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The use of acetylsalicylic acid (ASA) is problematic in subjects with histories of hypersensitivity reactions (HRs) to it or with cross-reactive types of nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity. We sought to evaluate the efficacy of low-dose ASA challenge (LDAC) and desensitization to allow ASA therapy at an antiplatelet dose in patients with atherosclerotic cardiovascular disease (ASCVD) or multiple related risk factors and histories of HRs to ASA or ≥ 2 chemically unrelated NSAIDs. We studied prospectively all patients with such histories and ≥ 3 risk factors for ASCVD (group I), chronic coronary syndrome (CCS, group II), and acute coronary syndrome (ACS) with indication for ASA desensitization (group III). Patients from groups I and II underwent LDACs (cumulative dose of 110 mg), while those from group III were desensitized (cumulative dose of 100.1 mg). We evaluated 103 patients: 62 from group I, 24 from group II, and 17 from group III. Eighty-two of the 86 patients from the first two groups underwent LDACs and 2 reacted. Subsequently, 22 (27.5%) of the 80 patients with negative LDACs were administered dual antiplatelet therapy with ASA after successful percutaneous coronary interventions, thus sparing desensitizations. The remaining 4 patients with CCS and all 17 patients from group III were successfully desensitized. In this pragmatic study, LDAC proved to be a safe and reliable diagnostic tool for identifying patients with histories of HRs to ASA or ≥ 2 different NSAIDs who can tolerate ASA at antiplatelet doses. Routine LDAC is advisable in all patients at high risk for ASCVD or with CCS who report HRs to ASA or ≥ 2 NSAIDs. ASA desensitization remains a safe and effective option in patients with ACS. Study flow-chart. ASCVD atherosclerotic cardiovascular disease; CCS chronic coronary syndrome; ACS acute coronary syndrome; ASA acetylsalicylic acid; DAPT dual antiplatelet therapy; PCI percutaneous coronary intervention; NSAIDs nonsteroidal anti-inflammatory drugs; NERD NSAID-exacerbated respiratory disease; NECD NSAID-exacerbated cutaneous disease; NIUAA NSAID-induced urticaria-angioedema or anaphylaxis; SNIUAA single NSAID-induced urticaria-angioedema or anaphylaxis; SNIDHR single NSAID-induced delayed hypersensitivity reaction., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background/objectives: The clinical approach to suspected or established coronary artery disease (CAD) has been revolutionized in the last few decades by coronary computed tomography (coroCT). Yet, uncertainty persists on its comparative diagnostic and clinical effectiveness. We conducted a systematic review on randomized controlled trials (RCTs) of coroCT., Methods: We searched RCTs in PubMed and The Cochrane Library, extracting as outcomes of interest long-term rates of death, myocardial infarction, revascularization, and invasive coronary angiography. Effects were estimated with risk ratios (RR) and 95% confidence intervals., Results: A total of 11 trials were included, with 19,957 patients followed for a median of 6months. One trial focused on screening, 3 on stable CAD, and 7 on acute CAD. Meta-analysis showed that coroCT was associated with a trend toward fewer deaths or myocardial infarctions (RR=0.84 [0.70-1.01]) whereas no significant difference was found for the risk of death (RR=0.91 [0.71-1.18]). Conversely, the risk of myocardial infarction tended to be lower with coroCT at the overall analysis (RR=0.77 [0.59-1.02]), and this effect reached statistical significance in studies focusing on subjects with stable CAD (RR=0.69 [0.49-0.99]). These potential benefits were offset (or mediated) by a significant albeit modest increase in the need for invasive angiography (RR=1.36 [1.08-1.72]), and ensuing coronary revascularization (RR=1.76 [1.29-2.40])., Conclusions: According to the current evidence base, coroCT is associated with an increased usage of invasive angiography and coronary revascularization when compared to standard of care, with possible benefits on nonfatal myocardial infarction, but without significant benefits on death or the composite of death or myocardial infarction., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

The evidence base on aspirin in primary prevention suggests that it can reduce significantly the risk of cardiovascular disease (CVD) events and cancer, especially colorectal, albeit increasing bleeding. There is, however, uncertainty on the optimal aspirin dose and preparation for primary prevention. We thus aimed to review main sources of evidence informing on daily dosage and preparation of aspirin for primary prevention of CVD and cancer. We collected and elaborated aspirin effectiveness and safety data from U.S. Preventive Services Task Force reports on aspirin in primary prevention, distinguishing average daily dose in <100mg, 100mg, and >100mg. The following preparations were also systematically compared: enteric coated, controlled release, non-coated, or otherwise unspecified. Fixed-effect pairwise and network meta-analytic models were run in a frequentist framework. Eleven randomized trials were shortlisted, enrolling 104,101 subjects, followed for a median of 60months. At pairwise analysis, aspirin was associated with significant reductions in death and CVD events, non-significant reductions in cancer death or incidence, and significant increases in the risk of intracranial and gastrointestinal (GI) bleeding. An average daily dose of 100mg had the highest probability of reducing death, cancer death, and cancer incidence, whereas higher doses seemed superior for reducing CVD events, and 100mg or less daily proved better tolerated. Coated preparations appeared more beneficial for death, cancer death, cancer incidence, and GI bleeding, whereas controlled release preparations appeared better for CVD events and non-coated ones for intracranial bleeding. In conclusion, an average daily dose of 100mg of coated aspirin seems more likely to confer favorable preventive effects on death and cancer, with higher doses more appealing for CVD prevention and lower doses better tolerated., (Copyright © 2016 Elsevier Inc. All rights reserved.)