Reduced Antiplatelet Effect of Aspirin Does Not Predict Cardiovascular Events in Patients With Stable Coronary Artery Disease

Abstract

Background: Increased platelet aggregation during antiplatelet therapy may predict cardiovascular events in patients with coronary artery disease. The majority of these patients receive aspirin monotherapy. We aimed to investigate whether high platelet-aggregation levels predict cardiovascular events in stable coronary artery disease patients treated with aspirin.

Methods and results: We included 900 stable coronary artery disease patients with either previous myocardial infarction, type 2 diabetes mellitus, or both. All patients received single antithrombotic therapy with 75 mg aspirin daily. Platelet aggregation was evaluated 1 hour after aspirin intake using the VerifyNow Aspirin Assay (Accriva Diagnostics) and Multiplate Analyzer (Roche; agonists: arachidonic acid and collagen). Adherence to aspirin was confirmed by serum thromboxane B₂. The primary end point was the composite of nonfatal myocardial infarction, ischemic stroke, and cardiovascular death. At 3-year follow-up, 78 primary end points were registered. The primary end point did not occur more frequently in patients with high platelet-aggregation levels (first versus fourth quartile) assessed by VerifyNow (hazard ratio: 0.5 [95% CI, 0.3-1.1], P=0.08) or Multiplate using arachidonic acid (hazard ratio: 1.0 [95% CI, 0.5-2.1], P=0.92) or collagen (hazard ratio: 1.4 [95% CI, 0.7-2.8], P=0.38). Similar results were found for the composite secondary end point (nonfatal myocardial infarction, ischemic stroke, stent thrombosis, and all-cause death) and the single end points. Thromboxane B₂ levels did not predict any end points. Renal insufficiency was the only clinical risk factor predicting the primary and secondary end points.

Conclusions: This study is the largest to investigate platelet aggregation in stable coronary artery disease patients receiving aspirin as single antithrombotic therapy. We found that high platelet-aggregation levels did not predict cardiovascular events.

Keywords: antiplatelet drug resistance; aspirin; coronary artery disease; prognosis.

Figure 1

Platelet aggregation as predictor of the primary outcome (cardiovascular death, nonfatal myocardial infarction, and ischemic stroke) with (A) the VerifyNow Aspirin Assay, (B) the Multiplate Analyzer using 1.0 mmol/L AA as agonist, and (C) the Multiplate Analyzer using 1.0 μg/mL collagen as agonist. AA indicates arachidonic acid; CI, confidence interval; HR, hazard ratio.

Figure 2

Platelet aggregation as predictor of the secondary outcome (all‐cause death, nonfatal myocardial infarction, ischemic stroke, and stent thrombosis) with (A) the VerifyNow Aspirin Assay, (B) the Multiplate Analyzer using 1.0 mmol/L AA as agonist, and (C) the Multiplate Analyzer using 1.0 μg/mL collagen as agonist. AA indicates arachidonic acid; CI, confidence interval; HR, hazard ratio.