Aspirin for the prevention of cardiovascular events in patients without clinical cardiovascular disease: a meta-analysis of randomized trials

Computed tomography and coronary artery calcium score for screening of coronary artery disease and cardiovascular risk management in asymptomatic individuals

Several risk prediction models exist to predict atherosclerotic cardiovascular disease in asymptomatic individuals, but systematic reviews have generally found these models to be of limited utility. The coronary artery calcium score (CACS) offers an improvement in risk prediction, yet its role remains contentious. Notably, its negative predictive value has a high ability to rule out clinically relevant atherosclerotic cardiovascular disease. Nonetheless, CACS 0 does not permanently reclassify to a lower cardiovascular risk and periodic reassessment every 5 to 10 years remains necessary. Conversely, elevated CACS (> 100 or > 75th percentile adjusted for age, sex and ethnicity) can reclassify intermediate-risk individuals to a high risk, benefiting from preventive medication. The forthcoming update to the Dutch cardiovascular risk management guideline intends to re-position CACS for cardiovascular risk assessment as such in asymptomatic individuals. Beyond CACS as a single number, several guidelines recommend coronary CT angiography (CCTA), which provides additional information about luminal stenosis and (high-risk) plaque composition, as the first choice of test in symptomatic patients and high-risk patients. Ongoing randomised studies will have to determine the value of atherosclerosis evaluation with CCTA for primary prevention in asymptomatic individuals.

Interventions for primary prevention of cardiovascular disease: umbrella review of systematic reviews

Background

Cardiovascular diseases are the leading cause of death globally. The aim of this overview of systematic reviews was to compare the effectiveness of different pharmacological and non-pharmacological interventions for the primary prevention of cardiovascular disease.

Methods

A structured search of the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE and the Database of Abstracts of Reviews of Effects archive was conducted to find systematic reviews that reported the effect of various pharmacological and non-pharmacological interventions for the primary prevention of cardiovascular disease from inception to March 2021. References of included studies were also checked. The included systematic reviews' methodological quality was assessed using the Assessment of Multiple Systematic Reviews 2 instrument (range, 0-16). The outcomes of each included review's meta-analysis were extracted and described narratively.

Results

This study analysed 95 systematic reviews, including 41 on non-pharmacological interventions and 54 on pharmacological interventions for cardiovascular health. The majority of the reviews focused on lipid-lowering interventions (n = 25) and antiplatelet medications (n = 21), followed by nutritional supplements, dietary interventions, physical activity, health promotion and other interventions. Only 1 of the 10 reviews addressing cardiovascular mortality showed a potential benefit, while the others found no effect. Antiplatelets were found to have a beneficial effect on all-cause mortality in 2 out of 12 meta-analyses and on major cardiovascular disease events in 8 out of 17 reviews. Lipid-lowering interventions showed beneficial effects on cardiovascular disease mortality, all-cause mortality and major cardiovascular disease events in varying numbers of the reviews. Glucose-lowering medications demonstrated significant benefits for major cardiovascular events, coronary heart disease events and mortality. However, the combination of dietary interventions, physical activities, nutritional supplements and polypills showed little or no significant benefit for major cardiovascular outcomes or mortality.

Future work and limitations

More research is needed to determine whether the effect of treatment varies depending on population characteristics. The findings of this review should be interpreted with caution because the majority of studies of non-pharmacological interventions compare primary prevention with usual care, which may include recommended pharmacological treatment in higher-risk patients (e.g. statins and/or antihypertensive medications, etc.). In addition, randomised controlled trial evidence may be better suited to the study of pharmacological interventions than dietary and lifestyle interventions.

Conclusions

This umbrella review captured the variability in different interventions on randomised controlled trial evidence on interventions for primary prevention of cardiovascular disease and identified areas that may benefit from further research. Specifically, this review focused on randomised controlled trial evidence on interventions for primary prevention of cardiovascular disease. Researchers may use these findings as a resource to direct new intervention studies and network meta-analyses to compare the efficacy of various interventions based on these findings.

Funding

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment (HTA) programme as award number 17/148/05.

Premature atherosclerosis: An analysis over 39 years in the Netherlands. Implications for young individuals in high-risk families

Cardiovascular disease (CVD), especially atherosclerotic cardiovascular disease (ASCVD), is one of the most important disease problems in the world accounting for an estimated 18.6 million deaths globally. Although older individuals are more often affected, ASCVD event at a young age is of particular importance because of more healthy years lost. Therefore, it is important to identify young individuals correctly at risk of ASCVD events in an early stage. Unfortunately, current risk score algorithms underestimate ASCVD event risk at a younger age. Both coronary artery calcium scoring (CACs) and family history of premature ASCVD (FH-PASCVD) have emerged as reliable screening tools to be able to identify individuals at risk for ASCVD events. Positive FH-PASCVD is associated with higher absolute CAC scores in first-degree 'healthy' family members and the proportion of individuals above the CACs percentile threshold to warrant treatment is also higher as compared to the general population. Therefore, a positive FH-PASCVD identifies so-called high-risk families and adding CAC scoring within these families identifies individuals at increased risk for ASCVD events. In individuals from high-risk families with an elevated CAC score, ASCVD events can be prevented when treated with statins and aspirin. Therefore, we suggest assessing FH-PASCVD in young 'healthy' individuals as a first screening step and subsequently performing CAC scoring to be able to start treatment at an early stage, since not only the lower is better, but also the earlier is better.

Peripheral Artery Disease: Overview of Diagnosis and Medical Therapy

Peripheral artery disease (PAD) affects approximately 230 million people worldwide and is associated with an increased risk of major adverse cardiovascular and limb events. Even though this condition is considered a cardiovascular equivalent, it remains an underrecognized and undertreated entity. Antiplatelet and statin therapy, along with smoking cessation, are the foundations of therapy to reduce adverse events but are challenging to fully implement in this patient population. Race and socioeconomic status also have profound impacts on PAD outcomes.

Pre-aspirin use has no benefit on the neurological disability and mortality after cardiovascular events: A nation-wide population-based cohort study

To evaluate the effects of aspirin in the primary prevention, we evaluated disability grades and mortality after ischemic/hemorrhagic stroke and myocardial infarction (MI). A retrospective nation-wide propensity score-matched cohort study was performed using the Korean National Health Information Database. From 3,060,639 subjects who were older than 55 and performed national health examinations in 2004 and 2005, we selected the aspirin group (N = 8770) was composed of patients who had received aspirin prior to cardiovascular events. Cox proportional hazards model was used to compare the acquisition times for neurologic disability grades and survival times between the aspirin and control groups. Only in hemorrhagic stroke, the severe neurologic disability risk was higher in the aspirin group (hazard ratio [HR], 1.21; 95% confidence interval [CI], 1.02-1.42). The aspirin group was associated with higher 90-day (HR, 1.33; 95% CI, 1.23-1.44) and long-term mortality risk (HR, 1.06; 95% CI, 1.03-1.10) after pooling 3 events. The old age was a strong risk factor for 90-day mortality in hemorrhagic stroke (50s: reference; 60s: HR 2.21, 95% CI 1.50-3.25; 70s: HR 3.63, 95% CI 2.48-5.30; 80s: HR 6.69, 95% CI 4.54-9.65; >90s: HR 11.28, 95% CI 6.46-19.70). Pre-aspirin use in cardiovascular events has detrimental effects on severe neurological disability in hemorrhagic stroke and short-/long-term mortality in 3 cardiovascular events. The use of aspirin for the primary prevention especially in the elderly should be very cautious because the old age is a strong risk factor for 90-day mortality after hemorrhagic stroke.

