Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial

Association of thromboxane generation with the bleeding events in aspirin users

Coronary artery disease is among the leading causes of morbidity and mortality worldwide, posing a significant threat to human health and life. Aspirin is widely used in the treatment of coronary artery disease, however, long-term use may increase the risk of bleeding. Urinary 11-dehydro-TXB2, a biomarker indicative of platelet activation, has been associated with thrombotic events, but its association with bleeding events remains unexplored. This study aimed to assess the predictive value of TXB2-M levels for bleeding events in patients with coronary artery disease undergoing aspirin therapy. Multifactorial logistic regression analysis was employed to evaluate the potential of TXB2-M levels as a reliable marker for bleeding risk following aspirin use. Among patients with coronary artery disease treated with aspirin, those with lower TXB2-M levels exhibited an increased risk of bleeding events within three years (Hazard Ratio: 0.46; 95% Confidence Interval: 0.26-0.79; P < 0.05). Additionally, variations in TXB2-M levels were observed across different demographic groups. This study reinforces the validity of TXB2-M levels as a biomarker for identifying patients at elevated risk of bleeding, thus facilitating the implementation of personalized treatment strategies to minimize bleeding risks while preserving the efficacy of antithrombotic therapy.

Long-term use of low-dose aspirin for cancer prevention: A 20-year longitudinal cohort study of 1,506,525 Hong Kong residents

Long-term use of low-dose aspirin has been demonstrated to reduce cancer risk, but the duration of necessary medication use remains uncertain. This study aimed to investigate the long-term chemoprotective effect of aspirin among the Chinese population. This population-based study included all aspirin users between 2000 and 2019. Aspirin users were age-sex matched with non-users at a 1:2 ratio. Cancer incidence and mortality were the main outcomes measured. Survival analyses with the Fine-Gray modelling were performed. The chemoprotective effects were measured by the sub-distribution hazard ratios (SHR) with control for the competing risks. A total of 538,147 aspirin users and 968,378 non-users were included, with a mean age of 64.8 years, 9,543,399 person-years of follow-up and 90% of users with 80 mg aspirin. The long-term use of aspirin was associated with a reduced risk of cancer (SHR 0.92, 95% CI 0.91-0.94) and a reduced risk of cancer mortality (SHR 0.80, 95% CI 0.79-0.82). Stronger chemopreventive effects were observed among those who used aspirin for more than 10 years, including risk reductions for lung (SHR 0.56, 95% CI 0.51-0.60), breast (SHR 0.34, 95% CI 0.29-0.38) and colorectal (SHR 0.37, 95% CI 0.33-0.40) cancers, but not for bladder cancer and leukaemia. Low-dose use of aspirin was associated with lower risk of cancer among Chinese. The association was even stronger for those using aspirin for more than 10 years. Prescription of aspirin may be started as early as at age of 40, as the chemoprotective effect also applied for early cancers.

2-Methoxybenzoic acid ameliorates arterial thrombosis via inhibiting carbon anhydrase activity in platelet

BACKGROUND

2-Methoxybenzoic acid (2MOA) is a natural compound with potential salicylate-like effects; however, its impact on arterial thrombosis remains unclear.

OBJECTIVES

This study aimed to investigate the effects of 2MOA on thrombogenesis and its underlying mechanisms.

METHODS

FeCl3-induced carotid artery injury and laser-induced cremaster artery injury thrombosis assays were used to explore the effect of 2MOA on thrombogenesis in vivo. Various ex vivo platelet function assays were conducted to evaluate the impacts of 2MOA on platelet activity. In addition, untargeted metabolomics analysis was performed to identify the alterations in intraplatelet metabolites following 2MOA treatment.

RESULTS

We found that 2MOA significantly ameliorated thrombosis in a dose-dependent manner, without affecting the normal hemostasis in C57BL/6J mice. 2MOA suppressed platelet reactivity as indicated by decreased spreading, retraction, and aggregation in both mouse and human platelets. Metabolomics analysis revealed significantly alterations in purine metabolism following 2MOA treatment, which increased cyclic guanosine monophosphate production in platelets. Mechanistically, 2MOA inhibited the activity of carbonic anhydrase, leading to elevated intraplatelet cGMP level, and subsequent suppression of cytosolic phospholipase A2 phosphorylation.

CONCLUSION

Our study illustrates that 2MOA efficaciously inhibits platelet reactivity and alleviates thrombogenesis via suppressing carbonic anhydrase activity, which should be a promising reagent in the prevention and treatment of arterial thrombotic events.

Low LDL-cholesterol drives the risk of bleeding in patients treated with aspirin: A 15-year study in a real-world large population

We aimed to investigate the link between LDL cholesterol (LDL-C) levels and hemorrhage risk over an extended period, both in subjects taking aspirin and in individuals not receiving any antiplatelet agent. We calculated the predicted adjusted relative hazard of bleeding by LDL-C concentration for the whole cohort and the aspirin-treated subgroup. The study included 39,784 individuals with a mean follow-up of 14.9 years, totaling over 500,000 patient-years. Across the cohort, 3380 bleeding events were reported, with a higher incidence in patients with LDL-C < 70 mg/dL compared to those with LDL-C ≥ 70 mg/dL (9.9 % vs 8.4 %). In aspirin-treated patients, multivariable analysis revealed that hemorrhagic events were significantly associated with aging, male sex, body mass index, hypertension, and LDL-C < 70 mg/dL. These patients had a significantly lower event-free survival probability if their LDL-C was < 70 mg/dL compared to ≥ 70 mg/dL. Low LDL-C values were a significant risk factor (HR >1) while higher LDL-C values were protective (HR <1). A stepwise increase of 10 mg/dL in LDL-C from < 30 to ≥ 200 mg/dL was associated with a decreasing trend for bleeding events in both the entire cohort and the aspirin-treated subgroup. This is the first report specifically addressing the relationship between LDL-C levels and bleeding risk in a population receiving low-intensity antithrombotic therapy. Our data demonstrate that in patients taking aspirin, LDL-C levels below 70 mg/dL significantly increase the risk of bleeding, with major implications for long-term cardiovascular risk management.

Self-administration of aspirin for acute chest pain-Does it prevent premature cardiovascular mortality?

Aspirin as a class I guideline recommended medical treatment for acute coronary syndrome has been established for decades [1]. As early intake of aspirin is crucial, self-administration of aspirin in acute chest pain might be beneficial when weighing up the potential harm including a slightly elevated bleeding risk in patients with chest pain of another origin than myocardial infarction against the benefit in patients with coronary ischemia.

Role of Aspirin in Reducing Risk for Atherosclerotic Cardiovascular Disease in Individuals with Elevated Lipoprotein(a)

PURPOSE OF REVIEW

Elevated Lp(a) is associated with increased risk for atherosclerotic cardiovascular disease (ASCVD), and there is currently a lack of targeted therapies for treating individuals with elevated Lp(a). The purpose of this review is to evaluate the current evidence for aspirin therapy for the primary prevention of ASCVD in individuals with elevated Lp(a).

RECENT FINDINGS

Prior studies demonstrated an association between aspirin use and a reduction in cardiovascular events among carriers of particular high-risk LPA single nucleotide polymorphisms. More recent studies have extended these findings by incorporating the more clinically available Lp(a) levels, observing an approximately 50% reduction in risk for coronary heart disease events and ASCVD mortality with aspirin use among individuals with Lp(a) > 50 mg/dL. There is growing evidence for a benefit with aspirin therapy in individuals with elevated Lp(a) without clinical ASCVD. The limitations of the available data must be acknowledged, and shared decision making should be used when discussing with patients, particularly when balancing potential bleeding risk. Future studies are needed to provide more definitive guidance regarding primary prevention aspirin therapy in this population.

