SPECIAL SECTION: LETTER TO THE EDITOR
A randomized trial of aspirin on the risk of embolic events in patients with infective endocarditis
Derek L. Connolly, BSc(Hons), MB, ChB, PhD, MRCP(UK)
Sandwell and West Birmingham Hospitals NHS Trust, Lyndon, Birmingham, B71 4HJ, United Kingdom
Anirban Choudhury, MRCP (UK),
Russell C. Davis, MA, MRCP and
Greg Y. H. Lip, MD, FRCP, FESC, FACC
Derek.Connolly{at}swbh.nhs.uk
We read with great interest the study by Chan et al. (1). We are not surprised that high-dose aspirin (325 mg once daily) was not beneficial in patients with infective endocarditis and caused excessive bleeding. First, the dose of aspirin that has optimal benefits with low levels of bleeding in acute coronary syndromes has been shown to be far smaller (<100 mg daily) than used in the Chan study (2). Second, patients with infective endocarditis presenting with emboli have been documented to have excessive bleeding when given high-dose antiplatelet and fibrinolytic therapy after acute coronary embolism (3). Third, Chan et al. imply that vegetations in infective endocarditis are mostly platelet derived. Platelet activation can be independent of cyclo-oxygenase activity, and therefore aspirin may not inhibit platelet activation when other routes of platelet activation are stimulated (4,5). We therefore agree with the conclusion that high-dose aspirin is not indicated for infective endocarditis, but we would like to see further studies of other antiplatelet or anticoagulant drugs before negating the use of all these treatments for the prophylaxis of emboli in infective endocarditis. Clearly, in cases of coronary emboli, development of primary angioplasty and development of percutaneous clot removal devices mean that new technologies may afford further treatment options in this life-threatening scenario (6,7).
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References
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1. Chan KL, Dumesnil JG, Cujec B, et al. A randomized trial of aspirin on the risk of embolic events in patients with infective endocarditis. J Am Coll Cardiol. 2003;42:775–780[Abstract/Free Full Text]
2. Peters RJG, Mehta SR, Fox KAA, et al. Cure study. Circulation. 2003;108:1682–1687[Abstract/Free Full Text]
3. Connolly DL, Dardas PS, Crowley JJ, et al. Acute coronary embolism complicating aortic valve endocarditis treated with streptokinase and aspirin. J Heart Valve Dis. 1994;3:245–246[Medline]
4. Rinder CS, Student LA, Bonan JL, et al. Aspirin does not inhibit adenosine diphosphate induced platelet alpha granule release. Blood. 1993;82:505–512[Abstract/Free Full Text]
5. Kamath S, Blann AD, Chin BSP, et al. A study of platelet activation in atrial fibrillation and the effects of antithrombotic therapy. Eur Heart J. 2002;23:1788–1795[Abstract/Free Full Text]
6. Andersen HR, Nielsen TT, Rasmussen K, et al. A comparison of coronary angioplasty with fibrinolytic therapy in acute myocardial infarction. N Engl J Med. 2003;349:733–742[Abstract/Free Full Text]
7. Beran G, Lang I, Schreiber W, et al. Intracoronary thrombectomy with the X-sizer catheter system improves epicardial flow and accelerates ST-segment resolution in patients with acute coronary syndrome. Circulation. 2002;105:2355–2600[Abstract/Free Full Text]
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