Aspirin for the Primary Prevention of Cardiovascular Events: A Systematic Evidence Review for the U.S. Preventive Services Task Force

A Thorough Literature Review of the Potential Benefits and Drawbacks of Long-Term Aspirin Use for the Primary Prevention of Cardiovascular Disease

This article examines the role of aspirin in the primary prevention of cardiovascular disease. It highlights findings from major studies such as ASPREE (ASPirin in Reducing Events in the Elderly), ARRIVE (Aspirin to Reduce Risk of Initial Vascular Events), and ASPREE-XT (ASPirin in Reducing Events in the Elderly - eXTension) , among others. The review focuses on aspirin's role in primary prevention for specific populations including older adults, diabetics, hypertension patients, rheumatoid arthritis patients, kidney transplant recipients, and those with specific lipoprotein(a) genotypes, among other groups. We review these studies, noting aspirin's role in reducing events such as myocardial infarctions and its potential for increasing bleeding risks. The review also considers the implications for patients with kidney disease, referencing the Chronic Renal Insufficiency Cohort (CRIC) study and the International Polycap Study-3 (TIPS-3) trial. Additionally, it addresses the shifting paradigms in guidelines from the US Preventive Services Task Force and other entities, underscoring the importance of individualized aspirin use by balancing benefits against bleeding risks. The article further explores the concept of platelet reactivity, discusses strategies for improving adherence to aspirin therapy, and identifies existing research gaps, such as the phenomenon of aspirin resistance. It concludes by suggesting potential areas for future investigation to enhance understanding and application of aspirin in cardiovascular disease prevention.

[Drug therapy for acute and elective stent angioplasty]

CLINICAL ISSUE

Carotid artery stenoses are constrictions of the common carotid artery and the internal carotid artery. They cause around 15% of all cerebral ischemia, which is why their detection and correct treatment play an important role in clinical practice.

PRACTICAL RECOMMENDATIONS

Depending on the severity and clinical symptoms, carotid artery stenosis is treated conservatively, surgically or endovascularly by means of stent angioplasty. In the case of stent angioplasty in particular, correct drug therapy plays an important role in avoiding/reducing thromboembolic complications.

Pantoprazole and Vonoprazan Performed Well in Preventing Peptic Ulcer Recurrence in Low-Dose Aspirin Users

BACKGROUND

Low-dose aspirin (LDA) administration is associated with an elevated risk of recurring peptic ulcer (PU) and gastrointestinal (GI) hemorrhage.

AIMS

This systematic review and Bayesian network meta-analysis aimed to comprehensively assess the effectiveness of diverse medications in preventing the recurrence of PU and GI hemorrhage in patients with a history of PU receiving long-term LDA therapy.

METHODS

This systematic review and network meta-analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and was registered on PROSPERO (CRD42023406550). We searched relevant studies in main databases from inception to March 2023. All statistical analyses were performed using R (version 4.1.3), with the "Gemtc" (version 1.0-1) package. The pooled risk ratio (RR), corresponding 95% credible interval (95% CrI), and the surface under the cumulative ranking curve (SUCRA) were calculated.

RESULTS

11 Randomized clinical trials (RCTs) were included. The analysis underscored pantoprazole was the most efficacious for reducing the risk of PU recurrence (RR [95% CrI] = 0.02 [0, 0.28]; SUCRA: 90.76%), followed by vonoprazan (RR [95% CrI] = 0.03 [0, 0.19]; SUCRA: 86.47%), comparing with the placebo group. Pantoprazole also performed well in preventing GI hemorrhage (RR [95% CrI] = 0.01[0, 0.42]; SUCRA: 87.12%) compared with Teprenone.

CONCLUSIONS

For patients with a history of PU receiving LDA, pantoprazole and vonoprazan might be the optimal choices to prevent PU recurrence and GI hemorrhage.

Effect of Low-Dose Aspirin on the Elderly

Aspirin is a recognized and affordable antiplatelet medicine. Low amounts of aspirin have been used to prevent cardiovascular events, and it is still widely used for primary and secondary stroke prevention. The purpose of this review article is to evaluate the effects of using low doses of aspirin among elderly people. Although taking large dosages of aspirin (500 mg daily) reduces the long-term risk of colorectal cancer, its effectiveness for long-term prevention may be limited by adverse effects. Studies have assessed the relationship between aspirin dosage, incidence, and death in patients with colorectal cancer. Research has indicated that those with diabetes mellitus have an increased risk of cardiovascular events. Low amounts of aspirin have been used to prevent cardiovascular events. However, there is uncertainty regarding the potential benefits and risks associated with preventing the development of cardiovascular problems in individuals with diabetes. The use of aspirin lowers the risk of occlusive vascular events but raises the possibility of bleeding. More attention should be paid to reducing inappropriate aspirin usage in light of its prevalence, particularly among older persons, as the substantial continuous usage of this drug increases the chances of bleeding.

Identifying and reducing inappropriate aspirin use in primary care

OBJECTIVE

Recent studies have called into question the safety of aspirin use for the primary prevention of atherosclerotic cardiovascular disease, particularly in older adults. Therefore, the objectives of this study were to (1) develop a systematic approach to identifying patients aged 70 and older taking aspirin for primary prevention, (2) provide patient and provider education about updated literature and recommendations regarding aspirin safety and (3) evaluate the impact of this intervention on aspirin de-prescribing.

DESIGN

This was a quality improvement intervention with prospective, longitudinal follow-up.

SETTING

This study was conducted in two family medicine practices within an academic medical centre.

PARTICIPANTS

Patients aged 70 years and older with aspirin listed on the current medication list.

METHODS

This is an electronic medical record-based chart review and educational intervention based on shared decision-making to reduce inappropriate aspirin use in primary practice. A chart review process was developed to identify the clinical indication for aspirin use. Patients taking aspirin for primary prevention were flagged for the primary care providers to review. Multilevel logistic regression models assessed factors affecting aspirin de-prescribing and longitudinal trend.

RESULTS

Of 361 patients aged 70 years or older, 145 (40%) were taking aspirin for primary prevention of atherosclerotic cardiovascular disease. After 9 months, aspirin was deprescribed in 42 (29%) of these patients. Patients seen by their providers during the study period had lower odds of having aspirin on their medication list (OR=0.87, 95% CI: 0.81, 0.94) as compared with patients taking aspirin who were not seen by their healthcare provider.

CONCLUSION

This is the first study to develop and implement a method of identifying potentially inappropriate aspirin use based on recent clinical evidence highlighting the risk of aspirin use for primary prevention in older adults. Future initiatives can leverage existing electronic medical record platforms to efficiently identify patients and expand these efforts to larger patient populations.

Low-Dose Aspirin and the Risk of Stroke and Intracerebral Bleeding in Healthy Older People: Secondary Analysis of a Randomized Clinical Trial

Importance

Low-dose aspirin has been widely used for primary and secondary prevention of stroke. The balance between potential reduction of ischemic stroke events and increased intracranial bleeding has not been established in older individuals.

Objective

To establish the risks of ischemic stroke and intracranial bleeding among healthy older people receiving daily low-dose aspirin.

Design, Setting, and Participants

This secondary analysis of the Aspirin in Reducing Events in the Elderly (ASPREE) randomized, double-blind, placebo-controlled trial of daily low-dose aspirin was conducted among community-dwelling people living in Australia or the US. Participants were older adults free of symptomatic cardiovascular disease. Recruitment took place between 2010 and 2014, and participants were followed up for a median (IQR) of 4.7 (3.6-5.7) years. This analysis was completed from August 2021 to March 2023.

Interventions

Daily 100-mg enteric-coated aspirin or matching placebo.

Main Outcomes and Measures

Stroke and stroke etiology were predetermined secondary outcomes and are presented with a focus on prevention of initial stroke or intracranial bleeding event. Outcomes were assessed by review of medical records.

Results

Among 19 114 older adults (10 782 females [56.4%]; median [IQR] age, 74 [71.6-77.7] years), 9525 individuals received aspirin and 9589 individuals received placebo. Aspirin did not produce a statistically significant reduction in the incidence of ischemic stroke (hazard ratio [HR], 0.89; 95% CI, 0.71-1.11). However, a statistically significant increase in intracranial bleeding was observed among individuals assigned to aspirin (108 individuals [1.1%]) compared with those receiving placebo (79 individuals [0.8%]; HR, 1.38; 95% CI, 1.03-1.84). This occurred by an increase in a combination of subdural, extradural, and subarachnoid bleeding with aspirin compared with placebo (59 individuals [0.6%] vs 41 individuals [0.4%]; HR, 1.45; 95% CI, 0.98-2.16). Hemorrhagic stroke was recorded in 49 individuals (0.5%) assigned to aspirin compared with 37 individuals (0.4%) in the placebo group (HR, 1.33; 95% CI, 0.87-2.04).

Conclusions and Relevance

This study found a significant increase in intracranial bleeding with daily low-dose aspirin but no significant reduction of ischemic stroke. These findings may have particular relevance to older individuals prone to developing intracranial bleeding after head trauma.

Trial Registration

ISRCTN.org Identifier: ISRCTN83772183.