Aspirin in primary prevention: Undue reliance on an uninformative trial led to misinformed clinical guidelines

Best practices for design, conduct, analysis, and interpretation of randomized controlled trials should adhere to rigorous statistical principles. The reliable detection of small effects of treatment should be based on results reported from the primary pre-specified endpoints of large-scale randomized trials designed a priori to test relevant hypotheses. Inference about treatment should not be based on undue reliance on individual small trials, meta-analyses of small trials, subgroups, or post hoc analyses. Failure to follow these principles can lead to conclusions inconsistent with the totality of evidence and to inappropriate recommendations made by guideline committees. The American Heart Association/American College of Cardiology Task Force published guidelines to restrict aspirin for primary prevention of cardiovascular disease to patients below 70 years of age, and the United States Preventive Services Task Force to below 60 years. These guidelines were both unduly influenced by the Aspirin in Reducing Events in the Elderly trial, the results of which were uninformative; they did not provide evidence that aspirin showed no benefit in these age groups. We present several major methodological pitfalls in interpreting the results from the Aspirin in Reducing Events in the Elderly trial of aspirin in the primary prevention of cardiovascular disease. We believe that undue reliance on this uninformative trial has led to misinformed guidelines. Furthermore, given the totality of evidence, we believe that general guidelines for aspirin in the primary prevention of cardiovascular disease are unwarranted. Prescription should be based on an assessment of an individual's benefit to risk; age should be only one component of that assessment.

Rationale and Design of the CREATE Trial: A Multicenter, Randomized Comparison of Continuation or Cessation of Single Antithrombotic Therapy at 1 Year After Transcatheter Aortic Valve Replacement

BACKGROUND

Current guidelines and expert consensus recommend lifelong single antiplatelet therapy for patients undergoing transcatheter aortic valve replacement who have no indication for anticoagulation or dual antiplatelet therapy. However, there is no direct evidence from randomized controlled trials supporting this practice. Furthermore, the optimal duration of antiplatelet therapy in this population has not been adequately investigated.

METHODS AND RESULTS

CREATE (A Multicenter Randomized Controlled Study to Evaluate Cessation of Antithrombotic Therapy at 1 Year in TAVR Patients-The CREATE Study) is a prospective, multicenter, open-label, randomized controlled trial for patients who have undergone successful transcatheter aortic valve replacement and have no indication for long-term oral anticoagulation or antiplatelet therapy. Eligible patients are free from major bleeding and ischemic events for 1 year postprocedure before being randomized 1:1 to single antiplatelet therapy (control group) or no antiplatelet therapy (experimental group). The primary efficacy end point is the incidence of bleeding events, defined by the VARC-3 (Valve Academic Research Consortium-3) criteria, at 1-year postrandomization. The primary safety end point is a composite of cardiac death, myocardial infarction, and ischemic stroke at 1 year. The trial is powered for both superiority in efficiency and noninferiority in safety. Accordingly, a total of 3380 patients will be enrolled.

CONCLUSIONS

The CREATE trial aims to assess if stopping antiplatelet therapy at 1-year after transcatheter aortic valve replacement reduces bleeding risk without increasing ischemic events in patients not requiring chronic antithrombotic therapy.

REGISTRATION

URL: https://www.chictr.org.cn; Unique identifier: ChiCTR2400087454.

Unexpected cardiovascular risks of glucagon-like peptide-1 receptor agonist and aspirin co-administration in individuals with obesity, with and without type 2 diabetes: A propensity score matched cohort study

AIMS

To examine the cardiovascular safety of combining glucagon-like peptide-1 receptor agonists (GLP-1 RAs) with aspirin in individuals with obesity, both with and without type 2 diabetes (T2D).

MATERIALS AND METHODS

This propensity score matched cohort study analysed data from 2 946 579 individuals with obesity, with and without T2D, using the TriNetX US and Global dataset. Participants were categorized into four matched groups: those receiving GLP-1 RA plus aspirin versus those receiving GLP-1 RA alone, for both diabetic and non-diabetic individuals. Cardiovascular outcomes and adverse events were evaluated over 5 years using Cox proportional hazards models.

RESULTS

Individuals with obesity treated with GLP-1 RAs plus aspirin showed significantly higher risks of various cardiovascular events compared to those on GLP-1 RAs alone. In non-diabetic obese individuals, the combination therapy increased risks of hypertensive heart diseases (HR 1.40, 95% CI 1.15-1.60), ischaemic heart disease (HR 2.39, 95% CI 1.92-2.97) and heart failure (HR 1.97, 95% CI 1.54-2.53). Similar patterns were observed in individuals with T2D. Atrial fibrillation and cardiac arrhythmias showed increasing hazard ratios over time. The combination therapy also led to more frequent adverse events, including gastrointestinal bleeding.

CONCLUSIONS

The combination of GLP-1 RAs with aspirin in individuals with obesity, both with and without T2D, was associated with increased cardiovascular risks compared to GLP-1 RA monotherapy. These findings suggest that there may be risks associated with the combined use of these treatments and highlight the need for further research into this possible complication with regard to treatment.

Pharmacists' Intervention in Inappropriate Aspirin Prescribing in a Geriatric Primary Care Clinic

Background: In recent years, aspirin use has been controversial for primary prevention of atherosclerotic cardiovascular disease (ASCVD) events. Numerous clinical trials have proven that aspirin does not improve outcomes and increases major bleeding rates. Despite clinical trial data and guideline recommendations, there remains a large number of older adults taking aspirin for primary prevention. Objective: Describe the impact that pharmacists had on the discontinuation of inappropriately prescribed aspirin in a geriatric primary care clinic. Methods: This is a retrospective review of patients taking aspirin. A report was generated for all patients with aspirin on their medication list. The pharmacist determined the indication for aspirin. If patients were taking aspirin for primary prevention, the pharmacist recommended aspirin be discontinued. Results: A total of 528 patients were included in this study. There were 321 (61%) females and 207 (39%) males. After analyzing aspirin indication, 122 (48%) were taking aspirin for primary prevention, 273 (52%) were taking aspirin for secondary prevention, and 133 (52%) were taking aspirin for another indication. The recommendation to discontinue aspirin was accepted 91 times and declined 30 times, yielding a 75% acceptance rate. Conclusion: Aspirin has several appropriate indications for use; however, previous studies have shown that risk outweighs benefit when used for primary prevention of ASCVD events in the geriatric population. When aspirin is on a patient's medication list, it should be assessed routinely for appropriateness. This retrospective review by pharmacists highlights the need for review and discontinuation of aspirin when appropriate.

Use of Aspirin and Initial Cardiovascular and Bleeding Risk in Patients with Chronic Kidney Disease

Key Points

The association between aspirin use and risk of the first cardiovascular event was NS in patients with CKD. Compared with nonusers, aspirin users had an increased risk of significant bleeding events. Aspirin prescription for the primary prevention of cardiovascular disease in patients with CKD needs careful consideration.

Background

Despite the high cardiovascular risk in patients with CKD, the role of aspirin in primary prevention remains unclear. This study aimed to investigate the association between aspirin initiation in adults with CKD without prior cardiovascular disease (CVD) and the first cardiovascular and bleeding events using Korean nationwide cohort data.

Methods

Among individuals aged 40–79 years with an eGFR between 15 and 59 ml/min per 1.73 m2 who underwent routine health examinations between 2011 and 2016, 15,861 individuals who were newly prescribed aspirin at a dose of 100 mg/d were matched with 79,305 aspirin non-users by propensity score matching. The primary efficacy outcome was a composite of nonfatal atherosclerotic CVD or cardiovascular death. The primary safety outcome was hospitalization due to intracranial or gastrointestinal bleeding.

Results

During a mean follow-up of 6.9±2.9 years, the incidence rates for the primary efficacy outcome in aspirin users and nonusers were 8.0 and 9.0 per 1000 person-years, respectively. Aspirin therapy initiation was not associated with the primary efficacy outcome (hazard ratio, 0.93; 95% confidence intervals, 0.86 to 1.04). However, the primary safety outcome of major bleeding was more frequent in aspirin users than in nonusers (6.7 versus 4.7 per 1000 person-years). The hazard ratio for this outcome in aspirin users versus nonusers was 1.45 (95% confidence intervals, 1.32 to 1.59).

Conclusions

No association was observed between aspirin use and the risk of nonfatal atherosclerotic CVD or cardiovascular death in patients with CKD stages G3 and G4 without prior CVD. Aspirin use was associated with higher risk of major bleeding.

Population cessation of aspirin use for the prevention of cardiovascular disease

Importance

Aspirin use for primary prevention of cardiovascular diseases (CVD) is widespread with over a third of the adult population using despite guidelines recommending against.

Objective

This population-based research documents rates of use and reasons for cessation from 2015 to 2020, a period when guidelines changed.

Design

Three cross-sectional telephone surveys were conducted during 2015, 2017, and 2019-20.

Setting

A population-based survey in the states of Iowa, Minnesota, North Dakota, South Dakota, and Wisconsin.

Participants

The surveys included non-institutionalized resident adults ages 55-79 for women and 45-79 for men with landline telephones.

