By CAFMI AI From New England Journal of Medicine
Efficacy of Aspirin Addition in Chronic Coronary Syndrome Patients
In a large-scale randomized controlled trial involving 10,000 patients with chronic coronary syndrome on oral anticoagulation, the efficacy of adding aspirin was rigorously evaluated. The primary efficacy endpoint was a composite measure including myocardial infarction, ischemic stroke, and cardiovascular death. Over a median follow-up period of three years, the study found that adding aspirin to oral anticoagulation did not significantly reduce these ischemic events compared to oral anticoagulation alone. This result challenges the common clinical practice of routinely combining aspirin with anticoagulants in this patient population. The lack of significant benefit in the prevention of ischemic outcomes indicates that clinicians should reconsider aspirin use in these scenarios to avoid unnecessary polypharmacy without positively impacting cardiovascular event prevention.
Risks and Safety Concerns: Increased Bleeding with Aspirin
While the study demonstrated no significant ischemic outcome benefit from aspirin, it revealed a marked safety concern: a doubling of major bleeding events among patients receiving aspirin in addition to oral anticoagulation. Major bleeding is a critical complication in patients with chronic coronary syndrome, often leading to hospitalization, transfusions, and heightened morbidity. This safety signal underlines the delicate balance between clot prevention and bleeding risk inherent in combining antiplatelet and anticoagulant therapies. The findings suggest careful risk stratification is essential, and many patients could safely discontinue aspirin to reduce bleeding incidence without increased risk of myocardial infarction, stroke, or cardiovascular death. This insight is particularly relevant for primary care clinicians and cardiologists managing long-term antithrombotic therapy in an aging population with multiple comorbidities.
Clinical Implications and Practice Recommendations
The trial results have significant clinical implications for guideline development, patient counseling, and primary-care workflows. Given that aspirin addition did not confer ischemic event protection but substantially increased bleeding risk, clinicians should reassess the default use of aspirin in patients receiving oral anticoagulants for chronic coronary syndrome. Careful review of individual patient risk profiles including ischemic risk factors, bleeding history, and comorbid conditions is warranted. Clinical guidelines may evolve to recommend aspirin omission more broadly in this context. Additionally, patient education on the risks and benefits of antithrombotic strategies is essential to support shared decision-making. Regular follow-up to monitor for bleeding signs and to reassess ongoing need for aspirin can enhance safety. By optimizing therapy to balance prevention and harm, healthcare providers can improve outcomes and quality of life for patients with chronic coronary syndrome.
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