Aspirin Management in Patients with a Platelet Count Around 60 × 10³/µL

1. When Aspirin Should Be Continued

Acute coronary syndrome (ACS) patients – The 2025 ACC/AHA guideline gives a Class I recommendation to give a loading dose of 162–325 mg followed by a maintenance dose of 75–100 mg daily to reduce death and major adverse cardiovascular events (MACE). This recommendation applies even when the platelet count is ≥50 × 10³/µL. 1
Patients with recent coronary stent placement – Continuing aspirin is essential to prevent stent thrombosis, a complication associated with high mortality; the recommendation applies to drug‑eluting stents placed within the past 12 months. 5
Secondary‑prevention patients (established cardiovascular disease) – Aspirin provides a mortality and morbidity benefit that justifies continuation at platelet counts ≥50 × 10³/µL. 3
Individuals with diabetes mellitus and established cardiovascular disease – Low‑dose aspirin (75–162 mg daily) yields a net clinical benefit even with modest thrombocytopenia. 4

Planned high‑bleeding‑risk surgery (e.g., intracranial surgery, major urologic procedures) – Aspirin should be discontinued before the operation. 5
Absence of a cardiovascular indication (primary prevention in low‑risk patients) – Routine aspirin is not recommended. 3

Use the lowest effective dose – Plain (non‑enteric‑coated) aspirin 75–100 mg daily provides >90 % inhibition of platelet thromboxane generation while minimizing bleeding risk. This dose has comparable cardiovascular efficacy to higher doses. 7
Avoid higher doses (300–325 mg) – No additional cardiovascular benefit is observed, but gastrointestinal bleeding risk increases. 6
Prefer plain aspirin over enteric‑coated formulations – Enteric coating reduces bioavailability and may lead to inadequate platelet inhibition. 7

Bleeding risk with dual antiplatelet therapy – Adding a second antiplatelet agent raises major bleeding risk by approximately 0.4–1.0 % compared with aspirin alone. 5
Monitoring strategy – In patients where aspirin is continued with borderline thrombocytopenia, obtain serial platelet counts every 1–2 weeks and assess for clinical signs of bleeding (e.g., petechiae, mucosal bleeding, gastrointestinal symptoms).

Testing – Platelet function testing can be considered when aspirin resistance is suspected, although routine testing is rarely required. 8
Factors contributing to resistance – Smoking, concomitant NSAID use, and rapid platelet turnover can diminish aspirin’s antiplatelet effect. 10