubmed.gov/11786451 11786451]</ref>
==Aspirin==
===Mechanisms of Benefit===
*Aspirin is a potent anti-platelet agent.
*[[Aspirin]] induces an irreversible functional defect in platelets by inhibiting cyclo oxygenase (COX-1) and subsequently suppressing the activation of [[thromboxane A2]] that is responsible for platelet aggregation.<ref name="pmid8145785">Patrono C (1994) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8145785 Aspirin as an antiplatelet drug.] ''N Engl J Med'' 330 (18):1287-94. [http://dx.doi.org/10.1056/NEJM199405053301808 DOI:10.1056/NEJM199405053301808] PMID: [http://pubmed.gov/8145785 8145785]</ref>
*In patients with chronic stable angina, prior [[MI]] and [[unstable angina]], aspirin improves survival and prevents [[myocardial infarction|infarction]].<ref name="pmid11786451">Antithrombotic Trialists' Collaboration (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11786451 Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients.] ''BMJ'' 324 (7329):71-86. PMID: [http://pubmed.gov/11786451 11786451]</ref>
*Aspirin has shown to improve endothelial function and at high doses reduce acute phase reactants.
===Indication===
All patients with chronic stable angina, aspirin unless contraindicated should be started at 75 to 162 mg/day and continued indefinitely.<ref name="pmid15383474">Patrono C, Coller B, FitzGerald GA, Hirsh J, Roth G (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15383474 Platelet-active drugs: the relationships among dose, effectiveness, and side effects: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.] ''Chest'' 126 (3 Suppl):234S-264S. [http://dx.doi.org/10.1378/chest.126.3_suppl.234S DOI:10.1378/chest.126.3_suppl.234S] PMID: [http://pubmed.gov/15383474 15383474]</ref>
===Contraindications===
*Gastrointestinal bleed
*Aspirin hypersensitivity (triad of rhinitis, asthma and polyposis)
*Coagulation disorder
*Uncontrolled hypertension<ref name="pmid9635947">Hansson L, Zanchetti A, Carruthers SG, Dahlöf B, Elmfeldt D, Julius S et al. (1998) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9635947 Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group.] ''Lancet'' 351 (9118):1755-62. PMID: [http://pubmed.gov/9635947 9635947]</ref>
===Dosage===
*A dose range of 75 to 162 mg/day of aspirin<ref name="pmid11786451">Antithrombotic Trialists' Collaboration (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11786451 Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients.] ''BMJ'' 324 (7329):71-86. PMID: [http://pubmed.gov/11786451 11786451]</ref> appears to be effective and is associated with lower risk of gastrointestinal bleeding.
*In comparison to a dose range of 160-325 mg/day, a lower dose of aspirin (75-162 mg/day) has a higher efficacy for secondary prevention.


'''Mechanism of benefit:'''
*Aspirin improves endothelial function and at higher doses (300 mg/day) reduce the circulating levels of [[C-reactive protein]].<ref name="pmid9077376">Ridker PM, Cushman M, Stampfer MJ, Tracy RP, Hennekens CH (1997) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9077376 Inflammation, aspirin, and the risk of cardiovascular disease in apparently healthy men.] ''N Engl J Med'' 336 (14):973-9. [http://dx.doi.org/10.1056/NEJM199704033361401 DOI:10.1056/NEJM199704033361401] PMID: [http://pubmed.gov/9077376 9077376]</ref>
*[[Aspirin]] inhibits cyclo oxygenase and the subsequent suppression of [[thromboxane A2]], the key moderator of irreversible platelet aggregation.  
*Aspirin is a potent anti platelet agent and has been shown to improve survival and to prevent infarction in patients with [[unstable angina]] or after [[myocardial infarction]].


'''Aspirin dosing:'''
===Drug Interactions===
*A 75-mg dose has been shown to be effective and causes less gastrointestinal bleeding than the commonly prescribed 325 mg dose.
Use of [[warfarin]] in conjunction with [[aspirin]] and/or [[clopidogrel]] is associated with an increased risk of bleeding and therefore, close monitoring is required.
:*Aspirin also improves endothelial function and, when used in high dose (300 mg/day), has been shown to reduce circulating levels of [[C-reactive protein]]. Therefore, it should be started at 75 to 162 mg/day and continued indefinitely in all patients with chronic stable angina pectoris, unless contraindicated.
:*75 to 162 mg/day aspirin dosing range appears to have comparable efficacy for secondary prevention compared to dosing at 160-325 mg/day and also reduces bleeding risk.


