1
|
Nelson MR, Black JA. Aspirin: latest evidence and developments. Heart 2024; 110:1069-1073. [PMID: 39074973 DOI: 10.1136/heartjnl-2024-323948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/03/2024] [Indexed: 07/31/2024] Open
Abstract
Aspirin is a foundation drug of the pharmaceutical industry originally derived as an analgesic/anti-inflammatory agent but serendipitously discovered to have use as a prophylactic drug for major adverse cardiovascular events (MACE). Its modern-day utility in this latter role relies on its efficacy/safety balance in a contemporary population where, at least in high-income countries, age-standardised incident rates for MACE are falling, and where there are now competing therapeutic agents. Its future may be determined by its potential role as a chemoprophylactic or adjunct agent for cancer or other disease states. It therefore will continue to be the subject of further clinical research.
Collapse
Affiliation(s)
- Mark R Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - J Andrew Black
- Cardiology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| |
Collapse
|
2
|
Turck D, Bohn T, Castenmiller J, de Henauw S, Hirsch-Ernst KI, Knutsen HK, Maciuk A, Mangelsdorf I, McArdle HJ, Pentieva K, Siani A, Thies F, Tsabouri S, Vinceti M, Traber MG, Vrolijk M, Bercovici CM, de Sesmaisons Lecarré A, Fabiani L, Karavasiloglou N, Mendes V, Valtueña Martínez S, Naska A. Scientific opinion on the tolerable upper intake level for vitamin E. EFSA J 2024; 22:e8953. [PMID: 39099617 PMCID: PMC11294871 DOI: 10.2903/j.efsa.2024.8953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2024] Open
Abstract
Following a request from the European Commission, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was asked to deliver a scientific opinion on the revision of the tolerable upper intake level (UL) for vitamin E. As α-tocopherol is recognised as the only essential form of vitamin E, the Panel restricted its evaluation to α-tocopherol. Systematic reviews of the literature were conducted to assess evidence on priority adverse health effects of excess intake of vitamin E, namely risk of impaired coagulation and bleeding, cardiovascular disease and prostate cancer. The effect on blood clotting and associated increased risk of bleeding is considered as the critical effect to establish an UL for vitamin E. No new evidence has been published that could improve the characterisation of a dose-response. The ULs for vitamin E from all dietary sources, which were previously established by the Scientific Committee on Food, are retained for all population groups, i.e. 300 mg/day for adults, including pregnant and lactating women, 100 mg/day for children aged 1-3 years, 120 mg/day for 4-6 years, 160 mg/day for 7-10 years, 220 mg/day for 11-14 years and 260 mg/day for 15-17 years. A UL of 50 mg/day is established for infants aged 4-6 months and a UL of 60 mg/day for infants aged 7-11 months. ULs apply to all stereoisomeric forms of α-tocopherol. ULs do not apply to individuals receiving anticoagulant or antiplatelet medications (e.g. aspirin), to patients on secondary prevention for CVD or to patients with vitamin K malabsorption syndromes. It is unlikely that the ULs for vitamin E are exceeded in European populations, except for regular users of food supplements containing high doses of vitamin E.
Collapse
|
3
|
Maggio E, Bocchini VP, Carnevale R, Pignatelli P, Violi F, Loffredo L. Vitamin E supplementation (alone or with other antioxidants) and stroke: a meta-analysis. Nutr Rev 2024; 82:1069-1078. [PMID: 37698992 DOI: 10.1093/nutrit/nuad114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
CONTEXT A previous study showed that vitamin E is effective in reducing the incidence of myocardial infarction only when it is taken in the absence of other antioxidants. It is unclear if it also reduces the incidence of stroke. OBJECTIVE The aim of this meta-analysis is to compare the effect of vitamin E supplementation alone or combined with other antioxidants on the incidence of stroke. DATA SOURCES A search was performed in the following databases: PubMed, ISI Web of Science, SCOPUS, and Cochrane Library. DATA EXTRACTION Sixteen randomized controlled trials were selected to evaluate the effect of vitamin E supplementation on stroke. DATA ANALYSIS The range of vitamin E doses used was 33-800 IU. The follow-up period ranged from 6 months to 9.4 years. Compared with controls, when vitamin E was given alone it did not reduce the incidence of ischemic and hemorrhagic stroke. Conversely, compared with controls, supplementation of vitamin E with other antioxidants reduced ischemic stroke (random effects, RR: 0.91; 95% CI: 0.84-0.99; P = 0.02) but with a significant increase in hemorrhagic stroke (random effects, RR: 1.22; 95% CI: 1.0-1.48; P = 0.04). CONCLUSIONS Supplementation with vitamin E alone is not associated with stroke reduction. Instead, supplementation of vitamin E with other antioxidants reduces the incidence of ischemic stroke but increases the risk of hemorrhagic stroke, cancelling any beneficial effect derived. Thus, vitamin E is not recommended in stroke prevention. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration no. CRD42022258259.