Beyond Undetectable: Modeling the Clinical Benefit of Improved Antiretroviral Adherence in Persons With Human Immunodeficiency Virus With Virologic Suppression

Background

Incomplete antiretroviral therapy (ART) adherence has been linked to deleterious immunologic, inflammatory, and clinical consequences, even among virally suppressed (<50 copies/mL) persons with human immunodeficiency virus (PWH). The impact of improving adherence in the risk of severe non-AIDS events (SNAEs) and death in this population is unknown.

Methods

We estimated the reduction in the risk of SNAEs or death resulting from an increase in ART adherence by (1) applying existing data on the association between adherence with high residual inflammation/coagulopathy in virally suppressed PWH, and (2) using a Cox proportional hazards model derived from changes in plasma interleukin 6 (IL-6) and D-dimer from 3 randomized clinical trials. Comparatively, assuming 100% ART adherence in a PWH who achieves viral suppression, we estimated the number of persons in whom a decrease in adherence to <100% would need to be observed for an additional SNAE or death event to occur during 3- and 5-year follow-up.

Results

Increasing ART adherence to 100% in PWH who are suppressed on ART despite imperfect adherence translated into a 6%-37% reduction in the risk of SNAEs or death. Comparatively, based on an anticipated 12% increase in IL-6, 254 and 165 PWH would need to decrease their adherence from 100% to <100% for an additional event to occur over 3- and 5-year follow-up, respectively.

Conclusions

Modest gains in ART adherence could have clinical benefits beyond virologic suppression. Increasing ART adherence (eg, via an intervention or switch to long-acting ART) in PWH who remain virally suppressed despite incomplete adherence should be evaluated.

[Acetylsalicylic acid in primary and secondary prevention of atherosclerotic cardiovascular disease]

The article is devoted to an urgent problem - primary and secondary prevention of atherosclerotic cardiovascular diseases. Modern approaches to management tactics depending on age and the appointment of antiplatelet therapy with acetylsalicylic acid in low doses from 75 to 150 mg/day are presented. At the same time, the relatively high effectiveness of the use of ASA for primary prevention in men 40-69 years old without an increased risk of bleeding from the gastrointestinal tract is shown. Low doses of ASA provide little benefit in reducing the risk of CVD in people 40 years and older, when there is no history of CVD, but at the same time they are at increased risk of CVD.

A Cross-Sectional Study on the Prevalence of Self-Prescribed Aspirin Use for Prevention of Adverse Ischemic Vascular Events Among Moderate-Risk Individuals: A Single Center Study

Introduction Despite the overwhelming amount of evidence against the use of aspirin for primary prophylaxis of cardiovascular disease (CVD), the arguably unwarranted use of aspirin has increased over the years, which may or may not be based on any specific medical advice, and merely self-prescribed. Aim This study aimed to determine the prevalence of unwarranted aspirin use among moderate-risk individuals for the primary prevention of adverse vascular events in Saudi Arabia. Patient and method A cross-sectional study was conducted among 100 patients who presented to the emergency room (ER) due to suspected cardiac diseases. The data were collected from the patients who visited ER in King Fahad Hospital, Al-Hofuf, Saudi Arabia. Participants were asked about their socio-demographic characteristics, aspirin use habits, and their comorbidities. Results Of the 100 patients, 35% were aged more than 60 years old. The overall use of aspirin was 78%. The prevalence of aspirin use was significantly more common among the older age group (53.8%), those with associated chronic diseases, such as diabetes (59%) and hypertension (75.6%) and those with a previous history of hospitalization due to stroke or a cardiac event (66.7%). Conclusion The use of aspirin among patients who are at moderate risk of cardiovascular events was widely prevalent, but their unwarranted use was low. Older patients with chronic diseases who believed in its great benefit and tended to ignore its complications are the most common users of aspirin. More research is recommended to determine the prevalence and the factors associated with unwarranted use of aspirin in patients with CVD in our region.

Implications of the heterogeneity between guideline recommendations for the use of low dose aspirin in primary prevention of cardiovascular disease

The most recent primary cardiovascular disease (CVD) prevention clinical guidelines used in Europe, Italy, the USA, China, and South Korea differ in aspects of their approach to CVD risk assessment and reduction. Low dose aspirin use is recommended in certain high-risk patients by most but not all the countries. Assessment of traditional risk factors and which prediction models are commonly used differ between countries. The assessments and tools may not, however, identify all patients at high risk but without manifest CVD. The use of coronary artery calcium (CAC) score to guide decisions regarding primary prevention aspirin therapy is recommended only by the US primary prevention guidelines and the 2021 European Society of Cardiology guidelines. A more consistent and comprehensive global approach to CVD risk estimation in individual patients could help to personalize primary CVD prevention. Wider detection of subclinical atherosclerosis, together with structured assessment and effective mitigation of bleeding risk, may appropriately target patients likely to gain net benefit from low dose aspirin therapy.

Benefits and Risks Associated with Low-Dose Aspirin Use for the Primary Prevention of Cardiovascular Disease: A Systematic Review and Meta-Analysis of Randomized Control Trials and Trial Sequential Analysis

BACKGROUND

The role of aspirin in cardiovascular primary prevention remains controversial. Moreover, evidence for the potential benefits of aspirin in patients with high cardiovascular risk remains limited.

OBJECTIVE

The aim of this study was to explore the role of low-dose aspirin in primary prevention.

METHODS

The PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov databases were searched for randomized clinical trials (RCTs) from the date of inception to August 2021. The efficacy outcomes were major adverse cardiovascular events (MACE), myocardial infarction (MI), ischemic stroke (IS), all-cause mortality, and cardiovascular mortality, whereas safety outcomes were major bleeding, intracranial hemorrhage, and gastrointestinal (GI) bleeding. Subgroup analyses were based on different cardiovascular risks and diabetes statuses. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using the fixed- and random-effects models, and trial sequential analysis (TSA) was conducted to determine the robustness of the results.

RESULTS

A total of 10 RCTs fulfilled the inclusion criteria. The use of aspirin was associated with a significant reduction in the risk of MACE (RR 0.89, 95% CI 0.84-0.93), MI (RR 0.86, 95% CI 0.78-0.95), and IS (RR 0.84, 95% CI 0.76-0.93); however, aspirin also increased the risk of safety outcomes, i.e. major bleeding (RR 1.42, 95% CI 1.26-1.60), intracranial hemorrhage (RR 1.33, 95% CI 1.11-1.59), and GI bleeding (RR 1.91, 95% CI 1.44-2.54). Subgroup analyses revealed that in the absence of a statistically significant interaction, a trend toward a net benefit of lower incidence of cardiovascular events (number needed to treat of MACE: high risk: 682 vs. low risk: 2191) and lesser risk of bleeding events (number needed to harm of major bleeding: high risk: 983 vs. low risk: 819) was seen in the subgroup of high cardiovascular risk. Meanwhile, the greater MACE reduction was also detected in the high-risk group of diabetes or nondiabetes patients. Furthermore, a post hoc subgroup analysis indicated a significant rate reduction in patients aged ≤ 70 years but not in patients aged > 70 years. TSA confirmed the benefit of aspirin for MACE up to a relative risk reduction of 10%.

CONCLUSION

The current study demonstrated that the cardiovascular benefits of low-dose aspirin were equally balanced by major bleeding events. In addition, the potential beneficial effects might be seen in the population ≤ 70 years of age with high cardiovascular risk and no increased risk of bleeding.

Impact of pharmacist intervention to deprescribe inappropriate aspirin therapy in an outpatient anticoagulation clinic at a community hospital

Study objective

This study describes a pharmacist-led process to identify and discontinue inappropriate aspirin in patients receiving concomitant anticoagulant therapy and to evaluate the effectiveness of the intervention.

Setting

The study took place in an outpatient anticoagulation clinic within a small community hospital.

Participants

Patients ≥40 years old on indefinite anticoagulation therapy for atrial fibrillation and/or venous thromboembolism were included.

Design

This is a quality improvement initiative.

Interventions

Utilizing the electronic medical record and patient interview, use and indication for daily aspirin therapy was confirmed. Prospectively collected patient demographics and past medical history were used to determine appropriateness of aspirin therapy. For patients identified as receiving inappropriate aspirin therapy, a fax was sent to the referring provider recommending aspirin discontinuation.

Main outcome measures

To assess the effectiveness of the intervention, outcomes were retrospectively measured. The primary outcome was the percentage of "accepted" recommendations. Secondary outcomes included the prevalence, dosing, and indications for aspirin therapy.

Results

Eighty (33 %) of 242 patients were on aspirin. Fifty-two patients with atrial fibrillation and/or venous thromboembolism were assessed and aspirin was deemed inappropriate in 22 patients. The provider agreed with deprescribing aspirin therapy in 45 %. The most common dose and indication of aspirin therapy was 81 mg (98 %) and primary prevention (40 %) respectively.

Conclusions

In our small practice, pharmacist-led interventions were an effective means to recommend aspirin discontinuation in our identified patients. Further studies are needed to optimize a pharmacist's role and address the long-term effects of deprescription.

Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Updated Modeling Study for the US Preventive Services Task Force

IMPORTANCE

The US Preventive Services Task Force (USPSTF) is updating its 2016 recommendation on the use of aspirin for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC).

OBJECTIVE

To provide updated model-based estimates of the net balance in benefits and harms from routine use of low-dose aspirin for primary prevention.

DESIGN, SETTING, AND PARTICIPANTS

Microsimulation modeling was used to estimate long-term benefits and harms for hypothetical US cohorts of men and women aged 40 to 79 years with up to 20% 10-year risk for an atherosclerotic CVD event and without prior history of CVD or elevated bleeding risks.