Ethnic and Regional Differences in the Management of Angina: The Way Forward

For decades, there has been great interest in ethnic differences in the management of angina and stable cardiovascular disease. Clinical decisionmaking is known to be both consciously and unconsciously influenced by a patient's demographics, and this is due to in part to differences in clinical guidance and opinion. However, the evidence supporting such decision-making is sparse. Nonetheless, there is overwhelming evidence that international, national, regional, institutional, departmental and individual bias disproportionately affect subgroups of the population, resulting in adverse patient outcomes. While without doubt there will be rapid advancements in individualised therapies over the coming years and decades, the most beneficial immediate action clinicians can take is to reduce disparities in both the evidence base and care provision. Doing so will require great collaborative effort.

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.

De-risking primary prevention: role of imaging

Atherosclerotic cardiovascular disease (ASCVD) is a common disease among the general population, and includes four major areas: (1) coronary heart disease (CHD), manifested by stable angina, unstable angina, myocardial infarction (MI), heart failure, and coronary death; (2) cerebrovascular disease, manifested by transient ischemia attack and stroke; (3) peripheral vascular disease, manifested by claudication and critical limb ischemia; and (4) aortic atherosclerosis and aortic aneurysm (thoracic and abdominal). CHD remains the leading cause of death for both men and women in the United States. So, it is imperative to identify people at risk of CHD and provide appropriate medical treatment or intervention to prevent serious complications and outcomes including sudden cardiac death. Coronary artery calcification (CAC) is a marker of subclinical coronary artery disease. Therefore, coronary artery calcium score is an important screening method for Coronary artery disease (CAD). In this article, we performed a comprehensive review of current literatures and studies assessing the prognostic value of CAC for future cardiovascular disease (CVD) events. We searched PubMed, MEDLINE, Google Scholar, and Cochrane library. We also reviewed the 2018 American College of Cardiology (ACC)/American Heart Association (AHA) guideline on the assessment of CVD risk. A CAC score of zero corresponds to very low CVD event rates (∼1% per year) and hence a potent negative risk marker. This has been referred to as the ‘power of zero’ and affords the lowest risk of any method of risk calculation. It is now indicated in the 2018 ACC/AHA Cholesterol guidelines to be used to avoid statins for 5–10 years after a score of zero, and then re-assess the patient.

Clinical Applications of Aspirin as a Multi-potent Drug Beyond Cardiovascular Implications: A Proof of Concept for Anesthesiologists- A Narrative Review

To the best of our knowledge, aspirin (ASA) is known as a commonly used medication worldwide. Although the cardiovascular aspects of ASA are well-established, recently, it has been identified that ASA can yield multiple extra-cardiovascular therapeutic potencies in facing neurodegenerative disorders, various cancers, inflammatory responses, and the COVID-19 pandemic. In this review, we aimed to highlight the proven role of ASA administration in the variety of non-cardiovascular diseases, particularly in the field of anesthesiology.

Low-dose rivaroxaban plus aspirin in older patients with peripheral artery disease undergoing acute limb revascularization: insights from the VOYAGER PAD trial

AIMS

In this secondary analysis of the VOYAGER trial, rivaroxaban 2.5 mg twice/day plus aspirin 100 mg/day was assessed in older adults. Advanced age is associated with elevated bleeding risk and unfavourable net benefit for dual antiplatelet therapy in chronic coronary artery disease. The risk-benefit of low-dose rivaroxaban in patients ≥75 years with peripheral artery disease (PAD) after lower extremity revascularization (LER) has not been described.

METHODS AND RESULTS

The primary endpoint was a composite of acute limb ischaemia, major amputation, myocardial infarction, ischaemic stroke, or cardiovascular death. The principal safety outcome was thrombolysis in myocardial infarction (TIMI) major bleeding analysed by the pre-specified age cut-off of 75 years. Of 6564 patients randomized, 1330 (20%) were >75 years. Absolute 3-year Kaplan-Meier cumulative incidence rates for primary efficacy (23.4% vs. 19.0%) and safety (3.5% vs. 1.5%) endpoints were higher in elderly vs. non-elderly patients. Efficacy of rivaroxaban (P-interaction 0.83) and safety (P-interaction 0.38) was consistent irrespective of age. The combination of intracranial and fatal bleeding was not increased in patients >75 years (2 rivaroxaban vs. 8 placebo). Overall, benefits (absolute risk reduction 3.8%, number needed to treat 26 for the primary endpoint) exceeded risks (absolute risk increase 0.81%, number needed to harm 123 for TIMI major bleeding).

CONCLUSION

Patients ≥75 years with PAD are at both heightened ischaemic and bleeding risk after LER. No excess harm with respect to major, intracranial or fatal bleeding was seen in older patients yet numerically greater absolute benefits were observed. This suggests that low-dose rivaroxaban combined with aspirin should be considered in PAD after LER regardless of age.

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.

Contemporary Medical Management of Peripheral Artery Disease

Peripheral artery disease (PAD) is a manifestation of systemic atherosclerosis. Modifiable risk factors including cigarette smoking, dyslipidemia, diabetes, poor diet quality, obesity, and physical inactivity, along with underlying genetic factors contribute to lower extremity atherosclerosis. Patients with PAD often have coexistent coronary or cerebrovascular disease, and increased likelihood of major adverse cardiovascular events, including myocardial infarction, stroke and cardiovascular death. Patients with PAD often have reduced walking capacity and are at risk of acute and chronic critical limb ischemia leading to major adverse limb events, such as peripheral revascularization or amputation. The presence of polyvascular disease identifies the highest risk patient group for major adverse cardiovascular events, and patients with prior critical limb ischemia, prior lower extremity revascularization, or amputation have a heightened risk of major adverse limb events. Medical therapies have demonstrated efficacy in reducing the risk of major adverse cardiovascular events and major adverse limb events, and improving function in patients with PAD by modulating key disease determining pathways including inflammation, vascular dysfunction, and metabolic disturbances. Treatment with guideline-recommended therapies, including smoking cessation, lipid lowering drugs, optimal glucose control, and antithrombotic medications lowers the incidence of major adverse cardiovascular events and major adverse limb events. Exercise training and cilostazol improve walking capacity. The heterogeneity of risk profile in patients with PAD supports a personalized approach, with consideration of treatment intensification in those at high risk of adverse events. This review highlights the medical therapies currently available to improve outcomes in patients with PAD.