Collapse
Affiliation(s)
- Enrico Maggio
- Department of Clinical Internal, Anesthesiological, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Valeria Proietti Bocchini
- Department of Clinical Internal, Anesthesiological, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Roberto Carnevale
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- IRCCS Neuromed, Località Camerelle, Pozzilli (IS), Italy
| | - Pasquale Pignatelli
- Department of Clinical Internal, Anesthesiological, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Lorenzo Loffredo
- Department of Clinical Internal, Anesthesiological, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
4
|
Laudani C, Capodanno D, Angiolillo DJ. The pharmacology of antiplatelet agents for primary, secondary, and tertiary prevention of ischemic stroke. Expert Opin Pharmacother 2024; 25:1373-1390. [PMID: 39046451 DOI: 10.1080/14656566.2024.2385135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/06/2024] [Accepted: 07/23/2024] [Indexed: 07/25/2024]
Abstract
INTRODUCTION Ischemic etiology accounts for two thirds of all strokes in which platelet activation and aggregation play a major role. A variety of antiplatelet therapies have been tested for primary, secondary, and tertiary prevention, with certain patient subtypes benefiting more than others from a specific regimen. AREAS COVERED This review aims at synthetizing current evidence on pharmacology of antiplatelet agents approved for primary, secondary, and tertiary stroke prevention and their application among possible patient subtypes that may benefit more from their administration. EXPERT OPINION Management of ischemic stroke has largely evolved over the past decades. A better understanding of stroke pathophysiology has allowed to identify patients who can benefit most from antiplatelet therapies, with varying degrees of benefit depending on whether these agents are being used for primary, secondary, or tertiary prevention. Importantly, the antiplatelet treatment regimens currently available have expanded and no longer limited to aspirin but include other drugs such as P2Y12 and phosphodiesterase inhibitors, also used in combination, as well as precision medicine approaches using genetic testing aiming at optimizing the safety and efficacy in this population.
Collapse
Affiliation(s)
- Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "Rodolico - San Marco", University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "Rodolico - San Marco", University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| |
Collapse
|
5
|
Sammons EL, Buck G, Bowman LJ, Stevens WM, Hammami I, Parish S, Armitage J. ASCEND-Eye: Effects of Aspirin on Diabetic Retinopathy. Ophthalmology 2024; 131:771-779. [PMID: 38237868 DOI: 10.1016/j.ophtha.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 01/09/2024] [Accepted: 01/09/2024] [Indexed: 03/21/2024] Open
Abstract
PURPOSE Preclinical studies support a protective role for aspirin in early diabetic retinopathy (DR), but the findings from randomized trials are limited. We present randomized evidence for the efficacy and safety of aspirin on DR outcomes. DESIGN A substudy of the A Study of Cardiovascular Events in Diabetes (ASCEND) double-masked, randomized, placebo-controlled trial of 100 mg aspirin daily for the primary prevention of serious cardiovascular events in people with diabetes. PARTICIPANTS Fifteen thousand four hundred eighty United Kingdom adults at least 40 years of age with diabetes. METHODS Linkage to electronic National Health Service Diabetic Eye Screening Programme records in England and Wales and confirmation of participant-reported eye events via medical record review were carried out. Log-rank methods were used for intention-to-treat analyses of time until the first primary efficacy and safety outcomes. MAIN OUTCOME MEASURES The primary efficacy end point was the first record of referable disease after randomization, a composite of referable retinopathy or referable maculopathy based on the grading criteria defined by the United Kingdom National Screening Committee. The primary safety outcome was the first sight-threatening eye bleed, defined as clinically significant bleeding in the eye that resulted in unresolved visual loss or required an urgent