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This commentary refers to ‘Aspirin desensitization procedures in aspirin intolerant patients: a neglected topic in the ESC 2019 Chronic Coronary Syndrome guidelines’, by M. Bianco et al., on page 482.

Bianco et al. draw attention to the therapeutic challenge that aspirin intolerance not uncommonly presents to interventional cardiologists.1 In the ESC 2019 Guidelines on Chronic Coronary Syndromes, we describe several relevant points in this regard.2 Firstly, we state that other nonselective non-steroidal anti-inflammatory drugs are not suitable as an alternative to aspirin in view of their adverse cardiovascular risk profile. Secondly, we provide a Class IIb recommendation for using prasugrel or ticagrelor in patients who cannot tolerate aspirin. We do not suggest an alternative to aspirin as part of a dual therapy strategy with prasugrel or ticagrelor but do describe the results of the GEMINI-ACS study in which rivaroxaban 2.5 mg b.i.d. in combination with an oral P2Y12 inhibitor was compared with standard dual antiplatelet therapy and shown to have similar efficacy, albeit in stabilized patients after uncomplicated percutaneous coronary intervention (PCI) in the presence of aspirin.3 This presents the possibility of using such a regimen in patients where there are concerns about the risk of stent thrombosis with prasugrel or ticagrelor monotherapy. However, currently, there is insufficient evidence on which to base any recommendations for such a strategy, particularly since, as we indicate, the safety of performing PCI without aspirin pre-treatment is uncertain.

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