Intolerance to aspirin is relatively frequent and there is no other non-steroid anti-inflammatory medication to replace it.

The new guidelines of chronic coronary syndromes make class IIb recommendations to use prasugrel or ticagrelor in aspirin-intolerant patients. This is not meant to replace dual antiaggregation therapy in aspirin intolerant patients, when needed; it is just a recommendation to use monotherapy with the most potent antiaggregant we count on at present. 

Another alternative could stem from the GEMINI-ACS study where rivaroxaban 2.5 mg c/12h was used in combination with a P2Y12 inhibitor vs conventional dual antiaggregation, offering similar results. We have to remember the clinical context of GEMINI-ACS patients is completely different to that of a stable patient receiving scheduled PCI. 

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Desensitization is within the alternatives and is used in many centers, though there is some concern about its safety. Many patients refer an intolerance to aspirin that cannot clearly be attributed to an anaphylactic reaction. 

Adverse effects such as rash, angioedema or mild bronchospasms seem adequate for a desensitization strategy, and others such as the Samter triad (asthma, sinus inflammation and recurrent nasal polyps), severe bronchospasm or anaphylactic reactions, seem more adequate for monotherapy with prasugrel or ticagrelor with or without rivaroxaban, depending on thrombosis risk.

We should bear in mind that though aspirin desensitization studies show positive results, they are short term, and in small very heterogeneous cohorts. There is little information on long term results of desensitization. 

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Future guidelines should offer more information on the efficacy and safety of the different strategies to manage patients with aspirin intolerance. 

Original Title: 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.

Reference: Robert F. Storey et al. European Heart Journal (2019) 0, 1–2.

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