intervention such as laser photocoagulation, vitreoretinal surgery, intraocular injection, or a combination thereof. RESULTS Linkage data were obtained for 7360 participants (48% of those randomized in ASCEND). During the mean follow-up of 6.5 years, 539 participants (14.6%) experienced a referable disease event in the aspirin group, compared with 522 participants (14.2%) in the placebo group (rate ratio, 1.03; 95% confidence interval [CI], 0.91-1.16; P = 0.64). No statistically significant between-group difference was found in the proportions of sight-threatening eye bleed events (57 participants [0.7%] and 64 participants [0.8%], respectively; rate ratio, 0.89; 95% CI, 0.62-1.27). DISCUSSION These data exclude any clinically meaningful benefits of aspirin for DR, but give reassurance regarding the ophthalmologic safety of aspirin. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
Collapse
Affiliation(s)
- Emily L Sammons
- Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
| | - Georgina Buck
- Big Data Institute, Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, United Kingdom
| | - Louise J Bowman
- Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - William M Stevens
- Big Data Institute, Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, United Kingdom
| | - Imen Hammami
- Big Data Institute, Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, United Kingdom
| | - Sarah Parish
- Big Data Institute, Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, United Kingdom
| | - Jane Armitage
- Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
6
|
Tripathi S, Nath M, Misra S, Kumar P. From A to E: Uniting vitamins against stroke risk-A systematic review and network meta-analysis. Eur J Clin Invest 2024; 54:e14165. [PMID: 38291560 DOI: 10.1111/eci.14165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 12/05/2023] [Accepted: 01/07/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND AND AIM Stroke represents a significant public health challenge, necessitating the exploration of preventive measures. This network meta-analysis aimed to assess the efficacy of different vitamin treatments compared to a placebo in preventing stroke. METHODS A systematic electronic search in databases including PubMed, EmBASE, Web of Science, clinicaltrials.gov, and Google Scholar until 31 May 2023 was conducted, to identify published studies investigating the association between vitamin intake and the risk of stroke. Pooled risk ratio (RR) with 95% confidence intervals (CIs) was calculated using a frequentist network meta-analysis. Furthermore, we ranked vitamins based on p-scores, facilitating a comparative assessment of their effectiveness in preventing stroke. RESULTS A total of 56 studies, including 17 randomized controlled trials (RCTs) and 39 cohort studies were analyzed. Direct estimates obtained from network meta-analysis, we found that vitamin A (RR: .81 [.72-.91]), vitamin B-complex (RR: .85 [.74-.97]), vitamin B6 (RR: 79 [.68-.92]), folate (RR: .86 [.75-.97]), vitamin C (RR: .77 [.70-.85]) and vitamin D (RR: .73 [.64-.83]) were significantly associated with a decreased stroke risk. However, no significant association was observed for vitamin B2, vitamin B12, and vitamin E. Subsequent to network meta-analysis, vitamins were ranked in decreasing order of their efficacy in stroke prevention based on p-score, with vitamin D (p-score = .91), vitamin C (p-score = .79), vitamin B6 (p-score = .70), vitamin A (p-score = .65), vitamin B-complex (p-score = .53), folate (p-score = .49), vitamin B2 (p-score = .39), vitamin E (p-score = .28), vitamin B12 (.13) and placebo (.10). CONCLUSION Our study has established noteworthy connections between vitamin A, vitamin B-complex, vitamin B6, folate, vitamin C, and vitamin D in the realm of stroke prevention. These findings add substantial weight to the accumulating evidence supporting the potential advantages of vitamin interventions in mitigating the risk of stroke. However, to solidify and validate these observations, additional research is imperative. Well-designed clinical trials or cohort studies are needed to further explore these associations and formulate clear guidelines for incorporating vitamin supplementation into effective stroke prevention strategies.