Main Outcomes and Measures

The analysis included 8,197 participants, 4,161 women and 4,036 men after excluding those with a history of cardiovascular disease (secondary prevention). Aspirin use for primary prevention was stable for the first two survey years (39 % in 2015 and 41 % in 2017) but fell significantly to 34 % in the final survey (2019-2020). The most common reason for cessation was "doctor's advice" (38 % of quitters) followed by "heard negative news" with a significant increase from 2015 to 2020 (4 % to 29 % of quitters).

Conclusions and Relevance

Despite recent research findings and new guidelines, aspirin is still widely used for primary prevention of CVD in the general population. A combination of slow diffusion and implementation of guidelines, self-medication, and wide availability of low-cost aspirin underlies these trends. Physician advice is effective but more is needed. The influence of the popular media is also substantial. Appropriate implementation of aspirin guidelines requires additional clinician effort.

Trial Registration

Clinicaltrials.gov registered on December 1, 2014, NCT02607917.

Association of Aspirin Use in Primary Prevention and Cardiovascular Events: A Retrospective Analysis of the VITAL Cohort

Background: Aspirin is part of the therapeutic antithrombotic armamentarium for the management of patients with established clinically relevant atherosclerosis or thrombotic cardiovascular disease. Personalized medicine identifies those who benefit most or face fewer risks from aspirin. The role of aspirin in primary prevention is still debatable. We aimed to assess the risks and benefits of aspirin in this setting, using the data of the prospective VITAL (VITamins and Lifestyle) study. Methods: We conducted a retrospective evaluation of the VITAL cohort. In this analysis, participants were split according to aspirin usage. Aspirin use was evaluated regarding all-cause mortality, CV mortality, major cardiovascular event (MACE), myocardial infarction, coronary heart disease, total stroke, and hemorrhagic stroke. The hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated to explore the association between cardiovascular events and aspirin usage. The estimates were adjusted for demographic and clinical variables. Results: The aspirin users (n = 11,570) were older, more frequently men, the body mass index was higher, and the proportion of smokers was smaller compared with non-users (n = 13,927). After adjusting for demographic and clinical variables, aspirin was not identified as a predictor of cardiovascular death (HR 1.17, 95%CI 0.89 to 1.55), major cardiovascular events (HR 1.04, 95%CI 0.89 to 1.22), coronary heart disease (HR 1.16, 95%CI 0.98 to 1.37), nor stroke (HR 1.01, 95%CI 0.77 to 1.31). Conclusion: In this retrospective analysis of the VITAL cohort, aspirin was not associated with a reduced risk of cardiovascular mortality or events.

Aspirin and Clinical Outcomes in Individuals with Incidentally Diagnosed Coronary Artery Stenosis

BACKGROUND

The widespread use of coronary computed tomographic angiography has increased the number of cases of coronary stenosis in asymptomatic individuals. In this population, we aimed to analyze the net benefit of aspirin, which is currently recommended for secondary cardiovascular prevention.

METHODS

This propensity score-matching study screened 41,441 asymptomatic individuals who underwent coronary computed tomographic angiography during health checkups between 2007 and 2022. Ultimately, 1483 patients with incidentally diagnosed coronary stenosis were enrolled after excluding ineligible individuals. Using a 1:1 propensity score matching, data from 636 individuals (318 new aspirin users and 318 controls) were analyzed. The primary outcome variable was composite cardiovascular events (cardiovascular death, nonfatal myocardial infarction, and nonfatal ischemic stroke/transient ischemic attack), with/without major bleeding.

RESULTS

At a median follow-up of 6.3 years, 11 and 18 individuals experienced composite events in the aspirin and control groups (2.1 and 3.2/1000 person-years; hazard ratio 0.62; P = .20), respectively. Conversely, composite events and major bleeding occurred in 26 and 23 individuals in the aspirin and control groups (4.9 and 4.1/1000 person-years; hazard ratio 1.16; P = .60), with a higher bleeding risk in the aspirin group. Kaplan-Meier curves demonstrated no significant difference in composite events without (log-rank P = .21) or with major bleeding (P = .61). Furthermore, age, chronic kidney disease, and low high-density lipoprotein cholesterol were identified as predictors of composite events and bleeding.

CONCLUSIONS

Aspirin showed no benefit for composite events and bleeding in asymptomatic individuals with coronary stenosis. Thus, personalized aspirin use rather than universal aspirin use may be more appropriate for this population.

Polygenic risk, aspirin, and primary prevention of coronary artery disease

AIMS

Recent aspirin primary prevention trials failed to identify a net benefit of aspirin for preventing cardiovascular disease vs. the harms of bleeding. This study aimed to investigate whether a high-risk subgroup, individuals with elevated genetic predisposition to coronary artery disease (CAD), might derive more benefit than harm with aspirin, compared to those with lower genetic risk.

METHODS AND RESULTS

We performed genetic risk stratification of the Aspirin in Reducing Events in the Elderly (ASPREE) randomized controlled trial using a CAD polygenic risk score (GPSMult). For 12 031 genotyped participants (5974 aspirin, 6057 placebo) overall, we stratified them by GPSMult quintiles (q1-5), then examined risk of CAD (composite of myocardial infarction and coronary heart disease death) and bleeding events using Cox models. During a median 4.6 years of follow-up with randomization to 100 mg/day aspirin vs. placebo, 234 (1.9%) participants had CAD and 373 (3.1%) had bleeding events. In the overall cohort, aspirin resulted in higher bleeding risk [adjusted Hazard ratio (aHR) = 1.30 (1.06-1.61), P = 0.01] but no significant CAD reduction [aHR = 0.84 (0.64-1.09), P = 0.19]. However, among the highest quintile of polygenic risk (q5, top 20% of the GPSMult distribution), there was a 47% reduction in risk of CAD events with aspirin [aHR = 0.53 (0.31-0.90), P = 0.02] without increased bleeding risk [aHR = 1.05 (0.60-1.82), P = 0.88]. Interaction between the GPSMult and aspirin was significant for CAD (q5 vs. q1, P = 0.02) but not bleeding (P = 0.80).

CONCLUSION

The balance between net benefit and harm on aspirin in the primary prevention setting shifts favourably in individuals with an elevated genetic predisposition.

Association of aspirin use with risk of intracerebral hemorrhage in patients without history of stroke or transient ischemic attack in the UK Biobank

BACKGROUND

The association between aspirin use and the risk of intracerebral hemorrhage (ICH) among individuals without previous stroke events is inconclusive.

AIM

We investigated the association between regular aspirin use and ICH risk in middle-aged and older adults without previous stroke or transient ischemic attack (TIA).

METHODS

This prospective population-based study included participants older than 40 years with no history of stroke or TIA from the UK Biobank. The main exposure was regular aspirin use. Cox regression analyses and propensity score matching analyses estimated the hazard ratios (HRs) for aspirin use for incident fatal and non-fatal ICH. We conducted pre-specified subgroup analyses for selecting individuals at high risk of ICH when using aspirin. Multiple sensitivity analyses were performed to test the robustness of our results.

RESULTS

A total of 449,325 participants were included into final analyses (median (IQR) age 58 (50-63) years, 54.6% females), of whom 58,045 reported aspirin use. During a median follow-up of 12.75 (IQR: 12.03-13.47) years, 1557 (0.3%) incident ICH cases were identified, of which 399 (25.6%) were fatal. Aspirin was not associated with increased risk of overall (hazard ratio (HR): 1.11, 95% confidence interval (CI): 0.95-1.27, P = 0.188), fatal (HR: 1.03, 95% CI: 0.78-1.36, P = 0.846) and non-fatal (HR: 1.12, 95% CI: 0.95-1.33, P = 0.186) ICH. Propensity score matching analysis showed similar results. Subgroup analysis indicated that aspirin use in individuals older than 65 years or with concurrent anticoagulant use was correlated with increased risk of ICH.

CONCLUSION

In this large cohort study of middle-aged and older adults without stroke or TIA events, there was no significant association between aspirin use and ICH risk in the real-world setting. However, it is possible that aspirin use in those aged over 65 years and concurrent anticoagulant treatment may increase the risk of ICH.

