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Aspirin for Primary Prevention | Pentucket Medical Associates

Aspirin for Primary Prevention | Pentucket Medical Associates | Heart and Vascular Health | Scoop.it
Aspirin is used to prevent cardiac events like heart attack & stroke. Cardiologist Seth Bilazarian, MD explains aspirin use for primary & secondary prevention.
Seth Bilazarian, MD's insight:

The FDA no longer recommends aspirin for primary prevention

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Angioplasty Performed Without Pre-Procedural Aspirin

Angioplasty Performed Without Pre-Procedural Aspirin | Heart and Vascular Health | Scoop.it

Aspirin is an essential medicine before and after angioplasty or percutaneous coronary intervention (PCI). Previous studies suggest that pre-procedural aspirin is not administered to a clinically significant number of patients undergoing PCI. 

The study population comprised 65,175 patients, of whom 4,640 (7.1%) did not receive aspirin within 24 h before undergoing PCI. Aspirin nonreceivers were more likely to have had previous gastrointestinal bleeding or to present with cardiogenic shock or after cardiac arrest. Absence of aspirin before PCI was associated with a higher rate of death (3.9% vs. 2.8%; p < 0.001) and stroke (0.5% vs. 0.1%;  with no difference in need for transfusions. This association was consistent across multiple pre-specified subgroups.

Conclusions  Lack of aspirin before PCI was associated with significantly increased in-hospital mortality and stroke. Our study results support the need for quality efforts focused on optimizing aspirin use before PCI.

Seth Bilazarian, MD's insight:

The inexpensive, readily available medicine, aspirin before PCI reduces death and stroke significantly.  The 1.1% absolute risk reduction means that for every 91 people who are taking aspirin before angioplasty or PCI, one life will be saved.  This quality metric has become part of the pre-procedure assessment for patients it's so important

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Association of Aspirin With Major Bleeding

Association of Aspirin  With Major Bleeding | Heart and Vascular Health | Scoop.it

KEY TAKE AWAY: This trial looked at PRIMARY prevention.  The use of a drug to prevent a first event such as heart attack.  This study has no bearing on SECONDARY prevention.  Drug use to prevent a second event (after a heart attack).  The net benefit of aspirin for secondary prevention would substantially exceed the bleeding risk. =>  DON'T STOP if you are in this group.

There is a debate about aspirin in primary prevention.  Is the bleeding too high compared with reduced heart attack benefit?  Because risk factors for bleeding overlap with cardiovascular risk  factors, "guidelines advocating the routine use of aspirin for primary prevention for individuals above moderate risk of coronary heart disease should be carefully considered as this approach may not be advisable for all patients."

In this study18.5% of patients were younger than 50 - a low risk group.  The annual aspirin bleeding rate is about 0.6%.

I will continue to recommend aspirin for high risk men with multiple coronary risk factors including diabetes after age 50, who do not have a history of GI bleeding, consistent with guidelines from AHA and ADA.

 

The editorial by Jolanta M. Siller-Matula, MD, PhD accompanying the paper does a great job reviewing these issues.

http://goo.gl/82iPr ;

 

From the JAMA article:

The benefit of aspirin for primary prevention of cardiovascular events is relatively small for individuals with and without diabetes. This benefit could easily be offset by the risk of hemorrhage.

In 186,425 individuals treated with low-dose aspirin and matched controls without aspirin.  During 5.7 years follow-up, the bleeding rate was 5.58 for aspirin users and 3.60 (per 1000 person-years) for those without aspirin.  Aspirin was associated with a greater risk of major bleeding.  In a population-based cohort, aspirin use was significantly associated with an increased risk of major gastrointestinal or cerebral bleeding episodes. Patients with diabetes had a high rate of bleeding that was not independently associated with aspirin use.

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Dental Surgery and Antiplatelet Agents: Bleed or Die

Dental Surgery and Antiplatelet Agents: Bleed or Die | Heart and Vascular Health | Scoop.it

In patients taking antiplatelet medications who are undergoing dental surgery, physicians and dentists must weigh the bleeding risks in continuing antiplatelet medications versus the thrombotic risks in interrupting antiplatelet medications. Bleeding complications requiring more than local measures for hemostasis are rare after dental surgery in patients taking antiplatelet medications. Conversely, the risk for thrombotic complications after interruption of antiplatelet therapy for dental procedures apparently is significant, although small. When a clinician is faced with a decision to continue or interrupt antiplatelet therapy for a dental surgical patient, the decision comes down to “bleed or die.” That is, there is a remote chance that continuing antiplatelet therapy will result in a (nonfatal) bleeding problem requiring more than local measures for hemostasis versus a small but significant chance that interrupting antiplatelet therapy will result in a (possibly fatal) thromboembolic complication. The decision is simple: It is time to stop interrupting antiplatelet therapy for dental surgery.

Seth Bilazarian, MD's insight:

From the paper's conclusion:

When a clinician is faced with a decision to continue or interrupt antiplatelet therapy for a dental surgical patient, the decision comes down to “bleed or die.” That is, there is a remote (∼0.2%) chance that continuing antiplatelet therapy will result in a (nonfatal) bleeding problem requiring more than local measures for hemostasis versus an unknown but significant chance that interrupting antiplatelet therapy will result in a (possibly fatal) thromboembolic complication. The decision is fairly simple: It is time to stop interrupting antiplatelet therapy for dental surger

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Gene Signature Predicts Aspirin Resistance

Gene Signature Predicts Aspirin Resistance | Heart and Vascular Health | Scoop.it

About 60 million Americans take an aspirin a day to reduce the risk of strokes and heart attacks. But for 10 to 30% of those who follow this recommendation, this preventive therapy turns out not to offer any protection.

An NIH-funded team, based at Duke University Medical Center, has discovered a set of blood markers that predict who will benefit from aspirin therapy and who will not 

Aspirin reduces the risk of stroke and heart attack by changing the properties of platelets, which are sticky, gelatinous disc-shaped fragments of cells that help repair damaged blood vessels. The correct balance of platelets is important for good health. Too little platelet activity increases the risk of bleeding; too much boosts the risk of blood clots that can cause strokes and heart attacks. Low doses of aspirin make the platelets less sticky and thus less likely to form clots. This has been a mainstay of reducing heart attacks 

The scientists discovered an “aspirin response signature”—an activity profile of 60 genes—that revealed whose platelets didn’t respond to aspirin (that is, their platelets were still sticky). Interestingly, many of the genes that turned up in the signature were expressed in platelets, rather than in other blood cells. The diagnostic signature predicting aspirin resistance was also associated with deaths from stroke or heart attack.

People who don’t respond to aspirin may need a different dose of the drug or perhaps a different antiplatelet drug entirely—there are quite a few options out there. It’s another example of how studying gene activity can lead to personalized medicine.

Seth Bilazarian, MD's insight:

For practicing cardiologists and their patients identifying the non-responders to aspirin would be a huge advantage to reducing risks.  The alternative option would likely be plavix which is generically available as clopidogrel and is becoming much less expensive.

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Dr. KGM BIYABANI's comment, August 3, 2013 12:26 AM
Thank you for the insight...
shelbylaneMD's curator insight, August 18, 2013 11:51 AM

Great info for deciiding how to manage health care and prescribing practices.  Now, just to get docs to do this is the challenge..