Aspirin Hypersensitivity in Patients Undergoing Percutaneous Coronary Intervention. What Should We be Doing?

Author(s): George Kassimis*, Tushar Raina, Dimitrios Alexopoulos.

Journal Name: Current Vascular Pharmacology

Volume 17 , Issue 4 , 2019

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Graphical Abstract:


Abstract:

Aspirin plays a pivotal role in the management of patients with Coronary Artery Disease (CAD) with well-recognised benefits of reducing recurrent myocardial infarction and minimising the risk of stent thrombosis for those undergoing Percutaneous Coronary Intervention (PCI). Dual antiplatelet therapy is mandated for patients undergoing PCI and typically consists of aspirin and a P2Y12 receptor antagonist. Aspirin hypersensitivity poses a significant clinical dilemma, as the safety and efficacy of oral antiplatelet combinations that exclude aspirin have not been validated. Although, genuine hypersensitivity to aspirin is encountered infrequently, it can be challenging when managing patients with concomitant CAD given the paucity of safe and effective alternatives. Aspirin desensitization is a potential and safe option but may not always be practical. This review aims to highlight the challenges of aspirin hypersensitivity in patients undergoing PCI and propose a treatment algorithm to address this issue in clinical practice.

Keywords: Aspirin hypersensitivity, desensitization, ticagrelor monotherapy, percutaneous coronary intervention, DAPT, ACS.

