Aspirin use post-acute coronary syndromes: intolerance, bleeding and discontinuation.
BACKGROUND
While aspirin's secondary prevention benefit is clear, prior reports indicate that 19-83% of eligible patients may not use aspirin chronically.


METHODS
We investigated intolerance and bleeding while on aspirin and aspirin discontinuation using 5337 post-acute coronary syndrome patients considered appropriate for chronic antiplatelet therapy who were randomly assigned to aspirin in SYMPHONY and 2nd SYMPHONY and followed for 94 (64,157) days. Multivariable logistic regression models tested associations between baseline characteristics and aspirin discontinuation and bleeding.


RESULTS
Nearly 18% of patients discontinued study aspirin; 48% subsequently used open-label aspirin and 5% other antiplatelet or anticoagulant therapy. Black race, recurrent ischemia, hypertension, chronic obstructive pulmonary disease, lighter weight, shorter time to treatment and use of non-steroidal anti-inflammatory agents, diuretics, and digitalis were independently associated with early discontinuation. Early discontinuation was less likely in Eastern Europe, Latin America and Asia. Although major or minor bleeding was common (12.6%), only 1.0% of aspirin-treated patients were reported to discontinue due to bleeding. Gastrointestinal (10.5%) and puncture site (7.6%) were the most common bleeding locations. Bleeding risk was associated with lower estimated creatinine clearance, shorter time to treatment, smoking, Killip class >II, higher systolic blood pressure, and use of aspirin or heparin prior to starting study aspirin.


CONCLUSIONS
Despite early initiation and close follow-up, more than 9% of aspirin-treated patients discontinued therapy early and remained off treatment. Addressing the factors associated with both bleeding and discontinuation during chronic therapy is necessary to improve adherence to this inexpensive, life-saving therapy.
Newby
L Kristin
LK
Duke Clinical Research Institute and the Duke Centers for Education & Research on Therapeutics (CERTs), Durham, NC 27715-7969, USA. newby001@mc.duke.edu
Bhapkar
Manjushri V
MV
White
Harvey D
HD
Moliterno
David J
DJ
LaPointe
Nancy M Allen
NM
Kandzari
David E
DE
Verheugt
Freek W A
FW
Kramer
Judith M
JM
Armstrong
Paul W
PW
Califf
Robert M
RM
D000208:Acute Disease; D000368:Aged; D001241:Aspirin / Q000009:adverse effects* / Q000627:therapeutic use*; D003327:Coronary Disease / Q000150:complications / Q000188:drug therapy*; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced* / Q000209:etiology; D006801:Humans; D007677:Kidney Function Tests; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010349:Patient Compliance; D012307:Risk Factors
D001241:Aspirin