*Use of [[warfarin]] in conjunction with [[aspirin]] and/or [[clopidogrel]] is associated with an increased risk of bleeding and should be monitored closely.  
===Adverse Effects===
A higher dose of aspirin is associated with increased risk of gastrointestinal bleed.<ref name="pmid15383474">Patrono C, Coller B, FitzGerald GA, Hirsh J, Roth G (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15383474 Platelet-active drugs: the relationships among dose, effectiveness, and side effects: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.] ''Chest'' 126 (3 Suppl):234S-264S. [http://dx.doi.org/10.1378/chest.126.3_suppl.234S DOI:10.1378/chest.126.3_suppl.234S] PMID: [http://pubmed.gov/15383474 15383474]</ref>


'''Supportive trial data:'''
===Supportive Trial Data===
*'''Meta-analysis''' of 140,000 patients from the Antiplatelet Trialists’ Collaboration showed that aspirin (75-325 mg/day) reduced the rate of subsequent [[myocardial infarction]], [[stroke]], and death in patients with history of [[angina]] pectoris, myocardial infarction, [[CABG]], and stroke.  
*Meta-analysis (2002) of 140,000 patients from the ''Antiplatelet Trialists’ Collaboration'' showed that aspirin (75-325 mg/day) reduced the rate of subsequent [[myocardial infarction]], [[stroke]], and death in patients with history of [[angina pectoris]], myocardial infarction, [[CABG]], and stroke.<ref name="pmid11786451">Antithrombotic Trialists' Collaboration (2002) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11786451 Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients.] ''BMJ'' 324 (7329):71-86. PMID: [http://pubmed.gov/11786451 11786451]</ref>


*In the Swedish Angina Pectoris Aspirin Trial ('''SAPAT'''), aspirin (75 mg/day) in conjunction with the [[beta blocker]] sotalol conferred an additional 34% reduction in acute [[myocardial infarction]] and [[sudden cardiac death]] among men and women with chronic stable angina.
*Meta-analysis (2000) of 24 randomized controlled trials involving 66,000 patients showed significant increase in the incidence of gastrointestinal hemorrhage associated with long term aspirin therapy. There was no supportive evidence of lower dose or modified release formulations reducing the incidence of GI bleed.<ref name="pmid11073508">Derry S, Loke YK (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11073508 Risk of gastrointestinal haemorrhage with long term use of aspirin: meta-analysis.] ''BMJ'' 321 (7270):1183-7. PMID: [http://pubmed.gov/11073508 11073508]</ref>


*In the Swedish Angina Pectoris Aspirin Trial (''SAPAT'') (1992), aspirin (75 mg/day) in conjunction with the [[beta blocker]] sotalol conferred an additional 34% reduction in [[MI| acute myocardial infarction]] and [[sudden cardiac death]] among men and women with chronic stable angina.<ref name="pmid1360557">Juul-Möller S, Edvardsson N, Jahnmatz B, Rosén A, Sørensen S, Omblus R (1992) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=1360557 Double-blind trial of aspirin in primary prevention of myocardial infarction in patients with stable chronic angina pectoris. The Swedish Angina Pectoris Aspirin Trial (SAPAT) Group.] ''Lancet'' 340 (8833):1421-5. PMID: [http://pubmed.gov/1360557 1360557]</ref>


==ACC/AHA Guidelines- Pharmacotherapy to Prevent MI and Death and Reduce Symptoms (DO NOT EDIT)<ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).]''Circulation'' 99 (21):2829-48. PMID: [http://pubmed.gov/10351980 10351980]</ref><ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina).] ''Circulation'' 107 (1):149-58. PMID: [http://pubmed.gov/12515758 12515758]</ref>==
==2012 Chronic Angina Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)<ref name="pmid23166210">{{cite journal| author=Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP et al.| title=2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=Circulation | year= 2012 | volume= 126 | issue= 25 | pages= 3097-137 | pmid=23166210 | doi=10.1161/CIR.0b013e3182776f83 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23166210  }} </ref><ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina.] ''Circulation'' 116 (23):2762-72.[http://content.onlinejacc.org/cgi/reprint/50/23/2264.pdf] PMID: [http://pubmed.gov/17998462 17998462]</ref><ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. [http://circ.ahajournals.org/content/99/21/2829.full.pdf] PMID: [http://pubmed.gov/10351980 10351980]</ref>==
{{cquote|
===Class I===
'''1.''' [[Aspirin]] should be started at 75 to 162 mg per day and continued indefinitely in all patients unless contraindicated. ''(Level of Evidence: A)''