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.

Atherosclerosis: Conventional intake of cardiovascular drugs versus delivery using nanotechnology - A new chance for causative therapy?

Atherosclerosis is the leading cause of death in developed countries. The pathogenetic mechanism relies on a macrophage-based immune reaction to low density lipoprotein (LDL) deposition in blood vessels with dysfunctional endothelia. Thus, atherosclerosis is defined as a chronic inflammatory disease. A plethora of cardiovascular drugs have been developed and are on the market, but the major shortcoming of standard medications is that they do not address the root cause of the disease. Statins and thiazolidinediones that have recently been recognized to exert specific anti-atherosclerotic effects represent a potential breakthrough on the horizon. But their whole potential cannot be realized due to insufficient availability at the pathological site and severe off-target effects. The focus of this review will be to elaborate how both groups of drugs could immensely profit from nanoparticulate carriers. This delivery principle would allow for their accumulation in target macrophages and endothelial cells of the atherosclerotic plaque, increasing bioavailability where it is needed most. Based on the analyzed literature we conclude design criteria for the delivery of statins and thiazolidinediones with nanoparticles for anti-atherosclerotic therapy. Nanoparticles need to be below a diameter of 100 nm to accumulate in the atherosclerotic plaque and should be fabricated using biodegradable materials. Further, the thiazolidinediones or statins must be encapsulated into the particle core, because especially for thiazolidindiones the uptake into cells is prerequisite for their mechanism of action. For optimal uptake into targeted macrophages and endothelial cells, the ideal particle should present ligands on its surface which bind specifically to scavenger receptors. The impact of statins on the lectin-type oxidized LDL receptor 1 (LOX1) seems particularly promising because of its outstanding role in the inflammatory process. Using this pioneering concept, it will be possible to promote the impact of statins and thiazolidinediones on macrophages and endothelial cells and significantly enhance their anti-atherosclerotic therapeutic potential.

A Pathophysiologic Primary Prevention Review of Aspirin Administration to Prevent Cardiovascular Thrombosis

OBJECTIVE

Cardiovascular disease is the leading metabolic cause of mortality in the United States. Among current therapies, low-dose aspirin has been shown to reduce cardiovascular thrombosis. However, aspirin also causes major complications (hemorrhagic stroke and gastrointestinal bleeding). The American Heart Association recommends that aspirin only be prescribed for "high-risk" individuals. No guidelines are available as to the duration of aspirin therapy.

METHODS

A reasonable approach to aspirin administration is to determine the appropriateness of aspirin therapy based on the pathophysiology of coronary artery thrombosis. It suggests that the coronary artery calcium (CAC) score be used as the basis for determining "high risk." This score was shown to accurately predict future cardiovascular events. The greater the CAC score, the greater the extent of coronary artery atherosclerotic plaque and future cardiovascular risk.

RESULTS

A CAC score >400 places an individual at very-high 10-year risk for an atherosclerotic event. Since aggressive medical therapy initiates stabilization of unstable atherosclerotic plaques within 1 month and reversal within 2 years, this treatment significantly reduces the risk of the individual for a cardiovascular event. Thus, most individuals aged <75 years with a CAC score of >400 should receive aspirin therapy for a maximum of 2 years.

CONCLUSION

Utilization of a CAC score greatly simplifies the decision of whom to treat with aspirin and for what duration. Importantly, focusing on two factors (hemorrhage and plaque stabilization) is easily understood by both the physician and the patient.

ABBREVIATIONS

CAC = coronary artery calcium; CVD = cardiovascular disease; LDL = low-density lipoprotein; OCT = optical coherence tomography.

Predictors of hemorrhagic stroke in older persons taking nonsteroidal anti-inflammatory drugs: Results from the Food and Drug Administration Adverse Event Reporting System

BACKGROUND

Hemorrhagic strokes have not declined in the United States despite a decline worldwide.

PURPOSE

To identify hemorrhagic stroke risk associated with nonsteroidal anti-inflammatory drugs (NSAIDs), other medications associated with increased risk for hemorrhagic stroke, and diabetes, cardiovascular disease, gender, and age.

METHODS

A post hoc design was used to examine predictors of hemorrhagic stroke for adults of age 65 years and older from the Food and Drug Administration Adverse Events Reporting System database. The initial sample consisted of all cases reported during the third quarter of 2016 and the second quarter of 2018 with an NSAID as the primary suspect for the adverse drug event (ADE). An additional 397 cases with warfarin as the primary suspect were included in the final sample (N = 3,784) to test for bias from including only NSAID as the primary ADE suspect cases. Extracted data included the primary ADE (hemorrhagic stroke or other ADE), age, gender, primary suspect drug (NSAID or warfarin), and presence of a second NSAID, rivaroxaban, warfarin, clopidogrel, antidepressants (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants), inhaled corticosteroids, diabetes, or cardiovascular medications. Logistic regression was used to predict hemorrhagic stroke.

RESULTS

Aspirin and warfarin increased the risk for hemorrhagic stroke by 3.458 and 3.059, respectively. Presence of an additional NSAIDs reduced the risk by 48%.

IMPLICATIONS FOR PRACTICE

Hemorrhagic stroke risk specific to older adults may provide helpful estimates for practitioners as they weigh the risk benefit of prescribing aspirin as an antiplatelet therapy for older adults.

Targeted anti-inflammatory therapy is a new insight for reducing cardiovascular events: A review from physiology to the clinic

Despite considerable progressions, cardiovascular disease (CVD) is still one of the major causes of mortality around the world, indicates an important and unmet clinical need. Recently, extensive studies have been performed on the role of inflammatory factors as either a major or surrogate factor in the pathophysiology of CVD. Epidemiological observations suggest the theory of the role of inflammatory mediators in the development of cardiovascular events. This may support the idea that targeted anti-inflammatory therapies, on the background of traditional validated medical therapies, can play a significant role in prevention and even reduction of cardiovascular disorders. Many randomized controlled trials have shown that drugs commonly useful for primary and secondary prevention of CVD have an anti-inflammatory mechanism. Further, many anti-inflammatory drugs are being examined because of their potential to reduce the risk of cardiovascular problems. In this study, we review the process of inflammation in the development of cardiovascular events, both in vivo and clinical evidence in immunotherapy for CVD.