EXPOSURES

Low-dose (≤100 mg/d) aspirin for lifetime use, unless contraindicated by a bleeding event, and with stopping ages in 5-year intervals from age 65 to 85 years.

MAIN OUTCOMES AND MEASURES

Primary outcomes were lifetime net benefits measured in quality-adjusted life-years (QALYs) and life-years. Benefits included reduced nonfatal myocardial infarction and ischemic stroke. Harms included increased nonfatal major gastrointestinal bleeding and intracranial hemorrhage. Reduced CRC incidence was considered in sensitivity analysis.

RESULTS

Estimated lifetime net QALYs were positive for both men and women at 5% or greater 10-year CVD risk when starting between ages 40 and 59 years and at 10% or greater 10-year CVD risk when starting between ages 60 and 69 years. These estimates ranged from 2.3 (95% CI, -2.7 to 7.4) to 66.2 (95% CI, 58.2 to 74.1) QALYs per 1000 persons. Lifetime net life-years were positive for men at 5% or greater and women at 10% or greater 10-year CVD risk starting aspirin at ages 40 to 49 years and for men at 7.5% or greater and women at 15% or greater 10-year CVD risk at ages 50 to 59 years. These estimates ranged from 0.4 (95% CI, -6.1 to 6.9) to 52.4 (95% CI, 43.9 to 60.9) life-years per 1000 persons. Lifetime net life-years were negative in most cases for persons starting aspirin between ages 60 and 79 years, as were lifetime net QALYs for persons aged 70 to 79 years. Stopping aspirin between ages 65 and 85 years generally showed little advantage compared with lifetime use. Sensitivity analyses showed lifetime net benefits may be higher if aspirin reduced CRC incidence or CVD mortality and lower if aspirin increased fatal major gastrointestinal bleeding or reduced quality of life with routine use.

CONCLUSIONS AND RELEVANCE

This microsimulation study suggested that several population groups may benefit from taking aspirin for the primary prevention of CVD, primarily in persons starting at younger ages with higher 10-year CVD risk.

Priorities among effective clinical preventive services in British Columbia, Canada

Background

Despite the long-standing experience of rating the evidence for clinical preventive services, the delivery of effective clinical preventive services in Canada and elsewhere is less than optimal. We outline an approach used in British Columbia to assist in determining which effective clinical preventive services are worth doing.

Methods

We calculated the clinically preventable burden and cost-effectiveness for 28 clinical preventive services that received a ‘strong or conditional (weak) recommendation for’ by the Canadian Task Force on Preventive Health Care or an ‘A’ or ‘B’ rating by the United States Preventive Services Task Force. Clinically preventable burden is the total quality adjusted life years that could be gained if the clinical preventive services were delivered at recommended intervals to a British Columbia birth cohort of 40,000 individuals over the years of life that the service is recommended. Cost-effectiveness is the net cost per quality adjusted life year gained.

Results

Clinical preventive services with the highest population impact and best value for money include services that address tobacco use in adolescents and adults, exclusive breastfeeding, and screening for hypertension and other cardiovascular disease risk factors followed by appropriate pharmaceutical treatment. In addition, alcohol misuse screening and brief counseling, one-time screening for hepatitis C virus infection in British Columbia adults born between 1945 and 1965, and screening for type 2 diabetes approach these high-value clinical preventive services.

Conclusions

These results enable policy makers to say with some confidence what preventive manoeuvres are worth doing but further work is required to determine the best way to deliver these services to all those eligible and to establish what supportive services are required. After all, if a clinical preventive service is worth doing, it is worth doing well.

Aspirin to target arterial events in chronic kidney disease (ATTACK): study protocol for a multicentre, prospective, randomised, open-label, blinded endpoint, parallel group trial of low-dose aspirin vs. standard care for the primary prevention of cardiovascular disease in people with chronic kidney disease

Background

Chronic kidney disease (CKD) is a very common long-term condition and powerful risk factor for cardiovascular disease (CVD).

Low-dose aspirin is of proven benefit in the secondary prevention of myocardial infarction (MI) and stroke in people with pre-existing CVD. However, in people without CVD, the rates of MI and stroke are much lower, and the benefits of aspirin in the primary prevention of CVD are largely balanced by an increased risk of bleeding.

People with CKD are at greatly increased risk of CVD and so the absolute benefits of aspirin are likely to be greater than in lower-risk groups, even if the relative benefits are the same. Post hoc evidence suggests the relative benefits may be greater in the CKD population but the risk of bleeding may also be higher. A definitive study of aspirin for primary prevention in this high-risk group, recommended by the National Institute for Health and Care Excellence (NICE) in 2014, has never been conducted. The question has global significance given the rising burden of CKD worldwide and the low cost of aspirin.

Methods

ATTACK is a pragmatic multicentre, prospective, randomised, open-label, blinded endpoint adjudication superiority trial of aspirin 75 mg daily vs. standard care for the primary prevention of CVD in 25,210 people aged 18 years and over with CKD recruited from UK Primary Care.

Participants aged 18 years and over with CKD (GFR category G1-G4) will be identified in Primary Care and followed up using routinely collected data and annual questionnaires for an average of 5 years. The primary outcome is the time to first major vascular event (composite of non-fatal MI, non-fatal stroke and cardiovascular death [excluding confirmed intracranial haemorrhage and other fatal cardiovascular haemorrhage]). Deaths from other causes (including fatal bleeding) will be treated as competing events. The study will continue until 1827 major vascular events have occurred. The principal safety outcome is major intracranial and extracranial bleeding; this is hypothesised to be increased in those randomised to take aspirin. The key consideration is then whether and to what extent the benefits of aspirin from the expected reduction in CVD events exceed the risks of major bleeding.

Discussion

This will be the first definitive trial of aspirin for primary CVD prevention in CKD patients. The research will be of great interest to clinicians, guideline groups and policy-makers, in the UK and globally, particularly given the high and rising prevalence of CKD that is driven by population ageing and epidemics of obesity and diabetes. The low cost of aspirin means that a positive result would be of relevance to low- and middle-income countries and the impact in the developed world less diluted by any inequalities in health care access.

Trial registration

ISRCTN: ISRCTN40920200. EudraCT: 2018-000644-26. ClinicalTrials.gov: NCT03796156

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06132-z.

The effect of aspirin in patients with nonvaricose upper gastrointestinal bleeding and risk factors analysis

OBJECTIVE

This paper aims to explore the effect of aspirin on the in-hospital mortality of patients with NVUGIB.

METHODS

An observational study retrospectively examined 1514 patients with NVUGIB based on a multi-center database.

RESULT

Our study reported a mortality rate of 4.8% in patients with NVUGIB, with 163 patients had a history of aspirin. Among 163 patients with an aspirin history, 76 patients (46.6%) continued to take aspirin in the hospital, with an average duration of 0.66 days after bleeding. Subsequent multivariate regression analysis showed heart rate (p <.001, OR = 0.978, 95%CI 0.969-0.987) and albumin (p =.019, OR = 0.658, 95%CI 0.464-0.933) were independent factors for aspirin-therapy after bleeding. Patients who received aspirin after NVUGIB (log-rank = 3.968, p =.046) had better survival than those who did not, but it was not an independent risk factor. The levels of albumin (p < .001, OR = 0.288, 95%CI 0.165-0.505) and INR (p =.013, OR = 1.166, 95%CI 1.033-1.316) and heart rate (p =.005, OR = 1.017, 95%CI 1.005-1.029) were independent factors of in-hospital mortality.

CONCLUSIONS

The independent risk factors for in-hospital mortality in patients with NVUGIB were albumin and INR and heart rate. The history of aspirin and the aspirin therapy after the bleeding did not affect the in-hospital mortality in patients with NVUGIB.

Appraising the contemporary role of aspirin for primary and secondary prevention of atherosclerotic cardiovascular events

INTRODUCTION

Although the role of aspirin for primary prevention of atherosclerotic cardiovascular disease (ASCVD) has been disputed, its use in secondary ASCVD prevention is well established. Recent trials of primary prevention do not suggest a significant net benefit with aspirin, whereas accruing evidence supports adopting aspirin-free strategies in the context of potent P2Y₁₂ inhibition for the secondary prevention of selected patients undergoing percutaneous coronary intervention.

AREAS COVERED

This updated review aims at summarizing and appraising the pharmacological characteristics and the contemporary role of aspirin for the primary and secondary prevention of ASCVD.

EXPERT OPINION

Recent trials and metanalyses in the context of primary prevention highlighted a modest reduction in ischemic events with aspirin use, counterbalanced by a significant increase in bleeding events. However, ongoing studies on cancer prevention could modify the current paradigm of the unfavorable benefit-risk ratio of aspirin in patients with no overt ASCVD. Conversely, aspirin use is crucial for secondary ASCVD prevention, both in chronic and acute coronary syndromes. Nevertheless, after a brief period of dual antiplatelet therapy, patients at high bleeding risk may benefit from discontinuation of aspirin if a P2Y₁₂ inhibitor is used, hence reducing the bleeding risk with no rebound in thrombotic events.