===Class IIa===
===Aspirin (DO NOT EDIT))<ref name="pmid23166210">{{cite journal| author=Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP et al.| title=2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=Circulation | year= 2012 | volume= 126 | issue= 25 | pages= 3097-137 | pmid=23166210 | doi=10.1161/CIR.0b013e3182776f83 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23166210  }} </ref><ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina.] ''Circulation'' 116 (23):2762-72.[http://content.onlinejacc.org/cgi/reprint/50/23/2264.pdf] PMID: [http://pubmed.gov/17998462 17998462]</ref><ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. [http://circ.ahajournals.org/content/99/21/2829.full.pdf] PMID: [http://pubmed.gov/10351980 10351980]</ref>===
'''1.''' [[Clopidogrel]] when [[aspirin]] is absolutely contraindicated. ''(Level of Evidence: B)''


===Class IIb===
{|class="wikitable"
'''1.''' Low-intensity anticoagulation with [[warfarin]] in addition to [[aspirin]]. ''(Level of Evidence: B)''}}
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Treatment with aspirin 75 to 162 mg daily should be continued indefinitely in the absence of contraindications in patients with SIHD. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|-
|}


==See Also==
{|class="wikitable"
*[[The Living Guidelines: Chronic Stable Angina Pectoris | The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
|-
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Treatment with aspirin 75 to 162 mg daily and clopidogrel 75 mg daily might be reasonable in certain high-risk patients with SIHD ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|}


==Sources==
==ESC Guidelines- Pharmacological Therapy to Improve Prognosis in Patients with Stable Angina (DO NOT EDIT) <ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367}}</ref>==
*The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. PMID: [http://pubmed.gov/10351980 10351980]</ref>


*TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina <ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina).] ''Circulation'' 107 (1):149-58. PMID: [http://pubmed.gov/12515758 12515758]</ref>
===Aspirin (DO NOT EDIT)<ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367}}</ref>===


*The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina.] ''Circulation'' 116 (23):2762-72. [http://dx.doi.org/10.1161/CIRCULATIONAHA.107.187930 DOI:10.1161/CIRCULATIONAHA.107.187930] PMID: [http://pubmed.gov/17998462 17998462]</ref>
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[European society of cardiology#Classes of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Aspirin]] 75 mg daily in all patients without specific contraindications (i.e. active GI bleeding, aspirin allergy, or previous aspirin intolerance). ''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|}


==References==
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Latest revision as of 18:49, 31 October 2016

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [3]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [4]; John Fani Srour, M.D.; Jinhui Wu, M.D.; Lakshmi Gopalakrishnan. M.B.B.S.; Aysha Anwar, M.B.B.S[5]

Overview

In patients with ischemic heart disease, prophylactic low dose aspirin prevents arterial thrombosis by irreversible inactivation of platelet aggregation.[1][2][3][4]

Aspirin

Mechanisms of Benefit

  • Aspirin is a potent anti-platelet agent.
  • Aspirin induces an irreversible functional defect in platelets by inhibiting cyclo oxygenase (COX-1) and subsequently suppressing the activation of thromboxane A2 that is responsible for platelet aggregation.[5]
  • Aspirin has shown to improve endothelial function and at high doses reduce acute phase reactants.

Indication

All patients with chronic stable angina, aspirin unless contraindicated should be started at 75 to 162 mg/day and continued indefinitely.[3]

Contraindications

  • Gastrointestinal bleed
  • Aspirin hypersensitivity (triad of rhinitis, asthma and polyposis)
  • Coagulation disorder
  • Uncontrolled hypertension[6]

Dosage

  • A dose range of 75 to 162 mg/day of aspirin[4] appears to be effective and is associated with lower risk of gastrointestinal bleeding.
  • In comparison to a dose range of 160-325 mg/day, a lower dose of aspirin (75-162 mg/day) has a higher efficacy for secondary prevention.
  • Aspirin improves endothelial function and at higher doses (300 mg/day) reduce the circulating levels of C-reactive protein.[7]

Drug Interactions

Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with an increased risk of bleeding and therefore, close monitoring is required.