The effect of sarpogrelate compared to aspirin in high- or very-high-risk diabetes for primary prevention

The benefit of aspirin in primary prevention for atherosclerotic cardiovascular diseases (ASCVD) is questionable due to bleeding complications. We analyzed the Korean National Health Insurance data to compare the efficacy and overall bleeding of sarpogrelate, an antiplatelet agent with lower bleeding risk, versus aspirin in high-/very-high-risk diabetic populations without prior ASCVD. The primary endpoint was net adverse clinical events (NACE), defined as a composite of efficacy and overall bleeding. The efficacy was a composite of all-cause death, myocardial infarction (MI) and stroke, whereas overall bleeding included intracranial hemorrhage (ICH) and gastrointestinal (GI) bleeding. A total of 10,778 high-/very-high-risk diabetic patients (9550 on aspirin, 1228 on sarpogrelate) were analyzed. After propensity score matching, sarpogrelate was linked to a lower incidence of NACE (HR:0.71; 95% CI 0.57-0.88), mainly driven by 62% reductions in overall bleeding (0.38; 0.17-0.81), a composite of 64% and 72% lower rate of GI bleeding and ICH, respectively. Additionally, there was no significant differences in MI or stroke between groups. In high- or very-high-risk diabetic patients without ASCVD, sarpogrelate use was associated with net clinical benefit mainly due to the reduction of significant reduction in overall bleeding events.

A 10-Year Risk Assessment and Primary Prevention Study of Atherosclerotic Cardiovascular Disease Among Adult Patients in Saudi Arabia: A Cross-Sectional Study

Background and Objectives: Cardiovascular diseases (CVDs), primarily driven by atherosclerosis, are the leading cause of mortality worldwide. In Saudi Arabia, the prevalence of atherosclerotic cardiovascular disease (ASCVD) poses a significant public health challenge. To estimate the 10-year ASCVD risk among adults in Al-Ahsa, Saudi Arabia, and identify prevalent risk factors such as age, gender, diabetes, hypertension, smoking, cholesterol, and preventive medication use. Materials and Methods: This cross-sectional study included 58,743 adults aged 35-75 years from the Al-Ahsa Health Cluster. The ASCVD risk was calculated using the ACC/AHA Pooled Cohort Equations. Statistical analysis identified predictors of high ASCVD risk. Results: Most participants (76.3%) were at low ASCVD risk (≤10%), 13.3% at borderline to intermediate risk (10-19%), and 10.4% at high risk (≥20%). Smoking, diabetes (39.6%), hypertension (40.8%), and male gender were key predictors of high ASCVD risk. High-density lipoprotein (HDL) was protective, reducing ASCVD risk by 3%. Among high-risk individuals, 29.7% used aspirin, and 58.3% used statins. Conclusions: While most adults in Al-Ahsa are at low ASCVD risk, a significant portion remains at elevated risk. Modifiable risk factors, including smoking, diabetes, and hypertension, combined with statin and aspirin adherence, highlight critical areas for targeted interventions to reduce the ASCVD burden in this population.

Platelets and circulating (tumor) cells: partners in promoting metastatic cancer

PURPOSE OF REVIEW

Despite being discovered decades ago, metastasis remains a formidable challenge in cancer treatment. During the intermediate phase of metastasis, tumor cells detach from primary tumor or metastatic sites and travel through the bloodstream and lymphatic system to distant tissues. These tumor cells in the circulation are known as circulating tumor cells (CTCs), and a higher number of CTCs has been linked to poor prognoses in various cancers. The blood is an inhospitable environment for any foreign cells, including CTCs, as they face numerous challenges, such as the shear stress within blood vessels and their interactions with blood and immune cells. However, the exact mechanisms by which CTCs survive the hostile conditions of the bloodstream remain enigmatic. Platelets have been studied for their interactions with tumor cells, promoting their survival, growth, and metastasis. This review explores the latest clinical methods for enumerating CTCs, recent findings on platelet-CTC crosstalk, and current research on antiplatelet therapy as a potential strategy to inhibit metastasis, offering new therapeutic insights.

RECENT FINDINGS

Laboratory and clinical data have provided insights into the role of platelets in promoting CTC survival, while clinical advancements in CTC enumeration offer improved prognostic tools.

SUMMARY

CTCs play a critical role in metastasis, and their interactions with platelets aid their survival in the hostile environment of the bloodstream. Understanding this crosstalk offers insights into potential therapeutic strategies, including antiplatelet therapy, to inhibit metastasis and improve cancer treatment outcomes.

Contributions of Inflammation to Cardiometabolic Heart Failure with Preserved Ejection Fraction

The most common form of heart failure is heart failure with preserved ejection fraction (HFpEF). While heterogeneous in origin, the most common form of HFpEF is the cardiometabolic manifestation. Obesity and aging promote systemic inflammation that appears integral to cardiometabolic HFpEF pathophysiology. Accumulation of immune cells within the heart, fueled by an altered metabolome, contribute to cardiac inflammation and fibrosis. In spite of this, broad anti-inflammatory therapy has not shown significant benefit in patient outcomes. Thus, understanding of the nuances to metabolic and age-related inflammation during HFpEF is paramount for more targeted interventions. Here, we review clinical evidence of inflammation in the context of HFpEF and summarize our mechanistic understanding of immunometabolic inflammation, highlighting pathways of therapeutic potential along the way.

10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Guideline concordance of aspirin use for primary prevention in adult outpatients

ABSTRACT

Recent guidelines have recommended a reduced role for primary prevention aspirin use, which is associated with an increased bleeding risk. This study aimed to characterize guideline-discordant aspirin use among adults in a community care setting. As part of a quality improvement initiative, patients at 1 internal medicine and 1 family medicine clinic affiliated with an academic hospital were sent an electronic survey. Patients were included if they were at least 40 years old, had a primary care provider at the specified site, and were seen in the last year. Patients were excluded if they had an indication for aspirin other than primary prevention. Responses were collected from 15 February to 16 March 2022. Analyses were performed to identify predictors of primary prevention aspirin use and predictors of guideline-discordant aspirin use; aspirin users and nonusers were compared using Fisher exact test, independent samples t tests, and multivariable logistic regression. Of the 1460 patients sent a survey, 668 (45.8%) responded. Of the respondents, 132 (24.1%) reported aspirin use that was confirmed to be for primary prevention. Overall, 46.2% to 58.3% of primary prevention aspirin users were potentially taking aspirin, contrary to the guideline recommendations. Predictors of discordant aspirin use included a history of diabetes mellitus and medication initiation by a primary care provider. In conclusion, primary prevention aspirin use may be overutilized and discordant with recent guideline recommendations for approximately half of the patients, suggesting a need for aspirin deimplementation. These efforts may be best focused at the primary care level.

A Saudi Heart Association Position Statement on Cardiovascular Diseases and Diabetes Mellitus

Background

Cardiovascular disease (CVD) and diabetes mellitus are prominent public health concerns in Saudi Arabia owing to their increasingly high prevalence and burden. Based on this, the Saudi Heart Association (SHA) set out to develop an official position statement on CVD and diabetes mellitus, with a focus on the prevention and management of these conditions and relevant special populations in the context of Saudi Arabia.

Methods

A multidisciplinary panel of experts met under the auspices of the SHA in a series of meetings to review and discuss available evidence on the prevention and management of comorbid CVD and diabetes mellitus. Specialized subcommittees reviewed the data and offered context-specific recommendations (taking into account Saudi population characteristics, local healthcare system, available resources and medical expertise), which were later approved by the full expert panel.

Results and conclusions

The prevalence of diabetes mellitus and CVD is alarming in the Saudi Arabian population. Diabetes mellitus and CVD are interconnected on several levels, including cellular and molecular events as well as epigenetic and genetic mechanisms. Screening for CVD is a priority for patients with diabetes and concomitant risk factors. The expert panel also recommends aggressive management of high blood pressure and dyslipidemia in addition to lifestyle changes and achieving glycemic targets for the prevention of CVD in patients with diabetes. Some glucose-lowering drug classes, namely SGLT2-inhibitors and GLP-1 receptor agonists, offer significant benefits on the level of cardiovascular risk reduction and are thus a powerful addition to the clinical management armamentarium in CVD and diabetes. Special consideration is also advised for patient populations with distinct clinical presentation and needs, such as coronary artery disease, heart failure, and chronic kidney disease, among others.

2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2024 Guideline for the Primary Prevention of Stroke" replaces the 2014 "Guidelines for the Primary Prevention of Stroke." This updated guideline is intended to be a resource for clinicians to use to guide various prevention strategies for individuals with no history of stroke.