The Effect of Aspirin on the Primary Prevention of Major Adverse Cardiac and Cerebrovascular Events in Chinese Older Adults: A Registration Study

BACKGROUND

Low-dose acetylsalicylic acid (aspirin) prevents stroke and myocardial infarction in patients with cardiovascular disease (CVD), but whether it should be used for primary CVD prevention in older Chinese adults remains unclear.

METHODS

This prospective study investigated Chinese people aged > 70 years participating in the Kadoorie Study of Chronic Disease. The subjects were grouped as aspirin users and nonusers. Propensity score matching (PSM) was used to achieve balanced baseline characteristics. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE). The secondary outcomes were all-cause mortality, cardiovascular and/or cerebrovascular disease (CCVD) mortality, and bleeding events. Survival curves were used to compare the outcomes between groups. Cox regression was used to identify the risk factors for the outcomes.

RESULTS

In total, 4791 participants were categorized as aspirin users (n = 257) or nonusers (n = 4534). PSM resulted in 252 and 951 participants in the aspirin user and nonuser groups, respectively. Median follow-up was 8.6 years. Aspirin did not influence MACCE, all-cause mortality, or bleeding events, but it did influence CCVD deaths (p = 0.019). Male sex (hazard ratio [HR] 1.652; 95% confidence interval [CI] 1.217-2.243; p = 0.001), body mass index (BMI) (HR 1.053; 95% CI 1.008-1.100; p = 0.021), and systolic blood pressure (HR 1.009; 95% CI 1.003-1.016; p = 0.004) were independent risk factors for MACCE. Survival analysis showed higher rates of CCVD mortality among aspirin users (HR 1.363; 95% CI 1.040-1.786; p = 0.025), but this was not significant in the regression analysis.

CONCLUSIONS

There were no significant benefits from using aspirin as primary prevention for MACCE in older Chinese adults.

Aspirin in the Modern Era of Cardiovascular Disease Prevention

Aspirin’s antithrombotic effects have a long-established place in the prevention of cardiovascular disease (CVD), and its traditional use as a core therapy for secondary prevention of CVD is well recognized. However, with the advent of newer antiplatelet agents and an increasing understanding of aspirin’s bleeding risks, its role across the full spectrum of modern CVD prevention has become less certain. As a consequence, recent trials have begun investigating aspirin-free strategies in secondary prevention. For example, a contemporary metanalysis of trials that assessed P2Y₁₂ inhibitor monotherapy versus prolonged (≥ 12 months) dual antiplatelet therapy (which includes aspirin) after percutaneous coronary intervention reported a lower risk of major bleeding and no increase in stent thrombosis, all-cause mortality, myocardial infarction (MI), or stroke in the P2Y₁₂ monotherapy group.

In contrast to secondary prevention, aspirin’s role in primary prevention has always been more controversial. While historical trials reported a reduction in MI and stroke, more contemporary trials have suggested diminishing benefit for aspirin in this setting, with no reduction in hard outcomes, and some primary prevention trials have even indicated a potential for harm. In this review, we discuss how changing population demographics, enhanced control of lipids and blood pressure, changes in the definition of outcomes like MI, evolution of aspirin formulations, and updated clinical practice guidelines have all impacted the use of aspirin for primary and secondary CVD prevention.

Successful implementation of best medical treatment for patients with asymptomatic carotid artery stenosis within a randomized controlled trial (SPACE-2)

Background

Asymptomatic carotid artery stenosis (ACS) can be treated with carotid endarterectomy (CEA), carotid artery stenting (CAS), or best medical treatment (BMT) only. For all treatment options, optimization of vascular risk factors such as arterial hypertension, hyperlipidemia, smoking, obesity, and insufficient physical activity is essential. Data on adherence to BMT and lifestyle modification in patients with ACS are sparse. The subject of this investigation is the implementation and quality of risk factor adjustment in the context of a randomized controlled trial.

Methods

A total of 513 patients in the prematurely terminated, randomized, controlled, multicenter SPACE-2 trial (ISRCTN 78592017) were analyzed within one year after randomization into 3 groups (CEA, CAS, and BMT only) for implementation of prespecified BMT recommendations and lifestyle modifications. Measurement time points were the screening visit and visits after one month (D30), 6 months (M6), and one year (A1). Differences between groups and follow-up visits (FUVs) relative to the screening visit were investigated.

Findings

For all FUVs, a significant increase in statin medication (91% at A1; p < 0.0001) was demonstrated to be associated with a significant decrease (p < 0.01) in cholesterol levels (median 167 mg/dl at A1) and LDL cholesterol levels (median 93 mg/dl at A1). The lowest cholesterol levels were achieved by patients in the BMT group. Seventy-eight percent of all patients reached predefined target cholesterol levels (< 200 mg/dl), with significantly better rates in the BMT group (p = 0.036 at D30). Furthermore, a significant decrease in arterial blood pressure at all FUVs (p < 0.05) was associated with a significant increase in antihypertensive medication (96% at A1, p < 0.0001). However, only 28% of patients achieved the predefined treatment goal of a systolic blood pressure of ≤ 130 mmHg. Forty-two of a total of 100 smokers at the screening visit quit smoking within one year, resulting in a significant increase in nonsmokers at all FUVs (p < 0.0001). Recommended HbA1c levels (< 7%) were achieved in 82% without significant changes after one year. Only 7% of obese (BMI > 25) patients achieved sufficient weight reduction after one year without significant changes at all FUVs (median BMI 27 at A1; p = 0.1201). The BMT group showed significantly (p = 0.024) higher rates of adequate physical activity than the intervention groups. Furthermore, after one year, the BMT group showed a comparatively significantly better implementation of risk factor modification (77%; p = 0.027) according to the treating physician.

Interpretation

SPACE-2 demonstrated sustained improvement in the noninterventional management of vascular risk factors in patients treated in a clinical trial by general practitioners, internists and neurologists. The best implemented treatment targets were a reduction in cholesterol and HbA1c levels. In this context, a significant increase in statin use was demonstrated. Blood pressure control missed its target but was significantly reduced by intensification of antihypertensive medication. Patients on BMT only had better adjusted lipid parameters and were more physically active. However, all groups failed to achieve sufficient weight reduction. Due to insufficient patient recruitment, the results must be interpreted cautiously.

Trial registration: ISRCTN Registry, ISRCTN78592017, Registered 16 June 2007, https://www.isrctn.com/search?q=78592017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42466-021-00153-w.

Would You Recommend Aspirin to This Patient for Primary Prevention of Atherosclerotic Cardiovascular Disease? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of death in the United States. Reducing ASCVD risk through primary prevention strategies has been shown to be effective; however, the role of aspirin in primary prevention remains unclear. The decision to recommend aspirin has been limited by the difficulty clinicians and patients face when trying to balance benefits and harms. In 2016, the U.S. Preventive Services Task Force addressed this issue by determining the risk level at which prophylactic aspirin generally becomes more favorable, recommending aspirin above a risk cut point (>10% estimated ASCVD risk). In 2019, the American College of Cardiology and the American Heart Association issued a guideline on the primary prevention of CVD that recommends low-dose aspirin might be considered for the primary prevention of ASCVD among select adults aged 40 to 70 years who are at higher ASCVD risk but not at increased risk for bleeding. Here, 2 experts discuss how to apply this guideline in general and to a patient in particular while answering the following questions: How do you assess ASCVD risk, and what is the role, if any, of the coronary artery calcium score?; At what risk threshold of benefits and harms would you recommend aspirin or not?; and How do you help a patient come to a decision about starting or stopping aspirin therapy?

Misuse of Aspirin and Associated Factors for the Primary Prevention of Cardiovascular Disease

Background: The value of aspirin for primary prevention continues to be debated. Data showing whether aspirin use for primary prevention adheres to established guidelines in real world practice are sparse. Methods: A total of 13,104 patients without cardiovascular diseases (CVD) were selected from the DYS-lipidemia International Study of China, a national survey of patients with dyslipidemia in 2012. The CVD risk of the participants were calculated using the 10-year risk of Ischemic Cardiovascular Diseases model. The misuse of aspirin for primary prevention was defined as having CVD risk <10% with daily aspirin. Multivariate logistic regression models were used to explore risk factors associated with aspirin misuse. Results: The proportion of the patients categorized as low, moderate and high risk for CVD were 52.9, 21.6, and 25.4% respectively. The misuse frequency of aspirin was 31.0% (2,147/6,933) in patients with low risk. The misuse of aspirin increased with aging for both men and women. In the multivariate analysis, the independent risk factors associated with aspirin misuse were hypertension, diabetes mellitus, a family history of premature CVD, and elderly age. Level of total cholesterol is negatively associated with aspirin misuse. Patients from low level hospitals are more likely to be taking aspirin inappropriately. Results remained consistent after including 2,837 patients having 10-year risk for CVD between 10 and <20%. Conclusion: The misuse of aspirin for primary prevention is common in patients having CVD risk <10%. There are important opportunities to improve evidence-based aspirin use for the primary prevention of CVD in Chinese patients. Clinical Trial Registration:https://clinicaltrials.gov/, identifier [NCT01732952].

Effects of aspirin and statin use on venous thromboembolism prophylaxis and survival in patients with endometrial cancer

INTRODUCTION

Acetylsalicylic acid (aspirin) and statins are commonly used to manage and prevent cardiovascular diseases. Recent studies have suggested the benefits of aspirin or statin use in venous thromboembolism (VTE) prophylaxis and survival outcome improvement in women with endometrial cancer.