Aspirin for Primary Prevention of Coronary Artery Disease

Primary prevention of coronary artery disease (CAD) is an important means to reduce the burden of the disease. Aspirin has been widely prescribed over the last several decades as part of primary CAD prevention strategy. However, 3 recent hallmark trials - ARRIVE, ASCEND and ASPREE have raised serious questions about this common practice. Although, aspirin reduced incidence of non-fatal MI and stroke in these recent studies, bleeding risk was higher. In the present era, where regular exercise, healthy diet, smoking cessation, and statins are used to manage the risk factors of CAD, additional prescription of aspirin seems more harmful than beneficial. The guidelines of major societies such as European Society of Cardiology (ESC), American College of Cardiology (ACC), and American Heart Association (AHA) also reflect this shift. In this article, the authors aim to highlight the current evidence on aspirin use for primary prevention of CAD, in the context of evolving contrasting clinical trial data from the last 2 decades. We also highlight the pertinent sections of the most recent clinical guidelines of European Society of Cardiology, American College of Cardiology, and American Heart Association in this article.

Aspirin for primary prevention of cardiovascular disease: a meta-analysis with a particular focus on subgroups

BACKGROUND

The role of aspirin in primary prevention of cardiovascular disease (CVD) remains unclear. We aimed to investigate the benefit-risk ratio of aspirin for primary prevention of CVD with a particular focus on subgroups.

METHODS

Randomized controlled trials comparing the effects of aspirin for primary prevention of CVD versus control and including at least 1000 patients were eligible for this meta-analysis. The primary efficacy outcome was all-cause mortality. Secondary outcomes included cardiovascular mortality, major adverse cardiovascular events (MACE), myocardial infarction, ischemic stroke, and net clinical benefit. The primary safety outcome was major bleeding. Subgroup analyses involving sex, concomitant statin treatment, diabetes, and smoking were performed.

RESULTS

Thirteen randomized controlled trials comprising 164,225 patients were included. The risk of all-cause and cardiovascular mortality was similar for aspirin and control groups (RR 0.98; 95% CI, 0.93-1.02; RR 0.99; 95% CI, 0.90-1.08; respectively). Aspirin reduced the relative risk (RRR) of major adverse cardiovascular events (MACE) by 9% (RR 0.91; 95% CI, 0.86-0.95), myocardial infarction by 14% (RR 0.86; 95% CI, 0.77-0.95), and ischemic stroke by 10% (RR 0.90; 95% CI, 0.82-0.99), but was associated with a 46% relative risk increase of major bleeding events (RR 1.46; 95% CI, 1.30-1.64) compared with controls. Aspirin use did not translate into a net clinical benefit adjusted for event-associated mortality risk (mean 0.034%; 95% CI, - 0.18 to 0.25%). There was an interaction for aspirin effect in three patient subgroups: (i) in patients under statin treatment, aspirin was associated with a 12% RRR of MACE (RR 0.88; 95% CI, 0.80-0.96), and this effect was lacking in the no-statin group; (ii) in non-smokers, aspirin was associated with a 10% RRR of MACE (RR 0.90; 95% CI, 0.82-0.99), and this effect was not present in smokers; and (iii) in males, aspirin use resulted in a 11% RRR of MACE (RR 0.89; 95% CI, 0.83-0.95), with a non-significant effect in females.

CONCLUSIONS

Aspirin use does not reduce all-cause or cardiovascular mortality and results in an insufficient benefit-risk ratio for CVD primary prevention. Non-smokers, patients treated with statins, and males had the greatest risk reduction of MACE across subgroups.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019118474.

Update of Antiplatelet Therapy in Patients Without Known Cardiovascular Disease

Platelet activation and aggregation play a critical role in thrombosis, a fundamental pathophysiologic event responsible for the acute clinical manifestations of atherothrombotic events such as acute coronary syndrome, myocardial infarction, ischemic stroke/transient ischemic attack and peripheral artery disease. Dual antiplatelet therapy (low-dose aspirin plus ADP-P2Y12 receptor blockers) has become the cornerstone of therapy for the management of acute and chronic coronary artery disease and the prevention of ischemic complications associated with percutaneous coronary intervention. However, dual antiplatelet therapy in primary prevention of cardiovascular disease in patients without known cardiovascular disease did not significantly reduce the risk of cardiovascular events, such as myocardial infarction, stroke or death, but significantly increased the rate of bleeding. Furthermore, despite multiple randomized controlled trials evaluating the efficacy and safety of aspirin use in patients without known cardiovascular disease, its role in primary prevention is still unclear, especially in patients with a higher risk of cardiovascular disease (non-diabetic individuals with >2 risk factors for coronary artery disease, elderly >60 years with additional risk factors, and patients with diabetes). Currently, there are four ongoing randomized controlled trials aiming to fill the missing gap in the efficacy and safety of aspirin therapy for primary prevention in these patients. The current European and United States Guidelines agree that primary prevention of cardiovascular disease is essential, but there are some substantial differences in risk estimation and treatment strategies among patients without known cardiovascular disease. This short review is focused on these differences and practical treatment approach to these patients based on present European and United States recommendations.

Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly

BACKGROUND

Aspirin is a well-established therapy for the secondary prevention of cardiovascular events. However, its role in the primary prevention of cardiovascular disease is unclear, especially in older persons, who have an increased risk.

METHODS

From 2010 through 2014, we enrolled community-dwelling men and women in Australia and the United States who were 70 years of age or older (or ≥65 years of age among blacks and Hispanics in the United States) and did not have cardiovascular disease, dementia, or disability. Participants were randomly assigned to receive 100 mg of enteric-coated aspirin or placebo. The primary end point was a composite of death, dementia, or persistent physical disability; results for this end point are reported in another article in the Journal. Secondary end points included major hemorrhage and cardiovascular disease (defined as fatal coronary heart disease, nonfatal myocardial infarction, fatal or nonfatal stroke, or hospitalization for heart failure).

RESULTS

Of the 19,114 persons who were enrolled in the trial, 9525 were assigned to receive aspirin and 9589 to receive placebo. After a median of 4.7 years of follow-up, the rate of cardiovascular disease was 10.7 events per 1000 person-years in the aspirin group and 11.3 events per 1000 person-years in the placebo group (hazard ratio, 0.95; 95% confidence interval [CI], 0.83 to 1.08). The rate of major hemorrhage was 8.6 events per 1000 person-years and 6.2 events per 1000 person-years, respectively (hazard ratio, 1.38; 95% CI, 1.18 to 1.62; P<0.001).

CONCLUSIONS

The use of low-dose aspirin as a primary prevention strategy in older adults resulted in a significantly higher risk of major hemorrhage and did not result in a significantly lower risk of cardiovascular disease than placebo. (Funded by the National Institute on Aging and others; ASPREE ClinicalTrials.gov number, NCT01038583 .).

Screening for Peripheral Artery Disease Using the Ankle-Brachial Index: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Peripheral artery disease (PAD) is associated with a high risk for cardiovascular events and poor ambulatory function, even in the absence of symptoms. Screening for PAD with the ankle-brachial index (ABI) may identify patients in need of treatment to improve health outcomes.