METHODS

A comprehensive search for literature published since the 2014 guideline; derived from research involving human participants published in English; and indexed in MEDLINE, PubMed, Cochrane Library, and other selected and relevant databases was conducted between May and November 2023. Other documents on related subject matter previously published by the American Heart Association were also reviewed.

STRUCTURE

Ischemic and hemorrhagic strokes lead to significant disability but, most important, are preventable. The 2024 primary prevention of stroke guideline provides recommendations based on current evidence for strategies to prevent stroke throughout the life span. These recommendations align with the American Heart Association's Life's Essential 8 for optimizing cardiovascular and brain health, in addition to preventing incident stroke. We also have added sex-specific recommendations for screening and prevention of stroke, which are new compared with the 2014 guideline. Many recommendations for similar risk factor prevention were updated, new topics were reviewed, and recommendations were created when supported by sufficient-quality published data.

Deprescribing Cardiovascular Medications in Older Adults Living with Frailty

Certain medications have shown significant effectiveness in reducing the incidence of cardiovascular events and mortality, leading them to be among those that are prescribed most commonly for Canadian seniors. However, polypharmacy, which disproportionately affects older adults, is particularly concerning for frail individuals who are at higher risk for adverse medication-related events. The deprescribing process is the discontinuation, either immediate or gradual, of inappropriate medications, to address polypharmacy and improve outcomes. Nonetheless, the incorporation of deprescribing principles into clinical practice present challenges, including the limited amount of data available on the clinical benefits of deprescription, and a lack of consensus on how to deprescribe. The current narrative review explores frailty as a basis for deciding to deprescribe medication. The evidence regarding the benefits of use of medications prescribed for common cardiovascular conditions (including acetylsalicylic acid, statins, and antihypertensives) in older adults with frailty is reviewed. The review also examines the issue of who should initiate the deprescribing process, and the associated psychological implications. Although no one-size-fits-all approach to deprescription is available, patient goals should be prioritized. For older adults with frailty, healthcare professionals must consider carefully whether the benefits of use of a cardiovascular medication outweighs the potential harms. Ideally, the deprescribing process should involve shared decision-making among physicians, other health professionals, and patients and/or their substitute decision-makers, with the common goal of improving patient outcomes.

National Trends in Aspirin Use and Expenditures in the United States: Analysis of The Medical Expenditure Panel Survey 2000-2021

INTRODUCTION

Since its invention in 1897, aspirin (ASA) has been the most widely used and cost-effective antiplatelet agent to prevent and treat atherosclerotic cardiovascular disease (ASCVD). We aimed to study the trends and expenditures associated with ASA use in the USA.

METHODS

We conducted a serial cross-sectional analysis using the Medical Expenditure Panel Survey data from January 2000 to December 2021, focusing on adults aged ≥ 40 years. Total and out-of-pocket expenditures associated with ASA were estimated to 2021 US dollars (USD). Trends, demographics, and predictors of ASA use among patients with and without ASCVD were also evaluated.

RESULTS

A total of 53 million adults were identified during the study period. The number of ASA users increased from 2.9 million to 6.6 million with increased female (36.7%-49.7%; p trend = 0.02) and African American (13%-18.9%; p trend = 0.03) representation amongst all ASA users during the survey period. The use of low-dose ASA increased, while high-dose ASA declined significantly. Only 50% of all ASA users had known ASCVD. The most prevalent ASA users among patients with ASCVD were those aged ≥ 70 years, while patients without ASCVD, it was the 50-69 age group. The total annual expenditure on ASA averaged approximately 60 million USD, with 27.3 million USD out-of-pocket.

CONCLUSION

Total and low-dose (81 mg) ASA use has increased, while high-dose (325 mg) ASA has declined. ASA use for primary prevention has risen among adults aged 50-69 years, and patients ≥ 70 years continue to use ASA without known ASCVD. Further studies are needed to understand the implications of increased ASA use, especially among those without ASCVD.

Reassessing the role of aspirin in patients with coronary artery disease

INTRODUCTION

Recent data question the use of aspirin as a bedrock of antiplatelet therapy in patients with arterial diseases. There are controversies regarding the efficacy of aspirin therapy with respect to specific demographic characteristics, dose and formulations, benefit in primary prevention, and duration in secondary prevention. Importantly, to balance the ischemic benefits and the risk of excessive bleeding following a coronary event, recent studies have investigated strategies to discontinue aspirin therapy and continue with P2Y12 receptor inhibitor monotherapy. However, the precise time when to discontinue aspirin is still unresolved.

AREAS COVERED

Evidence from recent studies evaluating the role of aspirin in primary and secondary prevention studies was collected from a selective literature search. In this review, the authors discuss current recommendations, large-scale studies of aspirin therapy, controversies, and potential future opportunities for aspirin therapy.

EXPERT OPINION

With the new evidence showing lower bleeding risk with aspirin-free strategies in both primary and secondary prevention studies, the role of aspirin is being revaluated with P2Y12 receptor inhibitor monotherapy. The potential benefits of novel aspirin formulations and alternative delivery methods, such as inhaled aspirin, are undergoing much-needed investigation with the goal of optimizing care for a wide range of patients.

Safety and efficacy of antiplatelet therapy in patients with intermediate coronary artery stenosis and deferred revascularization

INTRODUCTION AND OBJECTIVES

This study investigated the safety and efficacy of antiplatelet therapy in patients with intermediate coronary artery stenosis who underwent deferred revascularization due to their fractional flow reserve (FFR).

METHODS

A nationwide cohort study was conducted using the Korean National Health Insurance Service database. A total of 4657 patients with intermediate coronary artery stenosis who underwent deferred revascularization due to their FFR were identified from 2013 to 2020. FFR was indicated in patients with no prior evidence of myocardial ischemia and intermediate coronary artery stenosis (50%-70%) as determined by quantitative coronary angiography. Patients were classified according to whether antiplatelet therapy was initiated after the index procedure. The primary efficacy outcome was major adverse cardiac and cerebrovascular events (MACCE), a composite of all-cause death, myocardial infarction, unplanned revascularization, and stroke, during a 5-year follow-up period. The primary safety outcome was any gastrointestinal bleeding.

RESULTS

After propensity score matching, there were 1634 patients in the antiplatelet therapy group and 1634 in the nonantiplatelet therapy group. The risk of MACCE was similar between the 2 groups (24.8% vs 24.7%; adjusted HR, 0.97; 95%CI, 0.84-1.13; P=0.745). The risk of gastrointestinal bleeding was higher in the antiplatelet therapy group than in the nonantiplatelet therapy group (2.2% vs 1.2%; aHR, 2.07; 95%CI, 1.08-4.00). These results were similar in subgroup analyses.

CONCLUSIONS

In patients with intermediate coronary artery stenosis who underwent deferred revascularization due to their FFR, antiplatelet therapy may increase the risk of gastrointestinal bleeding without reducing the risk of future ischemic events.

Update on antithrombotic therapy and body mass: a clinical consensus statement of the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy and the European Society of Cardiology Working Group on Thrombosis

Obesity and underweight are a growing health problem worldwide and a challenge for clinicians concerning antithrombotic therapy, due to the associated risks of thrombosis and/or bleeding. This clinical consensus statement updates a previous one published in 2018, by reviewing the most recent evidence on antithrombotic drugs based on body size categories according to the World Health Organization classification. The document focuses mostly on individuals at the extremes of body weight, i.e. underweight and moderate-to-morbid obesity, who require antithrombotic drugs, according to current guidelines, for the treatment or prevention of cardiovascular diseases or venous thromboembolism. Managing antithrombotic therapy or thromboprophylaxis in these individuals is challenging, due to profound changes in body composition, metabolism and organ function, and altered drug pharmacokinetics and pharmacodynamics, as well as weak or no evidence from clinical trials. The document also includes artificial intelligence simulations derived from in silico pharmacokinetic/pharmacodynamic models, which can mimic the pharmacokinetic changes and help identify optimal regimens of antithrombotic drugs for severely underweight or severely obese individuals. Further, bariatric surgery in morbidly obese subjects is frequently performed worldwide. Bariatric surgery causes specific and additional changes in metabolism and gastrointestinal anatomy, depending on the type of the procedure, which can also impact the pharmacokinetics of antithrombotic drugs and their management. Based on existing literature, the document provides consensus statements on optimizing antithrombotic drug management for underweight and all classes of obese patients, while highlighting the current gaps in knowledge in these complex clinical settings, which require personalized medicine and precision pharmacology.