AREAS COVERED

In this study, we reviewed the effects of aspirin or statin use on VTE prophylaxis and survival outcome in women with endometrial cancer.

EXPERT OPINION

Among women with endometrial cancer, aspirin use exerted a modest effect on VTE prophylaxis, whereas statin use was associated with a decreased prevalence of VTE, especially in women with obesity and type II cancer, compared with those in non-users. Aspirin use improved cause-specific survival in women with endometrial cancer, aged less than 60 years, who were obese and presented with type I cancer. Statin use was associated with better cause-specific survival in women with type II cancer. The combination of aspirin and statins may be the most effective strategy in improving on VTE prophylaxis and survival outcomes in obese women with type II cancer. Targeting of the appropriate population with endometrial cancer may enhance the efficacy of aspirin or statins on VTE prophylaxis and survival outcomes in women with endometrial cancer.

Impact of aspirin use on clinical outcomes in patients with vasospastic angina: a systematic review and meta-analysis

OBJECTIVES

The use of aspirin to prevent cardiovascular disease in vasospastic angina (VSA) patients without significant stenosis has yet to be investigated. This study aimed to investigate the efficacy of aspirin use among VSA patients.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Web of Science and Cochrane Central Register of Controlled Trials were searched for relevant information prior to October 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Aspirin use versus no aspirin use (placebo or no treatment) among VSA patients without significant stenosis.

DATA EXTRACTION AND SYNTHESIS

Two investigators extracted the study data. ORs and 95% CIs were calculated and graphed as forest plots. The Newcastle-Ottawa Quality Assessment Scale tool and Begg's funnel plot were used to assess risk of bias.

RESULTS

Four propensity-matched cohorts, one retrospective analysis and one prospective multicentre cohort, in total comprising 3661 patients (aspirin use group, n=1695; no aspirin use group, n=1966) were included in this meta-analysis. Aspirin use and the incidence of major cardiovascular adverse events with follow-up of 1-5 years were not significantly correlated (combined OR=0.90, 95% CI: 0.55 to 1.68, p=0.829, I²=82.2%; subgroup analysis: OR=1.09, 95% CI: 0.81 to 1.47, I²=0%). No significant difference was found between aspirin use and the incidence of myocardial infarction (OR=0.62, 95% CI: 0.09 to 4.36, p=0.615, I²=73.8%) or cardiac death (OR=1.73, 95% CI: 0.61 to 4.94, p=0.444, I²=0%) during follow-up.

CONCLUSION

Aspirin use may not reduce the risk of future cardiovascular events in VSA patients without significant stenosis.

PROSPERO REGISTRATION NUMBER

CRD42020214891.

Are interventions to improve cardiovascular disease risk factors in premenopausal women effective? A systematic review and meta-analysis

OBJECTIVES

Non-traditional risk factors place young women at increased risk of cardiovascular disease (CVD) over their lifetime. The current study undertakes a systematic review and meta-analysis of randomised controlled trials (RCTs) that examined the effectiveness of primary prevention interventions for CVD in premenopausal women.

METHODS

An electronic literature search was performed in key databases in July 2018 and updated in May 2020. RCTs that recruited predominately female participants with a proportion aged under 55 years and that compared primary prevention interventions of CVD with usual practice were included. Two reviewers undertook the selection process for study inclusion. Meta-analysis was conducted for studies based on the same intervention in order to synthesise the results.

RESULTS

14 RCTs with sample size ranging from 49 to 39 876 were included. Interventions included diet (2), vitamin E/antioxidants (3), lifestyle modification programme (7) and aspirin (2). The meta-analysis results indicated that diet nor vitamin E/antioxidant did not significantly lower the CVD risk profiles, while lifestyle modification programme involving components of lifestyle education, counselling and multiple follow-ups showed great potential to improve risk profiles. The lifestyle modification intervention improved blood pressure (-2.11 mm Hg, 95% CI -4.32 to 0.11, for systolic and -3.31 mm Hg (95% CI -4.72 to -1.91, for diastolic), physical activity (30.72 MET-min/week, 95% CI 23.57 to 37.87, for moderate physical activity 12.70 MET-min/week, 95% CI 8.27 to 17.14, for vigorous physical activity) and fasting blood glucose (-0.37 mmol/L, 95% CI -0.58 to -0.15). Subgroup meta-analysis in studies with a mean age under 51 years old suggested that lifestyle modification intervention remained to be effective in improving physical activity and fasting blood glucose.

CONCLUSION

The effective interventions identified in this review although with a small sample size and short duration could potentially inform future design of primary prevention of CVD in premenopausal women.

Risk of lower gastrointestinal bleeding and colorectal neoplasms following initiation of low-dose aspirin: a Danish population-based cohort study

OBJECTIVE

Aspirin may increase the risk of lower gastrointestinal bleeding (LGIB) from precursors of colorectal cancer (CRC). We investigated whether use of low-dose aspirin, through initiation of LGIB, may lead patients to undergo colonoscopy and polypectomy before manifest CRC.

DESIGN

We conducted a historical cohort study (2005-2013) of all Danish residents who initiated low-dose aspirin treatment (n=412 202) in a setting without screening for CRC. Each new aspirin user was matched with three non-users (n=1 236 560) by age, sex and region of residence on the date of their matched new user's first-time aspirin prescription (index date). We computed absolute risks (ARs), risk differences and relative risks (RRs) of LGIB, lower gastrointestinal endoscopy, colorectal polyps and CRC, comparing aspirin users with non-users.

RESULTS

The ARs were higher for new users than non-users for LGIB, lower gastrointestinal endoscopy, colorectal polyps and CRC within 3 months after index. Comparing new users with non-users, the RRs were 2.79 (95% CI 2.40 to 3.24) for LGIB, 1.73 (95% CI 1.63 to 1.84) for lower gastrointestinal endoscopy, 1.56 (95% CI 1.42 to 1.72) for colorectal polyps and 1.73 (95% CI 1.51 to 1.98) for CRC. The RRs remained elevated for more than 12 months after the index date, with the exception of CRC where the RRs were slightly decreased during the 3-5 years (RR 0.90, 95% CI 0.83 to 0.98) and more than 5 years (RR 0.91, 95% CI 0.82 to 1.00) following the index date.

CONCLUSION

These findings indicate that aspirin may contribute to reduce CRC risk by causing premalignant polyps to bleed, thereby expediting colonoscopy and polypectomy before CRC development.

Aspirin Actions in Treatment of NSAID-Exacerbated Respiratory Disease

Non-steroidal Anti-inflammatory drugs (NSAID)-exacerbated respiratory disease (N-ERD) is characterized by nasal polyposis, chronic rhinosinusitis, adult-onset asthma and hypersensitive reactions to cyclooxygenase-1 (COX-1) inhibitors. Among the available treatments for this disease, a combination of endoscopic sinus surgery followed by aspirin desensitization and aspirin maintenance therapy has been an effective approach. Studies have shown that long-term aspirin maintenance therapy can reduce the rate of nasal polyp recurrence in patients with N-ERD. However, the exact mechanism by which aspirin can both trigger and suppress airway disease in N-ERD remains poorly understood. In this review, we summarize current knowledge of aspirin effects in N-ERD, cardiovascular disease, and cancer, and consider potential mechanistic pathways accounting for the effects of aspirin in N-ERD.

Appropriateness of aspirin prescribing for primary and secondary prevention of cardiovascular disease in type 2 diabetes in different care settings

Background

Type 2 diabetes is associated with an increased cardiovascular risk. Use of aspirin has been shown to be of benefit for secondary prevention of cardiovascular disease in patients with type 2 diabetes; benefits in primary prevention have not been clearly proven.

Aims

This study aims to (a) determine if aspirin is prescribed appropriately in type 2 diabetes for primary or secondary prevention of cardiovascular disease (CVD) and (b) evaluate whether there are differences in aspirin prescribing according to where people receive their care.

Design

Cross-sectional study

Methods

The medical records of individuals with type 2 diabetes aged over 18 years and attending Elmwood Primary Care Centre and Cork University Hospital Diabetes outpatient clinics (n = 400) between February and August 2017 were reviewed.

Results

There were 90 individuals exclusively attending primary care and 310 persons attending shared care. Overall, 49.0% (n = 196) of those were prescribed aspirin, of whom 42.3% were using it for secondary prevention. Aspirin was used significantly more in people attending shared care (p < 0.001). About 10.8% of individuals with diabetes and CVD attending shared care met guidelines for, but were not prescribed aspirin.

Conclusion

A significant number of people with type 2 diabetes who should have been prescribed aspirin for secondary prevention were not receiving it at the time of study assessment. In contrast, a substantial proportion who did not meet criteria for aspirin use was prescribed it for primary prevention.

Chinese Guideline on the Primary Prevention of Cardiovascular Diseases

Abstract

Cardiovascular disease is the leading cause of mortality in China. Primary prevention of cardiovascular disease with a focus on lifestyle intervention and risk factor control has been shown to effectively delay or prevent the occurrence of cardiovascular events. To promote a healthy lifestyle and enhance the detection, diagnosis, and treatment of cardiovascular risk factors such as hypertension, dyslipidemia, and diabetes, and to improve the overall capacity of primary prevention of cardiovascular disease, the Chinese Society of Cardiology of Chinese Medical Association has collaborated with multiple societies to summarize and evaluate the latest evidence with reference to relevant guidelines and subsequently to develop recommendations for primary cardiovascular disease prevention in Chinese adults. The guideline consists of 10 sections: introduction, methodology for developing the guideline, epidemiology of cardiovascular disease in China and challenges in primary prevention, general recommendations for primary prevention, assessment of cardiovascular risk, lifestyle intervention, blood pressure control, lipid management, management of type 2 diabetes, and use of aspirin. The promulgation and implementation of this guideline will play a key role in promoting the practice of primary prevention for cardiovascular disease in China.

