Don’t use aspirin for primary prevention of cardiovascular disease
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1805 (Published 21 April 2010) Cite this as: BMJ 2010;340:c1805
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We read with interest the manuscript written by Barnett and
colleagues estimating the use of aspirin therapy for primary prevention
(1).
Although aspirin has been shown consistently to be effective in preventing
fatal and non-fatal cardiovascular diseases (CVD), the absolute benefits
of anti platelets therapy are somewhat heterogeneous in different clinical
settings. Consistent evidence showed that aspirin use increases the risk
of gastro intestinal bleeding events. Nevertheless, the decision to use or
not a certain medication for cardiovascular prevention depends on the
initial risk for cardiovascular disease (CVD) in that person. A low
absolute risk and the absence of other factors such as hypertension,
diabetes, and poor physical fitness, we recommend against the use of
aspirin. The decisions about aspirin therapy for primary prevention should
consider the overall risk for CVD. Unfortunately risk score for major
bleeding from aspirin use is not yet available.
The estimation of total cardiovascular risk is useful in individuals at
increased risk both for patient education and for deciding when to
initiate preventative strategies such as aspirin and statins.
Providing a risk score for the CVD should promote a discussion about
behavioral change and medical therapy that decrease the likely-hood of
disease progression. Appropriate intervention, guided by risk assessment,
has the potential to bring about a significant reduction in population
levels of long-term risk. Potential risk reduction strategies for
cardiovascular risk in asymptomatic patients include aggressive lifestyle
change, blood-pressure-lowering agents, cholesterol-lowering drug, and
aspirin.
We agree with Barnett and colleagues observation that all patients
currently taking aspirin for primary prevention must be evaluated
individually to reconsider whether such treatment is justified, but we
suggest that in the case of deciding whether to start aspirin therapy and
evaluation of benefit versus risk, global risk scores should be used (2).
The dosages used in the primary prevention trials ranged from 75 mg/d to
500-mg/d (3). In many patients a daily dose of 75 mg seems effective.
References
1.Barnett H, Burnill P, Iheanacho I. Don’t use aspirin for primary
prevention of cardiovascular disease. BMJ 2010; 340: c1805
2.Berger JS, Jordan CO, Lloyd-Jones D, Blumenthal RS. Screening for
cardiovascular risk in asymptomatic patients. J Am Coll Cardiol 2010;
55:1169-77
3.Wolff T, Miller T, Ko S. Aspirin for the primary prevention of
cardiovascular events: an update of the evidence for the U.S. preventive
services task force. Ann Intern. Med. 2009; 150:405-410
Competing interests:
None declared
Competing interests: No competing interests
Use and misuse of aspirin in the hypertension clinic
Editor,
We read the recent paper by Barnett, Burrill, and Iheanacho, with a
great
interest (1). In the much-publicised “HOT” studying patients with
hypertension, although aspirin use significantly (p=0·002) reduced acute
myocardial infarction, the benefit became non-significant when all
myocardial infarctions, including silent, were considered (2). Of
particular
interest to us are the “barriers to change”, which the authors perceive to
be
responsible for wide spread use of aspirin in primary prevention.
The British Hypertension Society (BHS) has published guidelines and
recently
reaffirmed its advise regarding the use of aspirin in patients with
hypertension (3-4). However, we notice that in many patients attending our
hypertension clinic, aspirin was being prescribed or withheld
inappropriately.
We therefore conducted a survey of 734 patients to investigate the use or
misuse of aspirin (defined as per the BHS guidelines) in our clinic in
2005.
The patients were divided in four groups, ie. taking aspirin which is not
indicated (no target organ damage & 10-year cardiovascular risk below
20%
or blood pressure not controlled), on aspirin and should be been taking
aspirin (target organ damage or 10-year cardiovascular risk above 20% and
blood pressure controlled), not on aspirin and shouldn’t be on aspirin (no
target organ damage & 10-year cardiovascular risk below 20% or blood
pressure not controlled), and lastly not taking aspirin although should
have
been prescribed (target organ damage or 10-year cardiovascular risk above
20% and blood pressure controlled). Although most of patients were
correctly
either taking or not taking aspirin, we found that 78 (10%) patients were
taking aspirin despite no clear-cut indication and 107 (16%) patients were
not
prescribed aspirin although they did meet the BHS criteria (Figure). We
feel
that in the absence of clear-cut guidelines from national and
international
bodies (possibly due to lack of randomised, placebo controlled adequately
sized trials) both general practitioners as well as hospital doctors
remain
unsure when it comes to aspirin prescription or stoppage.
References
1. Barnett H, Burrill P, Iheanacho I.Don't use aspirin for primary
prevention
of cardiovascular disease. BMJ 2010;340:c1805
2. Hansson L, Zanchetti A, Carruthers SG, Dahlöf B, Elmfeldt D, Julius S,
et
al. Effects of intensive blood-pressure lowering and low-dose aspirin in
patients with hypertension: principal results of the Hypertension Optimal
Treatment (HOT) randomised trial. HOT Study Group. Lancet 1998;351:1755-
62
3. Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JP, et
al.
The BHS guidelines working party. British Hypertension Society guidelines
for
hypertension management, 2004 - BHS IV: Summary. BMJ 2004;328:634-640
4. Sever PS, BHS working party. Aspirin and primary prevention: BHS
reaffirms its guidance. BMJ 2010;340:c1183
Competing interests:
None declared
Competing interests: No competing interests