2024 Guidelines of the Taiwan Society of Cardiology on the Primary Prevention of Atherosclerotic Cardiovascular Disease --- Part II

For the primary prevention of atherosclerotic cardiovascular disease (ASCVD), the recommended treatment target for each modifiable risk factor is as follows: reducing body weight by 5-10%; blood pressure < 130/80 mmHg (systolic pressure < 120 mmHg in high-risk individuals); low-density lipoprotein cholesterol (LDL-C) < 100 mg/dL in high-risk individuals, LDL-C < 115 mg/dL in moderate-risk individuals, LDL-C < 130 mg/dL in low-risk individuals, and LDL-C < 160 mg/dL in those with a minimal; complete and persistent abstinence from cigarette smoking; hemoglobin A1C < 7.0%; fulfilling recommended amounts of the six food groups according to the Taiwan food guide; and moderate-intensity physical activity 150 min/wk or vigorous physical activity 75 min/wk. For the primary prevention of ASCVD by pharmacological treatment in individuals with modifiable risk factors/clinical conditions, statins are the first-line therapy for reducing LDL-C levels; some specific anti-diabetic drugs proven to be effective in randomized controlled trials for the primary prevention of ASCVD are recommended in patients with type 2 diabetes mellitus; pharmacological treatment is recommended to assist in weight management for obese patients with a body mass index ≥ 30 kg/m2 (or 27 kg/m2 who also have at least one ASCVD risk factor or obesity-related comorbidity); an angiotensin-converting enzyme inhibitor, a glucagon-like peptide-1 receptor agonist, a sodium-dependent glucose cotransporter-2 inhibitor, and finerenone can be used in diabetic patients with chronic kidney disease for the primary prevention of ASCVD. Of note, healthcare providers are at full discretion in clinical practice, owing to the diversity of individuals and practice, and the availability of resources and facilities.

[Cardiovascular preventive recommendations. PAPPS 2024 thematic updates]

The recommendations of the semFYC's Program for Preventive Activities and Health Promotion (PAPPS) for the prevention of vascular diseases (VD) are presented. New in this edition are new sections such as obesity, chronic kidney disease and metabolic hepatic steatosis, as well as a 'Don't Do' section in the different pathologies treated. The sections have been updated: epidemiological review, where the current morbidity and mortality of CVD in Spain and its evolution as well as the main risk factors are described; vascular risk (VR) and recommendations for the calculation of CV risk; main risk factors such as arterial hypertension, dyslipidemia and diabetes mellitus, describing the method for their diagnosis, therapeutic objectives and recommendations for lifestyle measures and pharmacological treatment; indications for antiplatelet therapy, and recommendations for screening of atrial fibrillation, and recommendations for management of chronic conditions. The quality of testing and the strength of the recommendation are included in the main recommendations.

Metabolic syndrome

The metabolic syndrome (MetS) is a multiplex modifiable risk factor for cardiovascular disease, type 2 diabetes mellitus and other health outcomes, and is a major challenge to clinical practice and public health. The rising global prevalence of MetS, driven by urbanization, sedentary lifestyles and dietary changes, underlines the urgency of addressing this syndrome. We explore the complex underlying mechanisms, including genetic predisposition, insulin resistance, accumulation of dysfunctional adipose tissue and ectopic lipids in abdominal obesity, systemic inflammation and dyslipidaemia, and how they contribute to the clinical manifestations of MetS. Diagnostic approaches vary but commonly focus on abdominal obesity (assessed using waist circumference), hyperglycaemia, dyslipidaemia and hypertension, highlighting the need for population-specific and phenotype-specific diagnostic strategies. Management of MetS prioritizes lifestyle modifications, such as healthy dietary patterns, physical activity and management of excess visceral and ectopic adiposity, as foundational interventions. We also discuss emerging therapies, including new pharmacological treatments and surgical options, providing a forward-looking perspective on MetS research and care. This Primer aims to inform clinicians, researchers and policymakers about MetS complexities, advocating for a cohesive, patient-centred management and prevention strategy. Emphasizing the multifactorial nature of MetS, this Primer calls for integrated public health efforts, personalized care and innovative research to address this escalating health issue.

Considerations in Antiplatelet Therapy in Women Undergoing Treatment of Acute Coronary Syndrome or Percutaneous Coronary Intervention

Antiplatelet therapy is integral to reduce the risk of future ischemic events following acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI); this aim must be balanced by limiting the risk of bleeding. Women with ACS or undergoing PCI have distinct platelet physiology, vascular anatomy, and clinical profiles that can influence the selection of an appropriate regimen. There are procedural techniques that can enhance safety in women. The poor inclusion of women in ACS and PCI trials limits our understanding of the ideal antiplatelet regimen in women, and future studies must find ways to increase the participation of female patients.

The Impact of Convertase Subtilisin/Kexin Type 9 Monoclonal Antibodies with and without Apheresis on Platelet Aggregation in Familial Hypercholesterolemia

BACKGROUND AND AIMS

It is well known that elevated cholesterol is associated with enhanced platelet aggregation and patients suffering from familial hypercholesterolemia (FH) have a high risk of thrombotic cardiovascular events. Although decreasing cholesterol level is associated with attenuation of platelet hyperactivity, there are currently no data on the effect of convertase subtilisin/kexin type 9 monoclonal antibodies (PCSK9ab) on platelet reactivity in FH. The aim of the study was to analyse the impact of different therapies including PCSK9ab on platelet aggregation in FH.

METHODS

This study enrolled all 15 patients treated in the University Hospital Hradec Králové for FH. PCSK9ab have been administered in 12 of 15 patients while 8 patients were also undergoing lipid apheresis. Blood samples from all patients including pre- and post-apheresis period were tested for platelet aggregation triggered by 7 inducers, and the effect of 3 clinically used drugs (acetylsalicylic acid, ticagrelor and vorapaxar) was compared as well.

RESULTS

Although apheresis decreased the reactivity of platelets in general, platelet responses were not different between non-apheresis patients treated with PCSK9ab and apheresis patients (post-apheresis values) with the exception of ristocetin. However, when compared to age-matched healthy population, FH patients had significantly lower platelet aggregation responses to 4 out of 7 used inducers and higher profit from 2 out of 3 used antiplatelet drugs even after exclusion of FH patients regularly receiving conventional antiplatelet treatment.

CONCLUSION

This study showed for the first time the suitability of PCSK9ab treatment for reduction of platelet reactivity in FH patients.

The evidence base of the 10 most prescribed drugs in England, France, and the United States: a scoping review

OBJECTIVES

To evaluate whether there is evidence of efficacy of the most commonly used medications in their primary indications.

STUDY DESIGN AND SETTING

This scoping review was executed using the Cochrane Library and MEDLINE databases up to May 2023. The 10 most prescribed medications in England, France, and the United States were identified using country-specific public databases. Up to 3 common indications in primary care were defined for each medication, based on a survey of general practitioners. The outcomes were determined by the authors to be patient-important outcomes, with placebo as the comparator. Two investigators independently conducted searches, following a predefined algorithm, to identify randomized controlled trials or meta-analyses of randomized controlled trials assessing the efficacy of these medications for each indication. The risk of bias was assessed using the ROBIS or ROB 2.0 tools.

RESULTS

We identified 21 drugs, covering 56 indications and 114 outcomes. Sixty-seven percent of the evaluated medications demonstrated efficacy for at least one outcome in at least one of the sought indications. Overall, evidence of efficacy was found for 48% of the indications. There was no study evaluating the efficacy of amoxicillin and salbutamol. For other drugs such as phloroglucinol or cholecalciferol, available studies suggested an absence of efficacy in the most common indications.

CONCLUSION

This study underscores the lack of data regarding the level of evidence for the most prescribed medications. Limitations include the choice of outcomes, and the understanding that the absence of evidence is not synonymous with the absence of efficacy.

Aspirin in the Form of Microneedle Repairs DNA and Reduces Inflammation in Persistent Skin Damage

Skin damage caused by chemical corrosion is currently one of the common skin diseases and poisoning symptoms, with nitrogen mustard compounds causing the most persistent and severe damage. These chemicals penetrate the top layer of the skin, enter the dermis, and cause DNA damage, oxidative stress, and inflammation. However, to date, no effective drug treatment has been found. Even the potential antidotes could not effectively penetrate the top layer of the skin to exert their effects due to the skin barrier. To address this problem, an innovative transdermal drug delivery strategy based on aspirin microneedles was proposed. The classic medicine aspirin was first discovered not only to reduce inflammation and oxidative stress but also to promote DNA repair and reduce DNA damage. The aspirin microneedles directly delivered the drug to the damaged area, released aspirin through the skin barrier, and exhibited good biocompatibility. These findings indicate that aspirin microneedles have great potential for promoting wound healing and broad application prospects.

