Intolerance to aspirin in patients undergoing percutaneous coronary intervention in the setting of chronic coronary syndromes: perspectives from the ESC 2019 Chronic Coronary Syndromes guidelines

Bianco et al draw attention to the therapeutic challenge that aspirin intolerance not uncommonly presents to interventional cardiologists. In the ESC 2019 Guidelines on Chronic Coronary Syndromes, we describe several relevant points in this regard.[1] Firstly, we state that other nonselective non-steroidal antiinflammatory drugs are not suitable as an alternative to aspirin in view of their adverse cardiovascular risk profile. Secondly, we provide a class IIb recommendation for using prasugrel or ticagrelor in patients who cannot tolerate aspirin. We don't suggest an alternative to aspirin as part of a dual therapy strategy with prasugrel or ticagrelor but do describe the results of the GEMINI ACS study in which rivaroxaban 2.5 mg b.i.d. in combination with an oral P2Y12 inhibitor was compared with standard DAPT and shown to have similar efficacy, albeit in stabilized patients after uncomplicated percutaneous coronary intervention (PCI) in the presence of aspirin.[2] This presents the possibility of using such a regimen in patients where there are concerns about the risk of stent thrombosis with prasugrel or ticagrelor monotherapy. However, currently there is insufficient evidence on which to base any recommendations for such a strategy, particularly since, as we indicate, the safety of performing PCI without aspirin pre-treatment is uncertain.