A COGENT Argument for Gastrointestinal Protection With Low-Dose Aspirin.

D ual antiplatelet therapy with aspirin and P2Y12 inhibitors, such as clopidogrel, have become the mainstay of patients undergoing percutaneous coronary intervention (PCI) either for acute coronary syndromes or for stable coronary artery disease. Recent evidence suggests that lowdose aspirin defined as #100 mg daily is as effective as high-dose aspirin in secondary cardiovascular prevention (1). One may question why some still continue to prescribe high-dose aspirin in the setting of dual antiplatelet therapy (DAPT). However, many cardiologists may not be aware of the association of low-dose aspirin with a wide variety of gastrointestinal (GI) side effects, including upper and lower GI bleeding, peptic ulcers, and dyspepsia. In 2010, the American College of Cardiology, the American College of Gastroenterology, and the American Heart Association recommended that beyond the debate of a potential interaction between proton pump inhibitors (PPIs) and clopidogrel in patients receiving a coronary stent, upper GI bleeding also must be taken into account in the overall safety profile (2). They identified that factors such as the concomitant use of anticoagulant agents, steroids, or nonsteroidal antiinflammatory drugs; advanced age; and H. pylori infection were associated with an increased risk of GI bleeding. The association of high-dose aspirin and upper GI bleeding is well documented, but earlier studies have suggested that low-dose aspirin was not associated with these risks (3). Yu et al. (4) compared