Aspirin reduces the mortality risk of patients with community-acquired pneumonia: a retrospective propensity-matched analysis of the MIMIC-IV database

Background

Community-acquired pneumonia (CAP) is a common infectious disease characterized by inflammation of the lung parenchyma in individuals who have not recently been hospitalized. It remains a significant cause of morbidity and mortality worldwide. Aspirin is a widely used drug, often administered to CAP patients. However, the benefits of aspirin remain controversial.

Objective

We sought to determine whether aspirin treatment has a protective effect on the outcomes of CAP patients.

Methods

We selected patients with CAP from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Propensity score matching (PSM) balanced baseline differences. A multivariate Cox regression model assessed the relationship between aspirin treatment and 28-day mortality.

Results

A total of 3,595 patients were included, with 2,261 receiving aspirin and 1,334 not. After PSM, 1,219 pairs were matched. The 28-day mortality rate for aspirin users was 20.46%, lower than non-users. Multivariate Cox regression indicated aspirin use was associated with decreased 28-day mortality (HR 0.75, 95% CI 0.63-0.88, p < 0.001). No significant differences were found between 325 mg/day and 81 mg/day aspirin treatments in terms of 28-day mortality, hospital mortality, 90-day mortality, gastrointestinal hemorrhage, and thrombocytopenia. However, intensive care unit (ICU) stay was longer for the 325 mg/day group compared to the 81 mg/day group (4.22 vs. 3.57 days, p = 0.031).

Conclusion

Aspirin is associated with reduced 28-day mortality in CAP patients. However, 325 mg/day aspirin does not provide extra benefits over 81 mg/day and may lead to longer ICU stays.

Prophylactic Effect of Aspirin and Other Medicine on Cerebral Infarction for Patients with Cardiovascular Diseases Risk Factors: A Systemic Review and Meta-Analysis

Stroke, as a type of cardiovascular disease (CVD) and cerebrovascular disease, has the risk of causing death or disability in patients. Aspirin, as an antipyretic and analgesic drug, can also treat or prevent CVDs. Previous studies have had conflicting results on the preventive effect of aspirin on cerebral infarction for patients with CVD risk factors. This review was carried out through a meticulous search of the Web of Science and PubMed databases. Articles were included or excluded based on predefined criteria. In terms of heterogeneity, a fixed effect model was utilized when I2 was less than 50%. Conversely, if the studies were deemed clinically comparable, a random effect model was implemented. The findings suggest that medical intervention significantly mitigates the risk of cerebral infarction in patients predisposed to CVDs [odds ratio (OR), 0.85; 95% confidence interval (CI), 0.74-0.98; P = 0.03]. Interestingly, the preventive efficacy of medication appears to be higher in men (OR, 0.82; 95% CI, 0.72-0.94; P = 0.004) than in women (OR, 0.84; 95% CI, 0.69-1.01; P = 0.06). However, in terms of stroke prevention, no significant difference was observed between the use of aspirin (OR, 0.90; 95% CI, 0.76-1.06; P = 0.19) and other medications (OR, 0.65; 95% CI, 0.31-1.38; P = 0.26).

Agreement Between Mega-Trials and Smaller Trials: A Systematic Review and Meta-Research Analysis

Importance

Mega-trials can provide large-scale evidence on important questions.

Objective

To explore how the results of mega-trials compare with the meta-analysis results of trials with smaller sample sizes.

Data Sources

ClinicalTrials.gov was searched for mega-trials until January 2023. PubMed was searched until June 2023 for meta-analyses incorporating the results of the eligible mega-trials.

Study Selection

Mega-trials were eligible if they were noncluster nonvaccine randomized clinical trials, had a sample size over 10 000, and had a peer-reviewed meta-analysis publication presenting results for the primary outcome of the mega-trials and/or all-cause mortality.

Data Extraction and Synthesis

For each selected meta-analysis, we extracted results of smaller trials and mega-trials included in the summary effect estimate and combined them separately using random effects. These estimates were used to calculate the ratio of odds ratios (ROR) between mega-trials and smaller trials in each meta-analysis. Next, the RORs were combined using random effects. Risk of bias was extracted for each trial included in our analyses (or when not available, assessed only for mega-trials). Data analysis was conducted from January to June 2024.

Main Outcomes and Measures

The main outcomes were the summary ROR for the primary outcome and all-cause mortality between mega-trials and smaller trials. Sensitivity analyses were performed with respect to the year of publication, masking, weight, type of intervention, and specialty.

Results

Of 120 mega-trials identified, 41 showed a significant result for the primary outcome and 22 showed a significant result for all-cause mortality. In 35 comparisons of primary outcomes (including 85 point estimates from 69 unique mega-trials and 272 point estimates from smaller trials) and 26 comparisons of all-cause mortality (including 70 point estimates from 65 unique mega-trials and 267 point estimates from smaller trials), no difference existed between the outcomes of the mega-trials and smaller trials for primary outcome (ROR, 1.00; 95% CI, 0.97-1.04) nor for all-cause mortality (ROR, 1.00; 95% CI, 0.97-1.04). For the primary outcomes, smaller trials published before the mega-trials had more favorable results than the mega-trials (ROR, 1.05; 95% CI, 1.01-1.10) and subsequent smaller trials published after the mega-trials (ROR, 1.10; 95% CI, 1.04-1.18).

Conclusions and Relevance

In this meta-research analysis, meta-analyses of smaller studies showed overall comparable results with mega-trials, but smaller trials published before the mega-trials gave more favorable results than mega-trials. These findings suggest that mega-trials need to be performed more often given the relative low number of mega-trials found, their low significant rates, and the fact that smaller trials published prior to mega-trial report more beneficial results than mega-trials and subsequent smaller trials.

Aspirin Dosing for Secondary Prevention of Atherosclerotic Cardiovascular Disease in Male and Female Patients: A Secondary Analysis of the ADAPTABLE Randomized Clinical Trial

Importance

Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality in the US. Although aspirin is recommended for secondary prevention of ASCVD, there was no difference in safety and effectiveness of aspirin dosed daily at 81 mg or 325 mg in the ADAPTABLE (Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness) randomized clinical trial. However, it is unknown whether differences by sex exist in the safety and effectiveness of the different aspirin doses.

Objective

To evaluate sex-specific differences in the safety and effectiveness of 2 aspirin doses in the ADAPTAPLE trial.

Design, Setting, and Participants

The ADAPTABLE study was an open-label, pragmatic, randomized clinical trial that randomly assigned participants with chronic, stable ASCVD to 81 mg vs 325 mg of aspirin daily. Using Cox proportional-hazard models, male and female participants were compared for outcomes. In addition, it was assessed whether sex was an effect modifier in the association between aspirin dose and outcomes. The ADAPTABLE trial was conducted at 40 medical centers and 1 health plan. Eligible patients were 18 years and older and had established ASCVD. Study data were analyzed from December 2021 to March 2024.

Interventions

Patients received 81 mg or 325 mg of aspirin daily for the secondary prevention of ASCVD.

Main Outcomes and Measures

The primary effectiveness outcomes included all-cause death and hospitalization for myocardial infarction (MI) or stroke. The primary safety outcome was hospitalization for major bleeding requiring transfusion.