Adverse Effects

A higher dose of aspirin is associated with increased risk of gastrointestinal bleed.[3]

Supportive Trial Data

  • Meta-analysis (2002) of 140,000 patients from the Antiplatelet Trialists’ Collaboration showed that aspirin (75-325 mg/day) reduced the rate of subsequent myocardial infarction, stroke, and death in patients with history of angina pectoris, myocardial infarction, CABG, and stroke.[4]
  • Meta-analysis (2000) of 24 randomized controlled trials involving 66,000 patients showed significant increase in the incidence of gastrointestinal hemorrhage associated with long term aspirin therapy. There was no supportive evidence of lower dose or modified release formulations reducing the incidence of GI bleed.[8]

2012 Chronic Angina Guidelines for the Management of Patients With Chronic Stable Angina (DO NOT EDIT)[10][11][12]

Aspirin (DO NOT EDIT))[10][11][12]

Class I
"1. Treatment with aspirin 75 to 162 mg daily should be continued indefinitely in the absence of contraindications in patients with SIHD. (Level of Evidence: A) "
Class IIa
"1. Treatment with aspirin 75 to 162 mg daily and clopidogrel 75 mg daily might be reasonable in certain high-risk patients with SIHD (Level of Evidence: B) "

ESC Guidelines- Pharmacological Therapy to Improve Prognosis in Patients with Stable Angina (DO NOT EDIT) [13]

Aspirin (DO NOT EDIT)[13]

Class I
"1. Aspirin 75 mg daily in all patients without specific contraindications (i.e. active GI bleeding, aspirin allergy, or previous aspirin intolerance). (Level of Evidence: B) "

References

  1. ↑ (1994) Collaborative overview of randomised trials of antiplatelet therapy--I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists' Collaboration. BMJ 308 (6921):81-106. PMID: 8298418
  2. ↑ Patrono C, Bachmann F, Baigent C, Bode C, De Caterina R, Charbonnier B et al. (2004) Expert consensus document on the use of antiplatelet agents. The task force on the use of antiplatelet agents in patients with atherosclerotic cardiovascular disease of the European society of cardiology. Eur Heart J 25 (2):166-81. PMID: 14720534
  3. ↑ 3.0 3.1 3.2 Patrono C, Coller B, FitzGerald GA, Hirsh J, Roth G (2004) Platelet-active drugs: the relationships among dose, effectiveness, and side effects: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 126 (3 Suppl):234S-264S. DOI:10.1378/chest.126.3_suppl.234S PMID: 15383474
  4. ↑ 4.0 4.1 4.2 4.3 Antithrombotic Trialists' Collaboration (2002) Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 324 (7329):71-86. PMID: 11786451
  5. ↑ Patrono C (1994) Aspirin as an antiplatelet drug. N Engl J Med 330 (18):1287-94. DOI:10.1056/NEJM199405053301808 PMID: 8145785
  6. ↑ Hansson L, Zanchetti A, Carruthers SG, Dahlöf B, Elmfeldt D, Julius S et al. (1998) Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet 351 (9118):1755-62. PMID: 9635947
  7. ↑ Ridker PM, Cushman M, Stampfer MJ, Tracy RP, Hennekens CH (1997) Inflammation, aspirin, and the risk of cardiovascular disease in apparently healthy men. N Engl J Med 336 (14):973-9. DOI:10.1056/NEJM199704033361401 PMID: 9077376
  8. ↑ Derry S, Loke YK (2000) Risk of gastrointestinal haemorrhage with long term use of aspirin: meta-analysis. BMJ 321 (7270):1183-7. PMID: 11073508
  9. ↑ Juul-Möller S, Edvardsson N, Jahnmatz B, Rosén A, Sørensen S, Omblus R (1992) Double-blind trial of aspirin in primary prevention of myocardial infarction in patients with stable chronic angina pectoris. The Swedish Angina Pectoris Aspirin Trial (SAPAT) Group. Lancet 340 (8833):1421-5. PMID: 1360557
  10. ↑ 10.0 10.1 Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP; et al. (2012). "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 126 (25): 3097–137. doi:10.1161/CIR.0b013e3182776f83. PMID 23166210.
  11. ↑ 11.0 11.1 Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation 116 (23):2762-72.[1] PMID: 17998462
  12. ↑ 12.0 12.1 Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina). Circulation 99 (21):2829-48. [2] PMID: 10351980
  13. ↑ 13.0 13.1 Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology". Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.

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