[1]
Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European association for cardio-thoracic surgery (EACTS) developed with the special contribution of the European association of percutaneous cardiovascular interventions (EAPCI). Eur Heart J 2014; 35: 2541-619.
[2]
Laidlaw TM, Cahill KN. Current knowledge and management of hypersensitivity to aspirin and NSAIDs. J Allergy Clin Immunol Pract 2017; 5: 537-45.
[3]
Xue Y, Feng ZW, Li XY, et al. The efficacy and safety of cilostazol as an alternative to aspirin in Chinese patients with aspirin intolerance after coronary stent implantation: A combined clinical study and computational system pharmacology analysis. Acta Pharmacol Sin 2018; 39: 205-12.
[4]
Bianco M, Bernardi A, D’Ascenzo F, et al. Efficacy and safety of available protocols for aspirin hypersensitivity for patients undergoing percutaneous coronary intervention: A survey and systematic review. Circ Cardiovasc Interv 2016; 9: e002896.
[5]
Silberman S, Neukirch-Stoop C, Steg PG. Rapid desensitization procedure for patients with aspirin hypersensitivity undergoing coronary stenting. Am J Cardiol 2005; 95: 509-10.
[6]
Jneid H, Anderson JL, Wright RS, et al. 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/Non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): A report of the American college of cardiology foundation/American heart association task force on practice guidelines. Circulation 2012; 126: 875-910.
[7]
Bianco M, Cerrato E, Destefanis P, et al. Management of aspirin intolerance in patients undergoing PCI: The role of mono-antiplatelet therapy - A retrospective multicentre study. Minerva Cardioangiol 2019; 67: 94-101.
[8]
Kenaan M, Seth M, Aronow HD, Wohns D, Share D, Gurm HS. The clinical outcomes of percutaneous coronary intervention performed without pre-procedural aspirin. J Am Coll Cardiol 2013; 62: 2083-9.
[9]
DiNicolantonio JJ, Norgard NB, Meier P, et al. Optimal aspirin dose in acute coronary syndromes: An emerging consensus. Future Cardiol 2014; 10: 291-300.
[10]
Leon MB, Baim DS, Popma JJ, et al. A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent anticoagulation restenosis study investigators. N Engl J Med 1998; 339: 1665-71.
[11]
Schwartz L, Bourassa MG, Lespérance J, et al. Aspirin and dipyridamole in the prevention of restenosis after percutaneous transluminal coronary angioplasty. N Engl J Med 1988; 318: 1714-9.
[12]
Palmerini T, Biondi-Zoccai G, Della Riva D, et al. Stent thrombosis with drug-eluting and bare-metal stents: Evidence from a comprehensive network meta-analysis. Lancet 2012; 379: 1393-402.
[13]
D’Ascenzo F, Bollati M, Clementi F, et al. Incidence and predictors of coronary stent thrombosis: Evidence from an international collaborative meta-analysis including 30 studies, 221,066 patients, and 4276 thromboses. Int J Cardiol 2013; 167: 575-84.
[14]
Gollapudi RR, Teirstein PS, Stevenson DD, et al. Aspirin sensitivity: Implications for patients with coronary artery disease. JAMA 2004; 292: 3017-23.
[15]
Ramanuja S, Breall JA, Kalaria VG. Approach to “aspirin allergy” in cardiovascular patients. Circulation 2004; 110: 1-4.
[16]
Feng CH, White AA, Stevenson DD. Characterization of aspirin allergies in patients with coronary artery disease. Ann Allergy Asthma Immunol 2013; 110: 92-5.
[17]
McMullan KL. Aspirin allergy in patients with myocardial infarction: The allergist’s role. Ann Allergy Asthma Immunol 2014; 112: 90-3.
[18]
Kowalski ML, Makowska JS, Blanca M, et al. Hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) - classification, diagnosis and management: Review of the EAACI/ENDA(#) and GA2LEN/HANNA*. Allergy 2011; 66: 818-29.
[19]
Torres MJ, Barrionuevo E, Kowalski M, Blanca M. Hypersensitivity reactions to nonsteroidal anti-inflammatory drugs. Immunol Allergy Clin North Am 2014; 34: 507-24.
[20]
Rossini R, Iorio A, Pozzi R, et al. Aspirin desensitization in patients with coronary artery disease: Results of the multicenter adapted registry (Aspirin desensitization in patients with coronary artery disease). Circ Cardiovasc Interv 2017; 10: e004368.
[21]
Kowalski ML, Asero R, Bavbek S, et al. Classification and practical approach to the diagnosis and management of hypersensitivity to nonsteroidal anti-inflammatory drugs. Allergy 2013; 68: 1219-32.
[22]
Christou A, Kafkas N, Marinakos A, Katsanos S, Papanikitas K, Patsilinakos S. Rapid desensitisation of patients with aspirin allergy who undergo coronary angioplasty. Hellenic J Cardiol 2011; 52: 307-10.
[23]
De Luca G, Verdoia M, Binda G, Schaffer A, Suryapranata H, Marino P. Aspirin desensitization in patients undergoing planned or urgent coronary stent implantation. A single-center experience. Int J Cardiol 2013; 167: 561-3.
[24]
Wong JT, Nagy CS, Krinzman SJ, Maclean JA, Bloch KJ. Rapid oral challenge desensitization for patients with aspirin-related urticaria- angioedema. J Allergy Clin Immunol 2000. 105: 997e1001.
[25]