Targeting Contrast Agents With Peak Near-Infrared-II (NIR-II) Fluorescence Emission for Non-invasive Real-Time Direct Visualization of Thrombosis

Thrombosis within the vasculature arises when pathological factors compromise normal hemostasis. On doing so, arterial thrombosis (AT) and venous thrombosis (VT) can lead to life-threatening cardio-cerebrovascular complications. Unfortunately, the therapeutic window following the onset of AT and VT is insufficient for effective treatment. As such, acute AT is the leading cause of heart attacks and constitutes ∼80% of stroke incidences, while acute VT can lead to fatal therapy complications. Early lesion detection, their accurate identification, and the subsequent appropriate treatment of thrombi can reduce the risk of thrombosis as well as its sequelae. As the success rate of therapy of fresh thrombi is higher than that of old thrombi, detection of the former and accurate identification of lesions as thrombi are of paramount importance. Magnetic resonance imaging, x-ray computed tomography (CT), and ultrasound (US) are the conventional non-invasive imaging modalities used for the detection and identification of AT and VT, but these modalities have the drawback of providing only image-delayed indirect visualization of only late stages of thrombi development. To overcome such limitations, near-infrared (NIR, ca. 700-1,700 nm) fluorescence (NIRF) imaging has been implemented due to its capability of providing non-invasive real-time direct visualization of biological structures and processes. Contrast agents designed for providing real-time direct or indirect visualization of thrombi using NIRF imaging primarily provide peak NIR-I fluorescence emission (ca. 700-1,000 nm), which affords limited tissue penetration depth and suboptimal spatiotemporal resolution. To facilitate the enhancement of the visualization of thrombosis via providing detection of smaller, fresh, and/or deep-seated thrombi in real time, the development of contrast agents with peak NIR-II fluorescence emission (ca. 1000-1,700 nm) has been recently underway. Currently, however, most contrast agents that provide peak NIR-II fluorescence emissions that are purportedly capable of providing direct visualization of thrombi or their resultant occlusions actually afford only the indirect visualization of such because they only provide for the (i) measuring of the surrounding vascular blood flow and/or (ii) simple tracing of the vasculature. These contrast agents do not target thrombi or occlusions. As such, this mini review summarizes the extremely limited number of targeting contrast agents with peak NIR-II fluorescence emission developed for non-invasive real-time direct visualization of thrombosis that have been recently reported.

Multidisciplinary prevention and management strategies for colorectal cancer and cardiovascular disease

Colorectal cancer (CRC) and cardiovascular disease (CVD) are leading causes of morbidity and mortality worldwide. Their numerous shared and modifiable risk factors underscore the importance of effective prevention strategies for these largely preventable diseases. Conventionally regarded as separate disease entities, clear pathophysiological links and overlapping risk factors represent an opportunity for synergistic collaborative efforts of oncologists and cardiologists. In addition, current CRC treatment approaches can exert cardiotoxicity and thus increase CVD risk. Given the complex interplay of both diseases and increasing numbers of CRC survivors who are at increased risk for CVD, multidisciplinary cardio-oncological approaches are warranted for optimal patient care from primary prevention to acute disease treatment and long-term surveillance.

An Original Aspirin-Containing Carbonic Anhydrase 9 Inhibitor Overcomes Hypoxia-Induced Drug Resistance to Enhance the Efficacy of Myocardial Protection

PURPOSE

Hypoxic microenvironment plays a vital role in myocardial ischemia injury, generally leading to the resistance of chemotherapeutic drugs. This induces an intriguing study on mechanism exploration and prodrug design to overcome the hypoxia-induced drug resistance.

METHODS

In this study, we hypothesized that the overexpression of carbonic anhydrase 9 (CAIX) in myocardial cells is closely related to the drug resistance. Herein, bioinformatics analysis, gene knockdown, and overexpression assay certificated the correlation between CAIX overexpression and hypoxia. An original aspirin-containing CAIX inhibitor AcAs has been developed.

RESULTS

Based on the downregulation of CAIX level, both in vitro and in vivo, AcAs can overcome the acquired resistance and more effectively attenuate myocardial ischemia and hypoxia injury than that of aspirin. CAIX inhibitor is believed to recover the extracellular pH value so as to ensure the stable effect of aspirin.

CONCLUSION

Results indicate great potential of CAIX inhibitor for further application in myocardial hypoxia injury therapy.

Overview of Aspirin and Platelet Biology

Aspirin (ASA) has historically been one of the most important drugs in cardiology and has long been the cornerstone of antiplatelet therapy. Although its role in acute coronary syndrome remains undisputed, emerging data suggest that reappraisal of the efficacy of long-term ASA in some primary and secondary prevention may be warranted. The aim of this review is to place these new results in the context of previous evidence on aspirin by appraising the current body of evidence on its use of for cardiovascular diseases. This overview first summarizes the history of the discovery of aspirin, as well as its pharmacology and the concept of ASA resistance. We subsequently recapitulate the evidence of ASA on primary prevention and secondary prevention starting from the classical studies in order to serve as an introductory background to the examination of the most recent clinical trials that will be performed in the rest of the articles of this Supplement. Although the benefit of ASA in acute coronary syndrome remains incontrovertible, emerging evidence challenge the universal need for primary prevention, or for lifelong treatment in secondary prevention or all adults with stable coronary disease who are at highest risk for ASA-induced bleeding. The role of aspirin is quickly changing in recent times and this review provides a review for the clinician about the current role of this drug in cardiovascular care.

Aspirin for Primary Prevention of Cardiovascular Disease in the 21st Century: A Review of the Evidence

Aspirin (ASA) is the most commonly prescribed antiplatelet agent. Although the evidence for efficacy of aspirin for secondary prevention of ischemic events in patients with established cardiovascular disease is strong, its role in primary prevention has been subject of controversies over the past decades. In fact, historical trials have shown only modest benefit in terms of reduction of ischemic events, mostly myocardial infarction and to a lesser extent stroke, and only at the expense of an increased risk of bleeding. These observations have led to divergent recommendations from professional societies on the use of ASA for primary prevention of cardiovascular disease manifestations. However, recent results from three trials of primary prevention have shown either no benefit or modest benefit on combined ischemic end points, without any impact on hard cardiovascular events such as myocardial infarction or stroke, accompanied by an increased risk of bleeding. Overall, this translated into neutral net benefit or even harm with the use of aspirin in patients with no overt cardiovascular disease. These results have accordingly led to a downgrade in the current recommendations on the use of ASA for primary prevention. This article provides an overview on the current evidence on the use of aspirin for primary prevention of cardiovascular disease.

In-hospital prognosis of first-ever noncardiogenic ischemic stroke in patients with and without indication for prestroke antiplatelet therapy: Chinese Stroke Center Alliance

Background

It is unknown about the influence of prestroke antiplatelet use on early outcomes in patients with and without the indication. We aimed to evaluate the in-hospital prognosis of first-ever noncardiogenic ischemic stroke patients with and without indications of antiplatelet use for primary prevention.

Methods

This was a retrospective, observational study based on a prospective hospital-based registry (Chinese Stroke Center Alliance). Using the data with 436,660 first-ever noncardiogenic acute ischemic strokes recorded from Aug 1, 2015, to July 31, 2019, from 1,453 hospitals in China, we examined the associations between the indication for prestroke antiplatelet use and in-hospital clinical outcomes.

Results

Among 436,660 first-ever noncardiogenic ischemic stroke patients, 42,409 patients (9.7%) had a documented previous vascular indication and 394,251 (90.3%) did not. Compared to those without, patients with the indication were associated with increased prevalence of in-hospital morbid conditions, including stroke severity (OR 2.71; 95% CI: 2.62–2.81; P<0.0001), length of stay >14 days (OR 1.16; 95% CI: 1.13–1.19; P<0.0001), mortality (OR 2.20; 95% CI: 1.96–2.46, P<0.0001), and recurrence of ischemic stroke and transient ischemic attack (TIA) (OR 1.5; 95% CI: 1.43–1.59, P<0.0001). Among patients without indication, prestroke antiplatelet use was associated with lower mortality (OR 0.73, 95% CI: 0.56–0.96; P=0.0221); while among patients with indication, those receiving prestroke antiplatelet had lower odds ratios in stroke severity (P<0.0001) and disability (P=0.0003) than those who not.

Conclusions

Patients with indications of prestroke antiplatelet use were more likely to have unfavorable outcomes than those without. Prestroke antiplatelet might be associated with lower mortality, less disability, and less stroke severity in certain population groups. Future studies to improve risk prediction rules are needed to guide effective primary prevention for ischemic stroke.

Aspirin Use Is Associated With Decreased Mechanical Ventilation, Intensive Care Unit Admission, and In-Hospital Mortality in Hospitalized Patients With Coronavirus Disease 2019

BACKGROUND

Coronavirus disease-2019 (COVID-19) is associated with hypercoagulability and increased thrombotic risk in critically ill patients. To our knowledge, no studies have evaluated whether aspirin use is associated with reduced risk of mechanical ventilation, intensive care unit (ICU) admission, and in-hospital mortality.