OBJECTIVE

To systematically review evidence for the US Preventive Services Task Force on PAD screening with the ABI, the diagnostic accuracy of the test, and the benefits and harms of treatment of screen-detected PAD.

DATA SOURCES

MEDLINE, PubMed, and the Cochrane Central Register of Controlled Trials for relevant English-language studies published between January 2012 and May 2, 2017. Surveillance continued through February 7, 2018.

STUDY SELECTION

Studies of unselected or generally asymptomatic adults with no known cardiovascular disease.

DATA EXTRACTION AND SYNTHESIS

Independent critical appraisal and data abstraction by 2 reviewers.

MAIN OUTCOMES AND MEASURES

Cardiovascular morbidity; PAD morbidity; mortality; health-related quality of life; diagnostic accuracy; and serious adverse events.

RESULTS

Five studies (N = 5864 participants) were included that examined the indirect evidence for the benefits and harms of screening and treatment of screen-detected PAD. No population-based screening trials evaluated the direct benefits or harms of PAD screening with the ABI alone. A single diagnostic accuracy study of the ABI compared with magnetic resonance angiography gold-standard imaging (n = 306) found low sensitivity (7%-34%) and high specificity (96%-100%) in a screening population. Two adequately powered trials (n = 4626) in asymptomatic populations with and without diabetes with a variably defined low ABI (≤0.95 or ≤0.99) showed no statistically significant effect of aspirin (100 mg daily) for composite CVD outcomes (adjusted hazard ratio [HR], 1.00 [95% CI, 0.81-1.23] and HR, 0.98 [95% CI, 0.76-1.26]). One trial (n = 3350) demonstrated no statistically significant increase in major bleeding events with the use of aspirin (adjusted HR, 1.71 [95% CI, 0.99- 2.97]) and no statistically significant increase in major gastrointestinal bleeding (relative risk, 1.13 [95% CI, 0.44-2.91]). Two exercise trials (n = 932) in screen-relevant populations reported no differences in quality of life, Walking Impairment Questionnaire walking distance, or symptoms at 12 and 52 weeks; no harms were reported.

CONCLUSIONS AND RELEVANCE

There was no direct evidence and limited indirect evidence on the benefits of PAD screening with the ABI in unselected or asymptomatic populations. Available studies suggest low sensitivity and lack of beneficial effect on health outcomes, but these studies have important limitations.

Efficacy and Safety of Proton Pump Inhibitors in the Long-Term Aspirin Users: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Long-term aspirin use in cardiovascular disease prevention may result in gastrointestinal bleeding. Although proton pump inhibitors (PPI) have been shown to reduce the risks of peptic ulcers and dyspeptic symptoms in long-term aspirin users in the randomized controlled trials, there are safety concerns about the long-term use of PPI.

STUDY QUESTION

What is the safety and efficacy of PPI in patients using aspirin in long term for prevention of cardiovascular diseases and stroke?

METHODS

We searched MEDLINE, EMBASE, CENTRAL, CINAHL, ProQuest, and relevant references from inception through February 2015, and used random-effects model for meta-analysis.

RESULTS

A total of 10 publications from 9 studies (n = 6382) were included in the meta-analysis. Compared with control, PPI reduced the risks of peptic ulcers [risk ratio (RR): 0.19; 95% confidence interval: 0.13-0.26; P < 0.00001], gastric ulcers [0.24 (0.16-0.35); P < 0.00001], duodenal ulcers [0.12 (0.05-0.29); P < 0.00001], bleeding ulcers [0.22 (0.10-0.51); P = 0.0004], and erosive esophagitis [0.14 (0.07-0.28); P < 0.00001]. PPI increased the resolution of epigastric pain [1.13 (1.03-1.25); P = 0.01], heartburn [1.24 (1.18-1.31); P < 0.00001], and regurgitation [1.26 (1.13-1.40); P < 0.0001], but did not increase the risks of all-cause mortality [1.72 (0.61-4.87); P = 0.31], cardiovascular mortality [1.80 (0.59-5.44); P = 0.30], nonfatal myocardial infarction/ischemia [0.56 (0.22-1.41); P = 0.22], ischemic stroke/transient ischemic attack [1.09 (0.34-3.53); P = 0.89] and other adverse events.

CONCLUSIONS

The PPI seems to be effective in preventing peptic ulcers and erosive esophagitis and in resolution of dyspeptic symptoms without increasing adverse events, cardiac risks or mortality in long-term aspirin users.

Aspirin and incident depressive symptoms: A longitudinal cohort study over 8 years

OBJECTIVE

Aspirin exhibits anti-atherosclerotic and anti-inflammatory properties-two potential risk factors for depression. The relationship between aspirin use and depression, however, remains unclear. We investigated whether the aspirin use is associated with a decreased incidence of depressive symptoms in a large North American cohort.

METHODS

Data from the Osteoarthritis Initiative dataset, a multicenter, longitudinal study on community-dwelling adults was analyzed. Aspirin use was defined through self-report in the past 30 days and confirmed by a trained interviewer. Incident depressive symptoms were defined as a score of ≥16 in the 20-item Center for Epidemiologic Studies-Depression scale.

RESULTS

A total of 137 participants (mean age 65 y, 55.5% female) were using aspirin at baseline. Compared with 4003 participants not taking aspirin, no differences in Center for Epidemiologic Studies-Depression at baseline were evident (P = .65). After a median follow-up time of 8 years, the incidence of depressive symptoms was similar in those taking aspirin at baseline (43; 95% CI, 3-60) and in aspirin nonusers (38; 95% CI, 36-41) per 1000 y; log-rank test = 0.63). Based on Cox's regression analysis adjusted for 11 potential confounders, aspirin use was not significantly associated with the development of depressive symptoms (hazard ratio = 1.12; 95% CI, 0.78-1.62; P = .54). Adjustment for propensity scores or the use of propensity score matching did not alter the results.

CONCLUSION

Our study found that prescription of aspirin offered no significant protection against incident depressive symptoms. Whether aspirin is beneficial in a subgroup of depression with high levels of inflammation remains to be investigated in future studies.

Aspirin for Prevention of Cardiovascular Disease

We used data from the 2013 Mississippi Behavioral Risk Factor Surveillance System to examine aspirin use for the prevention of primary and secondary cardiovascular disease (CVD), based on the 2009 US Preventive Services Task Force (USPSTF) guidelines, among Mississippi men (aged 45–79 y) and women (aged 55–79 y) and to explore differences in aspirin use by sociodemographic characteristics. Among those without CVD, 39.1% of men and 45.9% of women reported taking aspirin, and among those with CVD, 85.9% of men and 85.1% of women reported taking aspirin. Data on preventive use of aspirin by sociodemographic characteristics yielded mixed results.