Silber S, Kirtane AJ, Belardi JA, et al. Lack of association between dual antiplatelet therapy use and stent thrombosis between 1 and 12 months following resolute zotarolimus-eluting stent implantation. Eur Heart J 2014; 35: 1949-56.
[26]
Kassimis G, Banning AP. Is it time to take bare metal stents off the catheter laboratory shelf? Eur Heart J 2016; 37: 3372-5.
[27]
Urban P, Meredith IT, Abizaid A. Polymer-free drug-coated coronary stents in patients at high bleeding risk. N Engl J Med 2015; 373: 2038-47.
[28]
Balleby IR, Orhoj TK, Terkelsen CJ, et al. Early healing after treatment of coronary lesions by everolimus, or biolimus eluting bioresorbable polymer stents One-month results of the SORTOUT VIII OCT study. This study was presented at Euro PCR 2015. Available at . https://www.pcronline.com/Cases-resources-images/Resources/Course-videos-slides/2015/Bioresorbable-scaffolds-and-new-DES?auth=true
[29]
Vranckx P, Valgimigli M, Windecker S, et al. Long-term ticagrelor monotherapy versus standard dual antiplatelet therapy followed by aspirin monotherapy in patients undergoing biolimus-eluting stent implantation: Rationale and design of the global leaders trial. EuroIntervention 2016; 12: 1239-45.
[30]
Baber U, Dangas G, Cohen DJ, et al. Ticagrelor with aspirin or alone in high-risk patients after coronary intervention: Rationale and design of the twilight study. Am Heart J 2016; 182: 125-34.
[31]
Baos S, Underwood W, Culliford L, et al. Platelet inhibition during ticagrelor monotherapy versus ticagrelor plus aspirin in patients with coronary artery disease (TEMPLATE study): Study protocol for a randomised controlled trial. Trials 2017; 18: 529.
[32]
Husted S, Emanuelsson H, Heptinstall S, Sandset PM, Wickens M, Peters G. Pharmacodynamics, pharmacokinetics, and safety of the oral reversible P2Y12 antagonist AZD6140 with aspirin in patients with atherosclerosis: A double-blind comparison to clopidogrel with aspirin. Eur Heart J 2006; 27: 1038-47.
[33]
Mahaffey KW, Wojdyla DM, Carroll K, et al. Ticagrelor compared with clopidogrel by geographic region in the platelet inhibition and patient outcomes (PLATO) trial. Circulation 2011; 124: 544-54.
[34]
Armstrong PC, Leadbeater PD, Chan MV, et al. In the presence of strong P2Y12 receptor blockade, aspirin provides little additional inhibition of platelet aggregation. J Thromb Haemost 2011; 9: 552-61.
[35]
Barillà F, Pulcinelli FM, Mangieri E, et al. Clopidogrel plus indobufen in acute coronary syndrome patients with hypersensitivity to aspirin undergoing percutaneous coronary intervention. Platelets 2013; 24: 183-8.
[36]
Kim IS, Jeong YH, Park Y, et al. Platelet inhibition by adjunctive cilostazol versus high maintenance-dose clopidogrel in patients with acute myocardial infarction according to cytochrome P450 2C19 genotype. JACC Cardiovasc Interv 2011; 4: 381-91.
[37]
Cruz-Fernández JM, López-Bescós L, García-Dorado D, et al. Randomized comparative trial of triflusal and aspirin following acute myocardial infarction. Eur Heart J 2000; 21: 457-65.
[38]
Fornaro G, Rossi P, Mantica PG, et al. Indobufen in the prevention of thromboembolic complications in patients with heart disease. A randomized, placebo-controlled, double-blind study. Circulation 1993; 87: 162-4.
[39]
Latib A, Ielasi A, Ferri L, et al. Aspirin intolerance and the need for dual antiplatelet therapy after stent implantation: A proposed alternative regimen. Int J Cardiol 2013; 165: 444-7.
[40]
Woessner KM. Aspirin desensitization for cardiovascular disease. Curr Opin Allergy Clin Immunol 2015; 4: 314-22.
[41]
Rossini R, Angiolillo DJ, Musumeci G, et al. Aspirin desensitization in patients undergoing percutaneous coronary interventions with stent implantation. Am J Cardiol 2008; 101: 786-9.
[42]
Tantry US, Gurbel PA. Rapid desensitization of the patients with aspirin hypersensitivity and coronary artery disease. Circ Cardiovasc Interv 2017; 10: e004881.
[43]
Khan DA, Soensky R. Drug allergy. J Allergy Clin Immunol 2010; 125(Suppl. 2): 126-37.
[44]
Cortellini G, Testi S, Severino M, et al. Aspirin challenge/desensitisation before coronary stenting in subjects with history of hypersensitivity. A pragmatic approach. Eur Ann Allergy Clin Immunol 2012; 44: 160-2.
[45]
McMullan KL, Wedner HJ. Safety of aspirin desensitization in patients with reported aspirin allergy and cardiovascular disease. Clin Cardiol 2013; 36: 25-30.
[46]
Lambrakis P, Rushworth GF, Adamson J, et al. Aspirin hypersensitivity and desensitization protocols: Implications for cardiac patients. Ther Adv Drug Saf 2011; 2: 263-70.
[47]
Schiano P, Steg PG, Barbou F, et al. A strategy for addressing aspirin hypersensitivity in patients requiring urgent PCI. Eur Heart J Acute Cardiovasc Care 2012; 1: 75-8.


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Article Details

VOLUME: 17
ISSUE: 4
Year: 2019
Page: [326 - 331]
Pages: 6
DOI: 10.2174/1570161116666180604100220
Price: $58

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