Don’t Leave Home Without It: Chewable Aspirin and Ischemic Coronary Disease

A recent “Top Paper” provides an excellent review of aspirin in the setting of acute coronary events and other vascular emergencies.¹ Analysis of a number of studies led to a practical suggestion: persons at known risk for myocardial infarction (MI) as well as older adults should carry a few tablets of soluble aspirin with them at all times, and they should chew and swallow the tablets in the event of chest pain—the earlier the better. Let’s look at why.

CHEW ON THIS: MULTIPLE STUDIES SHOW BENEFITS OF ASPIRIN
In general, giving aspirin to patients at increased vascular risk is consistent with the greatest benefit for the lowest cost. The “Top Paper” authors clarified that this is true apart from smoking cessation. They reviewed studies that address the benefits of aspirin in the setting of acute vascular events.

The Chinese Acute Stroke Trial demonstrated that giving aspirin within 3 hours of the onset of symptoms of brain ischemia reduced mortality. There was a 36% reduction in deaths among patients who received aspirin in this time frame, while there was only a 25% reduction among those who received aspirin later.

Another interesting observation is that the peak incidence of MI is in the early morning, a time when platelets are most sensitive to aggregating stimuli. One study showed that aspirin has a greater effect on MIs that occur at this time.

Other studies referenced in the “Top Paper” demonstrated that early use of aspirin during an acute cardiac ischemic event decreases infarct size and fatality. The reasons such a simple drug can be of benefit include:

• Decreased platelet aggregation.

• Increased fibrin clot permeability.

• Enhanced clot lysis.

• Anti-arrhythmic effects.

• Mitigation of catecholamine-induced vascular and myocardial injuries.

The rationale for the early use of aspirin is that over time greater and greater aggregation and fibrin production ensue. Although many patients undergo stenting for acute coronary events, when thrombolytic therapy is used instead, aspirin protects against heightened platelet activity after the lytic agent is given.

RECOMMENDATIONS FOR YOUR PATIENTS AT RISK
Acute ischemic cardiovascular events cause excess morbidity and mortality. The evidence in this “Top Paper” not only explains why aspirin is indicated but makes a strong case for its immediate use—at the first sign of chest pain and possibly at the first sign of a stroke. Those patients who are at high risk for any reason should comply with the suggestions in this paper:

• Carry aspirin everywhere you go and take it quickly at the first symptom of ischemia.

• Use an aspirin product that can be chewed and then swallowed.

This activity is protective and does not interfere with eventual therapy, whether it be dilatation and stenting, thrombolysis, or surgery.