Antiplatelet treatment in the primary prophylaxis of cardiovascular disease in patients with arterial hypertension

The benefits of using acetylsalicylic acid (ASA) in the primary prophylaxis of cardiovascular diseases may only slightly exceed the risk of serious bleeding. This warrants the search for alternative, safer preparations with antiaggregatory properties, which could be used in patients burdened with cardiovascular risk factors. Antiaggregatory compounds identified in water-soluble tomato extract include nucleosides, flavonoids, and phenolic acids. The action of standardized tomato extract is multidirectional, reversible, and weaker in comparison to ASA. The European Food Safety Authority (EFSA) has approved this preparation as a dietary agent with antiaggregatory properties. The use of standardized tomato extract appears beneficial in arterial hypertension patients with low or moderate cardiovascular risk and in patients in whom good pressure control cannot be achieved.

Drug repurposing in cancer

Cancer is a major health issue worldwide, and the global burden of cancer is expected to increase in the coming years. Whereas the limited success with current therapies has driven huge investments into drug development, the average number of FDA approvals per year has declined since the 1990s. This unmet need for more effective anti-cancer drugs has sparked a growing interest for drug repurposing, i.e. using drugs already approved for other indications to treat cancer. As such, data both from pre-clinical experiments, clinical trials and observational studies have demonstrated anti-tumor efficacy for compounds within a wide range of drug classes other than cancer. Whereas some of them induce cancer cell death or suppress various aspects of cancer cell behavior in established tumors, others may prevent cancer development. Here, we provide an overview of promising candidates for drug repurposing in cancer, as well as studies describing the biological mechanisms underlying their anti-neoplastic effects.

Low-Dose Aspirin Use and Cognitive Function in Older Age: A Systematic Review and Meta-analysis

OBJECTIVES

To investigate whether low-dose aspirin (<300 mg/d) can influence the onset of cognitive impairment or dementia in observational studies and improve cognitive test scores in randomized controlled trials (RCTs) in participants without dementia.

DESIGN

Systematic review and meta-analysis.

SETTING

Observational and interventional studies.

PARTICIPANTS

Individuals with no dementia or cognitive impairment initially.

MEASUREMENTS

Odds ratios (ORs) and 95% confidence intervals (CIs), adjusted for the maximum number of covariates from each study, were used to summarize data on the incidence of dementia and cognitive impairment in observational studies. Standardized mean differences (SMDs) were used for cognitive test scores in RCTs.

RESULTS

Of 2,341 potentially eligible articles, eight studies were included and provided data for 36,196 participants without dementia or cognitive impairment at baseline (mean age 66, 63% female). After adjusting for a median of three potential confounders over a median follow-up period of 6 years, chronic use of low-dose aspirin was not associated with onset of dementia or cognitive impairment (5 studies, N = 26,159; OR = 0.82, 95% CI = 0.55-1.22, P = .33, I² = 67%). In three RCTs (N = 10,037; median follow-up 5 years), the use of low-dose aspirin was not associated with significantly better global cognition (SMD=0.005, 95% CI=-0.04-0.05, P = .84, I² = 0%) in individuals without dementia. Adherence was lower in participants taking aspirin than in controls, and the incidence of adverse events was higher.

CONCLUSION

This review found no evidence that low-dose aspirin buffers against cognitive decline or dementia or improves cognitive test scores in RCTs.

Evaluation of peritoneal endometriosis treatment using intralesional acetylsalicylic acid injection in rabbits

PURPOSE

To investigate the efficacy of intralesional 20% aspirin injection for treatment of experimental peritoneal endometriosis.

METHODS

Peritoneal endometriosis was experimentally induced in forty adult nulligravid female rabbits. On day 30 post-endometriosis induction, rabbits were randomly divided to assess early (10 days) and late (20 days) effects of intralesional injection of physiological saline solution (control groups) in comparison to intralesional injection of 20% bicarbonate aspirin solution (experimental groups) as follows: control group 1 (10 days, n=10); control group 2 (20 days, n=10); experimental group 3 (10 days, n=10); experimental group 4 (20 days, n=10). Resected tissues, including endometriosis foci, were qualitatively (general morphology and signs of inflammatory cells infiltrate, necrosis and apoptosis) and quantitatively (remaining endometriosis area) assessed by histopathological analysis.

RESULTS

Extensive necrosis, hemorrhage, apoptosis, and fibrosis were observed in the experimental groups 3 and 4. Groups 1 and 2 presented typical endometrial tissue cysts, respectively. Groups 3 and 4 showed sparse endometrial tissue foci and no endometrial tissue, respectively. Quantitative analysis revealed that aspirin-treated groups 3 and 4 had significantly (p<0.05) smaller remaining endometriosis area, compared to control groups 1 and 2.

CONCLUSION

Intralesional 20% aspirin injection caused total destruction of peritoneal endometriosis foci in rabbits.

Long-term prognosis in patients continuing taking antithrombotics after peptic ulcer bleeding

AIM

To investigate the long-term prognosis in peptic ulcer patients continuing taking antithrombotics after ulcer bleeding, and to determine the risk factors that influence the prognosis.

METHODS

All clinical data of peptic ulcer patients treated from January 1, 2009 to January 1, 2014 were retrospectively collected and analyzed. Patients were divided into either a continuing group to continue taking antithrombotic drugs after ulcer bleeding or a discontinuing group to discontinue antithrombotic drugs. The primary outcome of follow-up in peptic ulcer bleeding patients was recurrent bleeding, and secondary outcome was death or acute cardiovascular disease occurrence. The final date of follow-up was December 31, 2014. Basic demographic data, complications, and disease classifications were analyzed and compared by t- or χ²-test. The number of patients that achieved various outcomes was counted and analyzed statistically. A survival curve was drawn using the Kaplan-Meier method, and the difference was compared using the log-rank test. COX regression multivariate analysis was applied to analyze risk factors for the prognosis of peptic ulcer patients.

RESULTS

A total of 167 patients were enrolled into this study. As for the baseline information, differences in age, smoking, alcohol abuse, and acute cardiovascular diseases were statistically significant between the continuing and discontinuing groups (70.8 ± 11.4 vs 62.4 ± 12.0, P < 0.001; 8 (8.2%) vs 15 (21.7%), P < 0.05; 65 (66.3%) vs 13 (18.8%), P < 0.001). At the end of the study, 18 patients had recurrent bleeding and three patients died or had acute cardiovascular disease in the continuing group, while four patients had recurrent bleeding and 15 patients died or had acute cardiovascular disease in the discontinuing group. The differences in these results were statistically significant (P = 0.022, P = 0.000). The Kaplan-Meier survival curve indicated that the incidence of recurrent bleeding was higher in patients in the continuing group, and the risk of death and developing acute cardiovascular disease was higher in patients in the discontinuing group (log-rank test, P = 0.000 for both). Furthermore, COX regression multivariate analysis revealed that the hazard ratio (HR) for recurrent bleeding was 2.986 (95%CI: 067-8.356, P = 0.015) in the continuing group, while HR for death or acute cardiovascular disease was 5.216 (95%CI: 1.035-26.278, P = 0.028).

