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Aspirin-exacerbated respiratory disease requiring emergent percutaneous coronary intervention — ABIM Board MCQ

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HardAllergic ConditionsAspirin-exacerbated respiratory disease requiring emergent percutaneous coronary interventionABIM Board

A 61-year-old man with asthma and recurrent nasal polyps presents 50 minutes after the onset of substernal chest pressure. Electrocardiography shows 3-mm ST-segment elevations in leads V2 through V5. The cardiac catheterization laboratory is immediately available. Six years ago, aspirin caused rhinorrhea, chest tightness, and wheezing within 40 minutes; ibuprofen subsequently caused an identical reaction. Neither episode involved urticaria, angioedema, hypotension, or mucosal lesions. He has no active bleeding or other contraindication to antithrombotic therapy. Which of the following is the most appropriate antiplatelet management strategy?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: E — Load a P2Y12 inhibitor and proceed with immediate PCI without aspirin, then begin monitored aspirin desensitization immediately after PCI

Explanation lettering: D = shown as A · E = shown as B · B = shown as C · C = shown as D · A = shown as E

The reproducible respiratory reactions to chemically unrelated cyclooxygenase-1 inhibitors, together with asthma and nasal polyps, identify aspirin-exacerbated respiratory disease rather than IgE-mediated allergy or gastrointestinal intolerance. Desensitization is appropriate for this phenotype because the previous reactions were respiratory and did not constitute severe anaphylaxis or a delayed mucocutaneous reaction. However, this patient has an acute anterior STEMI requiring emergent PCI; reperfusion should not be delayed to complete desensitization. PCI should proceed using a P2Y12 inhibitor, with aspirin desensitization initiated immediately afterward in a monitored setting. Successful desensitization should be followed by uninterrupted aspirin administration because loss of tolerance may require repeat desensitization. ([acc.org](https://www.acc.org/Latest-in-Cardiology/ten-points-to-remember/2024/05/08/19/22/aspirin-hypersensitivity-a-practical)) B reverses the appropriate sequence and is used when PCI is nonemergent. C may seem attractive because it avoids the culprit drug, but immediate post-PCI P2Y12 monotherapy is not the default ACS regimen; contemporary guidance supports aspirin plus a P2Y12 inhibitor, with selected transitions to monotherapy occurring later. D is inappropriate because the history already strongly supports true cross-reactive hypersensitivity, and an acute STEMI is not the setting for a diagnostic challenge. E exposes myocardium to ongoing ischemia despite immediate PCI availability; allergy consultation must not postpone emergent reperfusion.

Reference: Practical Guide on Aspirin Hypersensitivity: Key Points (May 8, 2024) — https://www.acc.org/Latest-in-Cardiology/ten-points-to-remember/2024/05/08/19/22/aspirin-hypersensitivity-a-practical Top Things to Know: 2025 Guideline for Acute Coronary Syndromes (February 27, 2025) — https://professional.heart.org/en/science-news/2025-guideline-for-the-management-of-patients-with-acute-coronary-syndromes/top-things-to-know