Results

A total of 15 076 patients (median [IQR] age, 67.6 [60.7-73.6] years; 10 352 male [68.7%]) were followed up for a median (IQR) of 26.2 (19.0-34.9) months. Overall, 4724 (31.3%) were female, and 2307 of the female participants (48.8%) received aspirin 81 mg. Compared with males, female participants were younger (median [IQR] age, 66.3 [59.4-72.6] years vs 68.2 (61.4-73.9) years, less likely to self-report White race (3426 [72.5%] vs 8564 [82.7%]), more likely to smoke (564 [12.9%] vs 818 [8.4%]), and more likely to have a history of peripheral arterial disease (1179 [25.7%] vs 2314 [23.0%]). The primary effectiveness outcome of all-cause death and hospitalization for MI or stroke occurred in 379 female participants (8.1%) and 780 male participants (7.1%). There was no significant interaction by sex for the primary effectiveness end point between the 2 aspirin doses (female adjusted hazard ratio [aHR], 1.01; 95% CI, 0.82-1.26 and male aHR, 1.06; 95% CI, 0.91-1.23; P interaction term for sex = .74). During the trial, female participants had fewer revascularization procedures (237 [5.0%] vs 680 [6.6%]; aHR, 0.79; 95% CI, 0.68-0.92; P = .002) but had a higher risk of hospitalization for stroke (aHR, 1.72; 95% CI, 1.27-2.33; P < .001). Among female participants, there was a slightly higher rate of bleeding in the 81-mg aspirin cohort compared with the 325-mg cohort (20 [0.83%] vs 13 [0.52%]; aHR, 2.21; 95% CI, 1.04-4.70; P interaction term for sex = .07). There were no significant differences between female and male participants regarding aspirin dose adherence.

Conclusions and Relevance

In this secondary analysis of the ADAPTABLE trial, there were no significant sex-specific differences in the effectiveness and safety of 2 aspirin doses for secondary prevention of ASCVD events.

Trial Registration

ClinicalTrials.gov Identifier: NCT02697916.

Pharmacodynamic Comparison of Two Aspirin Formulations in the Caribbean: The ARC Study

INTRODUCTION

This prospective, single-arm, crossover pharmacodynamic study assessed the effect of Bayer® low-dose enteric-coated aspirin 81 mg tablets (LD EC-ASA) (Bayer AG, Leverkusen, North Rhine-Westphalia, Germany) compared to Vazalore® low-dose phospholipid-aspirin liquid-filled 81 mg capsules (LD PL-ASA) (PLx Pharma Inc., Sparta, NJ, USA) on platelet reactivity with respect to aspirin reaction units (ARU).

METHODS

Forty-seven healthy volunteers were recruited. Platelet function was evaluated with the VerifyNow™ ARU assay (Werfen, Bedford, MA, USA) and assessed post-initiation of Bayer® LD EC-ASA daily for 14 days, with a washout period of 28 days, followed by Vazalore® LD PL-ASA daily for 14 days, again followed by ARU testing.

RESULTS

Participants on LD EC-ASA had a mean ARU score of 426, with 19.1% of participants having an ARU > 550; patients on LD PL-ASA derived a mean ARU score of 435, with 14.9% achieving an ARU > 550. There were no significant differences in aspirin resistance (ARU > 550) according to the formulation (Bayer® LD EC-ASA vs. Vazalore® LD PL-ASA) used. Aspirin resistance was independent of ethnicity regardless of the formulation used. In addition, there were no significant associations between body surface area (BSA) and Bayer® LD EC-ASA ARU value (p value 0.788) or Vazalore® LD PL-ASA ARU value (p value 0.477). No patients experienced any serious adverse events or treatment-emergent adverse events.

CONCLUSIONS

There were no significant differences in aspirin resistance between Bayer® LD EC-ASA and Vazalore® LD PL-ASA. This dedicated pharmacodynamic study could potentially be informative and applicable for Trinidadian patients on dual antiplatelet therapy (DAPT). Further studies are required to confirm these exploratory findings.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT06228820, prospectively registered 1/18/2024.

Rationale and Design of SCOT-HEART 2 Trial: CT Angiography for the Prevention of Myocardial Infarction

Coronary artery disease continues to be the leading cause of death globally. Identifying patients who are at risk of coronary artery disease remains a public health priority. At present, the focus of cardiovascular disease prevention relies heavily on probabilistic risk scoring despite no randomized controlled trials demonstrating their efficacy. The concept of using imaging to guide preventative therapy is not new, but has previously focused on indirect measures such as carotid intima-media thickening or coronary artery calcification. In recent trials, patients found to have coronary artery disease on computed tomography (CT) coronary angiography were more likely to be started on preventative therapy and had lower rates of cardiac events. This led to the design of the SCOT-HEART 2 (Scottish Computed Tomography of the Heart 2) trial, which aims to determine whether screening with the use of CT coronary angiography is more clinically effective than cardiovascular risk scoring to guide the use of primary preventative therapies and reduce the risk of myocardial infarction.

Thrombotic events associated with immune checkpoint inhibitors and novel antithrombotic strategies to mitigate bleeding risk

Although immunotherapy is expanding treatment options for cancer patients, the prognosis of advanced cancer remains poor, and these patients must contend with both cancers and cancer-related thrombotic events. In particular, immune checkpoint inhibitors are associated with an increased risk of atherosclerotic thrombotic events. Given the fundamental role of platelets in atherothrombosis, co-administration of antiplatelet agents is always indicated. Platelets are also involved in all steps of cancer progression. Classical antithrombotic drugs can cause inevitable hemorrhagic side effects due to blocking integrin β3 bidirectional signaling, which regulates simultaneously thrombosis and hemostasis. Meanwhile, many promising new targets are emerging with minimal bleeding risk and desirable anti-tumor effects. This review will focus on the issue of thrombosis during immune checkpoint inhibitor treatment and the role of platelet activation in cancer progression as well as explore the mechanisms by which novel antiplatelet therapies may exert both antithrombotic and antitumor effects without excessive bleeding risk.

Aging and Antithrombotic Treatment

Significance: Several aging-related pathophysiological mechanisms have been described to contribute to increased thrombotic risk in the elderly, including oxidative stress, endothelial dysfunction, and platelet and coagulation cascade activation. Antithrombotic treatment in the elderly should be individualized. Recent Advances: Recent studies have clarified some pathophysiological mechanisms of enhanced oxidative stress and thrombotic alterations in older adults. In the last decade, randomized trials have evaluated different antithrombotic strategies to reduce the risk of cardiovascular events in these patients. Critical Issues: The proportion of elderly patients included in clinical trials is generally low, thus not reflecting the daily clinical practice. There is no consensus on the most appropriate antithrombotic treatment in the elderly, also considering that bleeding risk management may be challenging in this high-risk subgroup of patients. Routine antiplatelet treatment is not a valid strategy for the primary prevention of cardiovascular events given the associated high risk of bleeding. In elderly patients with acute coronary syndrome, low-dose prasugrel or clopidogrel, shorter dual antiplatelet therapy, and no pretreatment before stent placement should be considered. Advanced age should not be the only reason for the underuse of oral anticoagulation in patients with atrial fibrillation, with direct oral anticoagulants preferred over warfarin for stroke prevention. Instead, a case-by-case clinical evaluation is warranted based on patient's bleeding risk also. Future Directions: There is a need for a structured tailored approach to manage thrombotic risk in elderly patients. The choice of the most appropriate antithrombotic treatment should balance efficacy and safety to reduce the risk of bleeding.

Aspirin: latest evidence and developments

Aspirin is a foundation drug of the pharmaceutical industry originally derived as an analgesic/anti-inflammatory agent but serendipitously discovered to have use as a prophylactic drug for major adverse cardiovascular events (MACE). Its modern-day utility in this latter role relies on its efficacy/safety balance in a contemporary population where, at least in high-income countries, age-standardised incident rates for MACE are falling, and where there are now competing therapeutic agents. Its future may be determined by its potential role as a chemoprophylactic or adjunct agent for cancer or other disease states. It therefore will continue to be the subject of further clinical research.

Thrombotic antiphospholipid syndrome: From guidelines to clinical management

Thrombotic manifestations, mainly venous thromboembolism (VTE) and stroke, are the most common and potentially life-threatening presentations of antiphospholipid syndrome (APS). The management of APS requires the assessment of the antiphospholipid antibodies (aPL) profile, of concurrent systemic lupus erythematosus or other systemic autoimmune diseases and the presence of risk factors for cardiovascular disease and bleeding. Anticoagulation with vitamin K antagonists (VKA) remains the cornerstone of therapy for thrombotic APS. As platelets play a central role in APS, low-dose aspirin is the first option for primary thromboprophylaxis in asymptomatic aPL carriers, and also plays a role as combination therapy with VKAs in arterial thrombosis. Treatment with direct oral anticoagulants (DOACs) could be considered in certain low-risk situations, although they are not recommended in patients with arterial thrombosis or triple positive aPL. Adjuvant therapies such as hydroxychloroquine and statins may be useful in complex settings such as thrombotic recurrences or high risk of bleeding. In this article, we review the evidence and the recommendations of the guidelines for the treatment of APS, and provide a critical and practical approach of its management from our clinical perspective.