METHODS

A retrospective, observational cohort study of adult patients admitted with COVID-19 to multiple hospitals in the United States between March 2020 and July 2020 was performed. The primary outcome was the need for mechanical ventilation. Secondary outcomes were ICU admission and in-hospital mortality. Adjusted hazard ratios (HRs) for study outcomes were calculated using Cox-proportional hazards models after adjustment for the effects of demographics and comorbid conditions.

RESULTS

Four hundred twelve patients were included in the study. Three hundred fourteen patients (76.3%) did not receive aspirin, while 98 patients (23.7%) received aspirin within 24 hours of admission or 7 days before admission. Aspirin use had a crude association with less mechanical ventilation (35.7% aspirin versus 48.4% nonaspirin, P = .03) and ICU admission (38.8% aspirin versus 51.0% nonaspirin, P = .04), but no crude association with in-hospital mortality (26.5% aspirin versus 23.2% nonaspirin, P = .51). After adjusting for 8 confounding variables, aspirin use was independently associated with decreased risk of mechanical ventilation (adjusted HR, 0.56, 95% confidence interval [CI], 0.37-0.85, P = .007), ICU admission (adjusted HR, 0.57, 95% CI, 0.38-0.85, P = .005), and in-hospital mortality (adjusted HR, 0.53, 95% CI, 0.31-0.90, P = .02). There were no differences in major bleeding (P = .69) or overt thrombosis (P = .82) between aspirin users and nonaspirin users.

CONCLUSIONS

Aspirin use may be associated with improved outcomes in hospitalized COVID-19 patients. However, a sufficiently powered randomized controlled trial is needed to assess whether a causal relationship exists between aspirin use and reduced lung injury and mortality in COVID-19 patients.

Current state-of-the-art antiplatelet and anticoagulation therapy in diabetic patients with coronary artery disease

Diabetes mellitus is a complex disease that leads to long-term damage to various organ systems. Among the numerous cardiovascular disease-related complications, thrombotic events frequently occur in patients with diabetes. Although guidelines exist for treating and preventing most diabetes-related co-morbidities, the evidence on antithrombotic therapy in primary and secondary prevention is limited due to the scarcity of randomized trials dedicated to patients with diabetes mellitus. Most of the available data are derived from studies that only included a small proportion of patients with diabetes. The present review provides an overview of the status of knowledge on antiplatelet and anticoagulation therapy in patients with diabetes, focusing on the risk-benefit balance of these therapies and future treatment strategies.

Aspirin in the Prevention of Cardiovascular Disease and Cancer

More than a century after its synthesis, daily aspirin, given at a low dose, is a milestone treatment for the secondary prevention of cardiovascular disease (CVD). Its role in primary prevention of CVD is still debated. Older randomized controlled trials showed that aspirin reduced the low incidence of myocardial infarction but correspondingly increased the low incidence of serious gastrointestinal bleeds without altering mortality. More recent trials see the benefit attenuated, perhaps obscured by other cardioprotective practices, while the bleeding risk remains, especially in older patients. Indirect evidence, both preclinical and clinical, suggests that aspirin may protect against sporadic colorectal cancer and perhaps other cancers. However, further studies are still necessary to warrant the consumption of aspirin for primary prevention of CVD and cancer by apparently healthy individuals.

Pros and Cons of Aspirin for the Primary Prevention of Cardiovascular Events: A Secondary Study of Trial Sequential Analysis

Background and Aims: Aspirin leads to substantial benefits for the secondary prevention of cardiovascular disease (CVD). We aimed to cast more light on aspirin's role for the primary prevention of CVD. Methods: Databases were searched for clinical trials comparing aspirin vs. no aspirin use in this meta-analysis. Efficacy and safety profiles were rigorously investigated. Trial sequential analysis (TSA) was used to determine the robustness of the results. Results: Fourteen studies with 163,840 participants were eligible (mean follow-up 6.2 y). Aspirin intake was found to be associated with 9, 13, and 12% reductions in the risk of cardiovascular events (CV events) (relative risk [RR]: 0.91, 95% confidence intervals [CI]: 0.87-0.96; risk difference (RD): 0.29%; absolute risk percentage (AR%): 7.61%; number needed to treat (NNT): 345), myocardial infarction (RR: 0.87, 95% CI: 0.77-0.97; RD: 0.21%; AR%: 11.11%; NNT: 488) and ischemic stroke (RR: 0.88, 95% CI: 0.80-0.96; RD: 0.21%; AR%: 16.14%; NNT: 476), respectively; aspirin intake was also associated with 40%, 30%, and 57% increases in the risk of major bleeding (RR: 1.40, 95% CI: 1.29-1.53; RD: 0.47%; AR%: 27.85; NNT: 214), intracranial bleeding (RR: 1.30, 95% CI: 1.11-1.52; RD: 0.10%; AR%: 22.99%; NNT: 1,000) and major gastrointestinal bleeding (RR: 1.57, 95% CI: 1.38-1.78; RD: 0.32%; AR%: 36.70%; NNT: 315), respectively. Further, populations with low doses of aspirin intake (≤100 mg), populations <65 y old or populations with body mass index (BMI) ≧ 25 experienced more advantages; high-risk (10-y cardiovascular risk ≧10%) and full diabetic individuals reported hardly clinical benefits. Conclusion: Aspirin intake was associated with a reduced risk of CV events and an increased incidence of bleeding profiles in primary prevention. It is necessary to identify individual's CVD risk using clear examinations or assessments before aspirin intake, and truly realize individualized prescription.

Low-Dose Aspirin Use Among African American Older Adults

OBJECTIVES

Existing epidemiologic information shows disparities in low-dose aspirin use by race. This study investigates the frequency, pattern, and correlates of both self- and clinician-prescribed low-dose aspirin use among underserved African Americans aged 55 years and older.

METHODS

This cross-sectional study conducted a comprehensive evaluation of all over-the-counter and prescribed medications used among 683 African American older adults in South Central Los Angeles, California. Correlation between use of low-dose aspirin and sociodemographic variables, health care continuity, health behaviors, and several major chronic medical conditions were examined. In addition, the use of low-dose aspirin as self prescribed versus clinician prescribed was examined. Multivariate logistic regression was performed to examine correlates of low-dose aspirin use.

RESULTS

Overall, 37% of participants were taking low-dose aspirin. Sixty percent of low-dose aspirin users were taking low-dose aspirin as self prescribed and 40% were taking it as prescribed by a clinician. Major aspirin-drug interactions were detected in 75% of participants who used low-dose aspirin, but no significant differences in aspirin-drug interactions were found between those who used aspirin as self prescribed and those who used it as clinician prescribed. No negative association between being diagnosed with gastrointestinal conditions and aspirin used was detected. Being diagnosed with diabetes mellitus or a heart condition was associated with higher use of aspirin. However, only 50% with high risk of cardiovascular took prescribed (38%) or self-prescribed (62%) low-dose aspirin. One third of participants aged 70 years and older with low risk of cardiovascular were using aspirin.

CONCLUSIONS

Among underserved African-American middle-aged and older adults, many who could potentially benefit from aspirin are not taking it; and many taking aspirin have no indication to do so and risk unnecessary side effects. Compared with non-Hispanic Whites, African Americans are more likely to be diagnosed with diabetes, hypertension, and heart conditions at earlier stages of life; as a result, the role of preventive intervention, including safe and appropriate use of low-dose aspirin among this segment of our population, is more salient. Interventional studies are needed to promote safe and effective use of low-dose aspirin among underserved African-American adults.

Research Progress of Herbal Medicines on Drug Metabolizing Enzymes: Consideration Based on Toxicology

The clinical application of herbal medicines is increasing, but there is still a lack of comprehensive safety data and in-depth research into mechanisms of action. The composition of herbal medicines is complex, with each herb containing a variety of chemical components. Each of these components may affect the activity of metabolizing enzymes, which may lead to herb-drug interactions. It has been reported that the combined use of herbs and drugs can produce some unexpected interactions. Therefore, this study reviews the progress of research on safety issues caused by the effects of herbs on metabolizing enzymes with reference to six categories of drugs, including antithrombotic drugs, non-steroidal anti-inflammatory drugs, anti-diabetic drugs, statins lipid-lowering drugs, immunosuppressants, and antineoplastic drugs. Understanding the effects of herbs on the activity of metabolizing enzymes could help avoid the toxicity and adverse drug reactions resulting from the co-administration of herbs and drugs, and help doctors to reduce the risk of prescription incompatibility.