CONCLUSION

After the occurrence of peptic ulcer bleeding, continuing antithrombotics increases the risk of recurrent bleeding events, while discontinuing antithrombotics would increase the risk of death and developing cardiovascular disease. This suggests that clinicians should comprehensively consider the use of antithrombotics after peptic ulcer bleeding.

Management of Cardiovascular Risk Factors in Type 2 Diabetes Mellitus Patients

People with Type 2 diabetes mellitus (T2DM), compared with non-diabetic individuals, have increased cardiovascular risk. Part of this excess risk is associated with a higher prevalence of other cardiovascular risk factors in these patients, such as obesity, dyslipidaemia, and hypertension. However, the increased cardiovascular risk present in T2DM cannot be attributed entirely to the high prevalence of traditional risk factors and other non-traditional risk factors may also be important for people with T2DM. Evidence suggests that in patients with T2DM, treatment of cardiovascular risk factors is very important in reducing the risk of cardiovascular disease (CVD). The poor control of risk factors observed in the diabetic population supports the need for more aggressive treatment of modifiable cardiovascular risk factors, especially in patients with previous CVD. There is little evidence on the independent association between traditional and non-traditional cardiovascular risk factors, however these risk factors do not appear in isolation and are produced at the same time, exacerbating the risk of a cardiovascular event. Targeting multiple markers of CVD risk offers the best chance of improving CVD outcomes. The objective of this review is to highlight the importance of managing cardiovascular risk factors in patients with T2DM.

Aspirin for Primary Cardiovascular Risk Prevention and Beyond in Diabetes Mellitus

Daily administration of low-dose aspirin has proved to be beneficial in preventing recurrent cardiovascular events. However, the role of aspirin for primary prevention in patients with no overt cardiovascular disease is more controversial. In fact, in lower risk patients, the modest benefit in reducing serious vascular events can be offset by the increased risk of bleeding, including intracranial and gastrointestinal hemorrhage. Diabetes mellitus has been associated with a substantially increased risk of both first and recurrent atherothrombotic events, which makes aspirin therapy of potential value in these subjects. Moving from general aspects of aspirin pharmacology and specific issues in diabetes mellitus, this article reviews the literature on the topic of aspirin for primary prevention in general, and in subjects with diabetes mellitus in particular, to culminate with arguments pro and con and a practical risk-based algorithm for aspirin initiation in daily practice.

Stratifying cardiovascular risk in diabetes: The role of diabetes-related clinical characteristics and imaging

Diabetes is a major coronary heart disease (CHD) and cardiovascular disease (CVD) risk factor and has traditionally been classified as a CHD risk equivalent. CVD risk, however, is heterogeneous among diabetic patients and thus further evaluation is warranted before initiating or titrating preventive pharmacotherapy. Prognostic clinical characteristics of diabetes such as age of onset, duration, and severity of diabetes, as well as concomitant cardiometabolic factors account for much of the variability in CHD and CVD risk. This heterogeneity can also be evaluated directly using non-invasive imaging, which allows for a more individualized risk assessment in order to minimize both under and overtreatment. In this paper, we review guideline recommendations for atherosclerotic CVD risk assessment driving the use of statins or aspirin for certain subgroups of patients with diabetes. We further discuss imaging techniques, such as stress myocardial perfusion imaging, coronary computed tomography angiography, and coronary artery calcium (CAC) scoring that can guide the decision to treat high-risk patients. Among imaging tests, current guidelines consider CAC scoring the most appropriate risk stratification tool for asymptomatic individuals with diabetes that can guide initiating/intensifying or withholding the most aggressive pharmacological therapies among high-risk (CAC>100) or low-risk (CAC=0) individuals, respectively.

A randomised controlled trial of low-dose aspirin for the prevention of fractures in healthy older people: protocol for the ASPREE-Fracture substudy

BACKGROUND

Disability, mortality and healthcare burden from fractures in older people is a growing problem worldwide. Observational studies suggest that aspirin may reduce fracture risk. While these studies provide room for optimism, randomised controlled trials are needed. This paper describes the rationale and design of the ASPirin in Reducing Events in the Elderly (ASPREE)-Fracture substudy, which aims to determine whether daily low-dose aspirin decreases fracture risk in healthy older people.

METHODS

ASPREE is a double-blind, randomised, placebo-controlled primary prevention trial designed to assess whether daily active treatment using low-dose aspirin extends the duration of disability-free and dementia-free life in 19 000 healthy older people recruited from Australian and US community settings. This substudy extends the ASPREE trial data collection to determine the effect of daily low-dose aspirin on fracture and fall-related hospital presentation risk in the 16 500 ASPREE participants aged ≥70 years recruited in Australia. The intervention is a once daily dose of enteric-coated aspirin (100 mg) versus a matching placebo, randomised on a 1:1 basis. The primary outcome for this substudy is the occurrence of any fracture-vertebral, hip and non-vert-non-hip-occurring post randomisation. Fall-related hospital presentations are a secondary outcome.

DISCUSSION

This substudy will determine whether a widely available, simple and inexpensive health intervention-aspirin-reduces the risk of fractures in older Australians. If it is demonstrated to safely reduce the risk of fractures and serious falls, it is possible that aspirin might provide a means of fracture prevention.

TRIAL REGISTRATION NUMBER

The protocol for this substudy is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12615000347561).

Drugs for Primary Prevention of Atherosclerotic Cardiovascular Disease: An Overview of Systematic Reviews

IMPORTANCE

The Million Hearts initiative emphasizes ABCS (aspirin for high-risk patients, blood pressure [BP] control, cholesterol level management, and smoking cessation). Evidence of the effects of drugs used to achieve ABCS has not been synthesized comprehensively in the prevention of primary atherosclerotic cardiovascular disease (ASCVD).

OBJECTIVE

To compare the efficacy and safety of aspirin, BP-lowering therapy, statins, and tobacco cessation drugs for fatal and nonfatal ASCVD outcomes in primary ASCVD prevention.

EVIDENCE REVIEW

Structured search of the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database (HTA), MEDLINE, EMBASE, and PROSPERO International Prospective Systematic Review Trial Register to identify systematic reviews published from January 1, 2005, to June 17, 2015, that reported the effect of aspirin, BP-lowering therapy, statin, or tobacco cessation drugs on ASCVD events in individuals without prevalent ASCVD. Additional studies were identified by searching the reference lists of included systematic reviews, meta-analyses, and health technology assessment reports. Reviews were selected according to predefined criteria and appraised for methodologic quality using the Assessment of Multiple Systematic Reviews (AMSTAR) tool (range, 0-11). Studies were independently reviewed for key participant and intervention characteristics. Outcomes that were meta-analyzed in each included review were extracted. Qualitative synthesis was performed, and data were analyzed from July 2 to August 13, 2015.

