Physicians' attitudes toward post-MI aspirin prophylaxis: findings from an online questionnaire in Europe and Latin America

Prescribing and medical non-adherence after myocardial infarction: qualitative interviews with general practitioners in Germany

BACKGROUND

An increasing prevalence of having survived a myocardial infarction increases the importance of medical secondary prevention. Although preventive medication reduces mortality, prescribing and adherence are known to be frequently insufficient. General practitioners are the most important prescriber. However, their perspective on prescribing and medical non-adherence following myocardial infarction has not yet been explored. Thus, the aim of this study was to explore the general practitioners' perspective on long-term care after myocardial infarction focussing on medical prevention.

METHODS

In this qualitative interview study we conducted episodic interviews with sixteen general practitioners from rural and urban surgeries in Germany. Framework analysis with focus on general practitioners' prescribing and patients' non-adherence was performed.

RESULTS

Almost all general practitioners reported following guidelines for myocardial infarction aftercare and prescribing the medication that was initiated in the hospital; however, they described deviating from guidelines because of drugs' side effects or patients' intolerances. Some questioned the benefits of medical secondary prevention for the oldest of patients. General practitioners perceived good adherence among their patients who had had an MI while they regarded their methods for assessing medical non-adherence as limited. They perceived diverse reasons for non-adherence, particularly side effects, patients' freedom from symptoms and patients' indifference to health. They attributed mainly negative characteristics, like lack of knowledge and understanding, to non-adherent patients. These characteristics contribute to the difficulty of convincing these patients to take medications as prescribed. General practitioners improved adherence by preventing side effects, explaining the medication's necessity, facilitating intake and involving patients in decision-making. However, about half of the general practitioners reported threatening their patients with negative consequences of non-adherence.

CONCLUSIONS

General practitioners should be aware that discharge medication can be insufficient and thus, should always check hospital recommendations for accordance with guideline recommendations. Improving physicians' communication skills and informing and motivating patients in an adequate manner, for example in simple language, should be an important goal in the hospital and the general practitioner setting. General practitioners should assess patients' motivations through motivational interviewing, which no general practitioner mentioned during the interviews, and talk with them about adherence and long-term treatment goals regularly.

Histamine H2 receptor antagonists for decreasing gastrointestinal harms in adults using acetylsalicylic acid: systematic review and meta-analysis

BACKGROUND

It is unclear if histamine H2 receptor antagonists (H2 blockers) prevent a variety of gastrointestinal harms among patients taking acetylsalicylic acid (ASA) over long periods.

METHODS

Electronic databases (e.g., MEDLINE, Embase and Cochrane Central Register of Controlled Trials; from inception to November 2010) and reference lists of retrieved articles were searched. Randomized placebo-controlled trials (RCTs) assessing the efficacy of H2 blockers in reducing gastrointestinal harms (bleeding, ulcers) among adults taking ASA for 2 weeks or longer were included. Two reviewers independently abstracted study and patient characteristics and appraised study quality using the Cochrane risk-of-bias tool. Peto odds ratio (OR) meta-analysis was performed, 95% confidence intervals (CIs) were calculated, and statistical heterogeneity was assessed using the I (2) and χ(2) statistics.

RESULTS

Six RCTs (4 major publications and 2 companion reports) with a total of 498 participants (healthy volunteers or patients with arthritis, cardiovascular or cerebrovascular disease, or diabetes mellitus) were included. One trial adequately reported allocation concealment and sequence generation, with the other 3 trials being judged as unclear for both aspects. In one RCT, no statistically significant differences for gastrointestinal hemorrhage requiring admission to hospital (p = 0.14) or blood transfusion (p = 0.29) were observed between the group receiving concomitant famotidine and ASA and the group receiving concomitant placebo and ASA. After a median of 8 weeks' follow-up, H2 blockers were more effective than placebo in reducing gastrointestinal hemorrhage (2 RCTs, total of 447 patients, OR 0.07, 95% CI 0.02-0.23) and peptic ulcers (3 RCTs, total of 465 patients, OR 0.21, 95% CI 0.12-0.36) among patients taking ASA for 2 weeks or longer. Despite substantial clinical heterogeneity across the studies, including types of H2 blockers, dosing of ASA and underlying conditions, no statistical heterogeneity was observed.

INTERPRETATION

H2 blockers reduced gastrointestinal harm among patients taking ASA for 2 weeks or longer. These results should be interpreted with caution, because of the small number of studies identified for inclusion.

Compliance as the major effectiveness determinant in preventive acetylsalicylic acid therapy

Acetylsalicylic acid (ASA) treatment of patients with cardiovascular disease (CVD) is one of the most effective methods for CVD event prevention. In a substantial proportion of the patients, however, long-term preventive ASA treatment compliance is low (44-71%). Low compliance is associated with reduced antiplatelet effects of ASA and a 2-3-fold increase in the risk of myocardial infarction (MI), ischemic stroke (IS), and other cardiovascular events. ASA therapy compliance could be improved by achieving better collaboration between doctors and patients, while educating patients and explaining the importance of following the doctors’ advice. In addition, enteric-coated ASA forms could play an important role in improving treatment tolerability and, therefore, increasing compliance. Other potentially effective measures include the use of modern packaging (calendar blisters) and information technologies (telephone communication, MGMM).

Risk assessment and aspirin use in Asian and Western populations

Objective

The aim of this review was to examine aspirin utilization, cardiovascular risk estimation, and clinical evidence for aspirin prophylaxis in Asian versus Western countries.

Methods

A literature search was performed using PubMed and the key terms “aspirin” and “Asia” or “Western”.

Results

Despite the growing burden of cardiovascular disease (CVD), aspirin is underutilized in high-risk patients in both Asian and Western countries. A number of risk estimation scores are available; however, validation is needed in countries such as Japan, India, and in South Asia. Underutilization of aspirin in Asia may be linked to an overestimation of bleeding risks. It is possible that a higher prevalence of Helicobacter pylori infection and genetic differences may make Asians more susceptible to gastrointestinal bleeding. Very low aspirin doses and even the wider use of gastroprotective agents may be the optimal approach to high-risk patients in Asia.

Conclusions

Based on the current evidence, aspirin should be used for CVD prevention when the risk:benefit ratio is favorable. A number of trials are underway, including the Diabetic Atherosclerosis Prevention by Cilostazol and Japanese Primary Prevention Project, which will provide key data on the benefits of aspirin in Asian patients at risk of CVD, and may improve aspirin utilization and risk estimation.

Physicians' attitudes toward post-MI aspirin prophylaxis: findings from an online questionnaire in Asia-Pacific

Mortality from cardiovascular diseases, such as myocardial infarction (MI), is predicted to increase dramatically in Asia-Pacific countries. However, there are few studies that estimate utilization of prophylactics, such as low-dose aspirin, in these countries. To determine this, an online survey was sent to physicians in 18 countries worldwide, and this article reports the findings from the Asia-Pacific region (N = 4372 respondents). The overall mean number of MI patients per respondent was 246 in the Asia-Pacific countries, and 55% of physicians (overall) rated their patient as having total compliance with aspirin. The use of aspirin monotherapy or combination therapy, aspirin dosage, and physician contact were all found to have a significant impact on compliance (all P < 0.00001). Educational material on the role of aspirin was ranked as the most effective measure to improve compliance. In conclusion, this survey indicates that educational initiatives on secondary prevention are urgently needed in Asia-Pacific countries.