Association between aspirin use and cardiovascular outcomes in ALLHAT participants with and without chronic kidney disease: A post hoc analysis

It is unclear whether aspirin is beneficial for prevention of CVD in patients with CKD. We performed a secondary analysis of the ALLHAT trial to assess the effect of baseline aspirin use on nonfatal myocardial infarction (MI) or fatal coronary heart disease (CHD), all‐cause mortality, and stroke. Baseline characteristics of aspirin users and nonusers were used to generate propensity‐matched cohorts. Using conditional Cox proportional hazard regression models, we examined the effect of aspirin on the outcomes in the cohort at large and across 3 levels of kidney function (eGFR ≥90, 60–89, and <60). 11 250 ALLHAT participants reported using aspirin at baseline. The propensity‐matched dataset included 6894 nonusers matched with replacement to achieve a balanced analysis population (n = 22 500). Risk of fatal CHD or nonfatal MI (HR = 0.94, 95% CI 0.86–1.02) and stroke (HR = 1.01, 95% CI 0.89–1.15) was not significantly different between groups. Aspirin users were at significantly lower risk of all‐cause mortality compared to nonusers (HR = 0.82, 95% CI 0.76–0.88). Aspirin use was not associated with incidence of fatal CAD or nonfatal MI in patients with CVD (HR = 0.93, CI 0.84–1.04) or without CVD at baseline (HR = 1.04, CI 0.82–1.32). Results were consistent across strata of GFR (interaction p value NS). In hypertensive patients at high cardiovascular risk, aspirin use is not associated with risk of nonfatal MI, fatal CHD, or stroke; however, aspirin use is associated with lower risk of all‐cause mortality. These results are consistent across baseline eGFR.

Polypharmacy and the use of low or limited value medications in advanced cancer

BACKGROUND

Patients with advanced malignancy are often on medications for co-morbidities, including those for primary or secondary prevention. The benefit from these medications can be limited and may result in adverse effects, interact with medications used for the malignancy or associated symptoms, increase pill burden and reduce quality of life.

AIMS

To evaluate the proportion of patients with advanced malignancy that were continued on low or limited value medications and identify the factors associated with this. We also sought to determine how prevalent polypharmacy was within this group of patients and the factors associated with this.

METHODS

A retrospective chart review was conducted of patients with incurable malignancy admitted under medical oncology at Liverpool Hospital over a 90-day period. Demographic variables, co-morbidities, disease related parameters and medications were reviewed. Criteria were established to identify low or limited value medications.

RESULTS

Seventy-eight patients were identified between September and December 2018. Thirty-day mortality was 33%. Sixty-five percent of the cohort was on five or more medications and 24% on 10 or more. One low or limited value medication was reported in 36% and 20% were on two or more. Age ≤60 years was associated with a risk of being on at least one unnecessary medication. Patients with fewer co-morbidities and those in their last 3 months of life were significantly less likely to have polypharmacy. Nine percent of the cohort was on three or more antihypertensives and 6% of patients were on three or more oral hypoglycaemics.

CONCLUSION

Polypharmacy and continued prescribing of low or limited value medications was identified in a high proportion of patients. Further studies are needed to assess the impact of continuing these medications, as well as investigation of patient and physician attitudes towards de-escalation.

Behavioral Counseling to Promote a Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Cardiovascular disease is the leading cause of death in the US, and poor diet and lack of physical activity are major factors contributing to cardiovascular morbidity and mortality.

OBJECTIVE

To review the benefits and harms of behavioral counseling interventions to improve diet and physical activity in adults with cardiovascular risk factors.

DATA SOURCES

MEDLINE, PubMed, PsycINFO, and the Cochrane Central Register of Controlled Trials through September 2019; literature surveillance through July 24, 2020.

STUDY SELECTION

English-language randomized clinical trials (RCTs) of behavioral counseling interventions to help people with elevated blood pressure or lipid levels improve their diet and increase physical activity.

DATA EXTRACTION AND SYNTHESIS

Data were extracted from studies by one reviewer and checked by a second. Random-effects meta-analysis and qualitative synthesis were used.

MAIN OUTCOMES AND MEASURES

Cardiovascular events, mortality, subjective well-being, cardiovascular risk factors, diet and physical activity measures (eg, minutes of physical activity, meeting physical activity recommendations), and harms. Interventions were categorized according to estimated contact time as low (≤30 minutes), medium (31-360 minutes), and high (>360 minutes).

RESULTS

Ninety-four RCTs were included (N = 52 174). Behavioral counseling interventions involved a median of 6 contact hours and 12 sessions over the course of 12 months and varied in format and dietary recommendations; only 5% addressed physical activity alone. Interventions were associated with a lower risk of cardiovascular events (pooled relative risk, 0.80 [95% CI, 0.73-0.87]; 9 RCTs [n = 12 551]; I2 = 0%). Event rates were variable; in the largest trial (Prevención con Dieta Mediterránea [PREDIMED]), 3.6% in the intervention groups experienced a cardiovascular event, compared with 4.4% in the control group. Behavioral counseling interventions were associated with small, statistically significant reductions in continuous measures of blood pressure, low-density lipoprotein cholesterol levels, fasting glucose levels, and adiposity at 12 to 24 months' follow-up. Measurement of diet and physical activity was heterogeneous, and evidence suggested small improvements in diet consistent with the intervention recommendation targets but mixed findings and a more limited evidence base for physical activity. Adverse events were rare, with generally no group differences in serious adverse events, any adverse events, hospitalizations, musculoskeletal injuries, or withdrawals due to adverse events.

CONCLUSIONS AND RELEVANCE

Medium- and high-contact multisession behavioral counseling interventions to improve diet and increase physical activity for people with elevated blood pressure and lipid levels were effective in reducing cardiovascular events, blood pressure, low-density lipoproteins, and adiposity-related outcomes, with little to no risk of serious harm.

Stroke Prevention in Older Adults: Recent Advances

The risks of stroke and dementia increase steeply with age, and both are preventable. At present, the best way to preserve cognitive function is to prevent stroke. Therapeutic nihilism based on age is common and unwarranted. We address recent advances in stroke prevention that could contribute greatly to prevention of stroke and dementia at a time when the aging of the population threatens to markedly increase the incidence of both. Issues discussed: (1) old patients benefit even more from lipid-lowering therapy than do younger patients; (2) patients with stiff arteries are at risk from a target systolic blood pressure <120 mm Hg; (3) the interaction of the intestinal microbiome, age, and renal function has important dietary implications for older adults; (4) anticoagulation with direct-acting oral anticoagulants should be prescribed more to old patients with atrial fibrillation; (5) B vitamins to lower homocysteine prevent stroke; and (6) most old patients in whom intervention is warranted for carotid stenosis would benefit more from endarterectomy than from stenting. An 80-year-old person has much to lose from a stroke and should not have effective therapy withheld on account of age. Lipid-lowering therapy, a more plant-based diet, appropriate anticoagulation or antiplatelet therapy, appropriate blood pressure control, B vitamins to lower homocysteine, and judicious intervention for carotid stenosis could do much to reduce the growing burden of stroke and dementia.

Recommendation of Aspirin-Guide App and Physicians Clinical Decision of Aspirin Use to Prevent CVD Among Diabetic Patients, Is there any Differences?

OBJECTIVE

This study aims to identify the prevalence of aspirin use among type 2 diabetic (T2DM) patients and assess the concordance in aspirin use among these patients as prescribed by physicians and as recommended by the Aspirin-Guide app.

METHODS

A total of 301 T2DM patients from King Khalid University Hospital in Riyadh, Saudi Arabia participated in this cross-sectional study. Patient's electronic medical records through eSihi system were reviewed and all data included in the free online and mobile app called Aspirin-Guide were collected in a specially designed data checklist.

RESULT

The prevalence of aspirin use was more common in patients who were in the age group of 51 to 59 and male participants' with T2DM. Males were nearly twice more likely to use aspirin compared to females (P = 0.001). Based on recommendations from the Aspirin-Guide app, 26% of the patients who were on aspirin (N = 51) were not eligible for aspirin therapy, while 37.7% (N = 40) of the patients eligible for aspirin therapy had not been put on aspirin by their physicians (P = 0.039). Male sex (P = 0.003), use of statins (P = 0.001), and being advised to use aspirin (P = 0.041), were significantly associated with aspirin use in T2DM patients.

CONCLUSION

There was a significant difference in the proportion of patients currently on aspirin as prescribed by their physicians and those eligible for aspirin therapy as per the Aspirin-Guide app. The use of an app to uniformized aspirin use among eligible patients should be based on up-to-date guidelines and account for patient acceptability and willingness to commence treatment.

The Risk of Gastrointestinal Hemorrhage in Low-Dose Aspirin Users with Diabetes Mellitus: Systematic Review and Meta-Analysis

Background

Our aim was to assess the risk of gastrointestinal (GI) hemorrhage associated with diabetes among patients taking low-dose aspirin (≤325 mg/day).

Methods

A systematic search was conducted for publication in English and Chinese using term equivalents for “GI hemorrhage”, “aspirin”, and “diabetes mellitus” up till April 2020. Electronic databases include PUBMED, EMBASE, Cochrane Library databases, Chinese National Knowledge Infrastructure (CNKI), Wanfang Database, and VIP Database. Two independent authors searched databases and reviewed abstracts for comprehensive studies keeping adequate study quality. Data of weighted odds ratios were statistically evaluated and potential bias was checked.

Results

Among 446 publications, eight case-control researches, including 1601 patients, were deemed for this meta-analysis. Patients with diabetes were associated with a higher risk of GI hemorrhage than patients without diabetes: the summary ORs were 3.10 (95% CI, 2.35–4.09). The heterogeneity of the reports was not significant (Chi² = 3.39, P = 0.85; I² = 0%).

Conclusion

The meta-analysis showed that aspirin users with diabetes were more likely to have GI hemorrhage. Hence, when treating diabetics with aspirin, the increased risk of GI bleeding should be taken in consideration.