FINDINGS

From a total of 1967 reports, 35 systematic reviews of randomized clinical trials were identified, including 15 reviews of aspirin, 4 reviews of BP-lowering therapy, 12 reviews of statins, and 4 reviews of tobacco cessation drugs. Methodologic quality varied, but 30 reviews had AMSTAR ratings of 5 or higher. Compared with placebo, aspirin (relative risk [RR], 0.90; 95% CI, 0.85-0.96) and statins (RR, 0.75; 95% CI, 0.70-0.81) reduced the risk for ASCVD. Compared with placebo, BP-lowering therapy reduced the risk for coronary heart disease (RR, 0.84; 95% CI, 0.79-0.90) and stroke (RR, 0.64; 95% CI, 0.56-0.73). Tobacco cessation drugs increased the odds of continued abstinence at 6 months (odds ratio range, 1.82 [95% CI, 1.60-2.06] to 2.88 [95% CI, 2.40-3.47]), but the direct effects on ASCVD were poorly reported. Aspirin increased the risk for major bleeding (RR, 1.54; 95% CI, 1.30-1.82), and statins did not increase overall risk for adverse effects (RR, 1.00; 95% CI, 0.97-1.03). Adverse effects of BP-lowering therapy and tobacco cessation drugs were poorly reported.

CONCLUSIONS AND RELEVANCE

This overview demonstrates high-quality evidence to support aspirin, BP-lowering therapy, and statins for primary ASCVD prevention and tobacco cessation drugs for smoking cessation. Treatment effects of each drug can be used to enrich discussions between health care professionals and patients in primary ASCVD prevention.

Aspirin for primary prevention of cardiovascular disease

Although aspirin has a well-established role in preventing adverse events in patients with known cardiovascular disease (CVD), its benefit in patients without a history of CVD remains under scrutiny. Current data have provided insight into the risks of aspirin use, particularly bleeding, compared with its benefits in primary CVD prevention. Although aspirin is inexpensive and widely available, especially in developing countries, there is lack of evidence that the benefits outweigh the adverse events with continuous aspirin use in primary CVD prevention. Therefore, the decision to initiate aspirin therapy should be an individual clinical judgment that weighs the absolute benefit in reducing the risk of a first cardiovascular event against the absolute risk of major bleeding, and tailored to the patient's CVD risk. This risk must be calculated, based on accurate and cost-benefit locally developed risk assessment tools, the most discriminating threshold be identified. Additionally, patients preferences should be taken into account when making the decision to initiate aspirin therapy in primary prevention of CVD or not. Physicians should continuously be trained to calculate their patients CVD risk, and concomitant strategies be emphasized.

Comparing the cost-effectiveness of four novel risk markers for screening asymptomatic individuals to prevent cardiovascular disease (CVD) in the US population

BACKGROUND

High sensitivity CRP (hsCRP), coronary artery calcification on CT (CT calcium), carotid artery intima media thickness on ultrasound (cIMT) and ankle-brachial index (ABI) improve prediction of cardiovascular disease (CVD) risk, but the benefit of screening with these novel risk markers in the U.S. population is unclear.

METHODS AND RESULTS

A microsimulation model evaluating lifelong cost-effectiveness for individuals aged 40-85 at intermediate risk of CVD, using 2003-2004 NHANES-III (N=3736), Framingham Heart Study, U.S. Vital Statistics, meta-analyses of independent predictive effects of the four novel risk markers and treatment effects was constructed. Using both an intention-to-treat (assumes adherence <100% and incorporates disutility from taking daily medications) and an as-treated (100% adherence and no disutility) analysis, quality adjusted life years (QALYs), lifetime costs (2014 US $), and incremental cost-effectiveness ratios (ICER in $/QALY gained) of screening with hsCRP, CT coronary calcium, cIMT and ABI were established compared with current practice, full adherence to current guidelines, and ubiquitous statin therapy. In the intention-to-treat analysis in men, screening with CT calcium was cost effective ($32,900/QALY) compared with current practice. In women, screening with hsCRP was cost effective ($32,467/QALY). In the as-treated analysis, statin therapy was both more effective and less costly than all other strategies for both men and women.

CONCLUSIONS

When a substantial disutility from taking daily medication is assumed, screening men with CT coronary calcium is likely to be cost-effective whereas screening with hsCRP has value in women. The individual perceived disutility for taking daily medication should play a key role in the decision.

Benefit-harm analysis and charts for individualized and preference-sensitive prevention: example of low dose aspirin for primary prevention of cardiovascular disease and cancer

BACKGROUND

Clinical practice guidelines provide separate recommendations for different diseases that may be prevented or treated by the same intervention. Also, they commonly provide recommendations for entire populations but not for individuals. To address these two limitations, our aim was to conduct benefit-harm analyses for a wide range of individuals using the example of low dose aspirin for primary prevention of cardiovascular disease and cancer and to develop Benefit-Harm Charts that show the overall benefit-harm balance for individuals.

METHODS

We used quantitative benefit-harm modeling that included 16 outcomes to estimate the probability that low dose aspirin provides more benefits than harms for a wide range of men and women between 45 and 84 years of age and without a previous myocardial infarction, severe ischemic stroke, or cancer. We repeated the quantitative benefit-harm modeling for different combinations of age, sex, and outcome risks for severe ischemic and hemorrhagic stroke, myocardial infarction, cancers, and severe gastrointestinal bleeds. The analyses considered weights for the outcomes, statistical uncertainty of the effects of aspirin, and death as a competing risk. We constructed Benefit-Harm Charts that show the benefit-harm balance for different combinations of outcome risks.

RESULTS

The Benefit-Harm Charts ( http://www.benefit-harm-balance.com ) we have created show that the benefit-harm balance differs largely across a primary prevention population. Low dose aspirin is likely to provide more benefits than harms in men, elderly people, and in those at low risk for severe gastrointestinal bleeds. Individual preferences have a major impact on the benefit-harm balance. If, for example, it is a high priority for individuals to prevent stroke and severe cancers while severe gastrointestinal bleeds are deemed to be of little importance, the benefit-harm balance is likely to favor low dose aspirin for most individuals. Instead, if severe gastrointestinal bleeds are judged to be similarly important compared to the benefit outcomes, low dose aspirin is unlikely to provide more benefits than harms.

CONCLUSIONS

Benefit-Harm Charts support individualized benefit-harm assessments and decision making. Similarly, individualized benefit-harm assessments may allow guideline developers to issue more finely granulated recommendations that reduce the risk of over- and underuse of interventions. The example of low dose aspirin for primary prevention of cardiovascular disease and cancer shows that it may be time for guideline developers to provide combined recommendations for different diseases that may be prevented or treated by the same intervention.