Collapse
Affiliation(s)
- Shashank Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Manabesh Nath
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Shubham Misra
- Department of Neurology, Yale University, New Haven, Connecticut, USA
| | - Pradeep Kumar
- Clinical Research Unit, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
7
|
Raggi P, Milic J, Manicardi M, Cinque F, Swain MG, Sebastiani G, Guaraldi G. Metabolic dysfunction-associated steatotic liver disease: An opportunity for collaboration between cardiology and hepatology. Atherosclerosis 2024; 392:117523. [PMID: 38522165 DOI: 10.1016/j.atherosclerosis.2024.117523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/07/2024] [Accepted: 03/14/2024] [Indexed: 03/26/2024]
Abstract
Altered metabolic function has many detrimental effects on the body that can manifest as cardiovascular and liver diseases. Traditional approaches to understanding and treating metabolic dysfunction-associated disorders have been organ-centered, leading to silo-type disease care. However, given the broad impact that systemic metabolic dysfunction has on the human body, approaches that simultaneously involve multiple medical specialists need to be developed and encouraged to optimize patient outcomes. In this review, we highlight how several of the treatments developed for cardiac care may have a beneficial effect on the liver and vice versa, suggesting that there is a need to target the disease process, rather than specifically target the cardiovascular or liver specific sequelae of metabolic dysfunction.
Collapse
Affiliation(s)
- Paolo Raggi
- Department of Medicine and Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.
| | - Jovana Milic
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Italy
| | - Marcella Manicardi
- Cardiology Department, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Felice Cinque
- SC-Medicina Indirizzo Metabolico, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan, Department of Pathophysiology and Transplantation, University of Milan, Italy; Division of Gastroenterology and Hepatology and Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC, Canada
| | - Mark G Swain
- Department of Medicine, University of Calgary Liver Unit, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Giada Sebastiani
- Division of Gastroenterology and Hepatology and Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC, Canada; Division of Experimental Medicine, McGill University, Montreal, QC, Canada
| | - Giovanni Guaraldi
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Italy; Department of Infectious Diseases, Azienda Ospedaliero-Universitaria, Policlinico of Modena, Modena, Italy
| |
Collapse
|
8
|
Liu H, Li J, Wu N, She Y, Luo Y, Huang Y, Quan H, Fu W, Li X, Zeng D, Jia Y. Supplementing Glucose Intake Reverses the Inflammation Induced by a High-Fat Diet by Increasing the Expression of Siglec-E Ligands on Erythrocytes. Inflammation 2024; 47:609-625. [PMID: 38448631 DOI: 10.1007/s10753-023-01932-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/10/2023] [Accepted: 11/10/2023] [Indexed: 03/08/2024]
Abstract
Siglec-9/E is a cell surface receptor expressed on immune cells and can be activated by sialoglycan ligands to play an immunosuppressive role. Our previous study showed that increasing the expression of Siglec-9 (the human paralog of mouse Siglec-E) ligands maintains functionally quiescent immune cells in the bloodstream, but the biological effects of Siglec-9 ligand alteration on atherogenesis were not further explored. In the present study, we demonstrated that the atherosclerosis risk factor ox-LDL or a high-fat diet could decrease the expression of Siglec-9/E ligands on erythrocytes. Increased expression of Siglec-E ligands on erythrocytes caused by dietary supplementation with glucose (20% glucose) had anti-inflammatory effects, and the mechanism was associated with glucose intake. In high-fat diet-fed apoE-/- mice, glucose supplementation decreased the area of atherosclerotic lesions and peripheral inflammation. These data suggested that increased systemic inflammation is attenuated by increasing the expression of Siglec-9/E ligands on erythrocytes. Therefore, Siglec-9/E ligands might be valuable targets for atherosclerosis therapy.
Collapse
Affiliation(s)
- Hongmei Liu
- Institute of Materia Medica and Department of Pharmaceutics, College of Pharmacy, Army Medical University, Chongqing, 400038, China
| | - Jin Li
- Institute of Materia Medica and Department of Pharmaceutics, College of Pharmacy, Army Medical University, Chongqing, 400038, China
| | - Niting Wu
- Institute of Materia Medica and Department of Pharmaceutics, College of Pharmacy, Army Medical University, Chongqing, 400038, China
| | - Yuanting She
- Department of Haematology, Daping Hospital of Army Medical University, Chongqing, 400042, China
| | - Yadan Luo
- Institute of Materia Medica and Department of Pharmaceutics, College of Pharmacy, Army Medical University, Chongqing, 400038, China
| | - Yan Huang
- Institute of Materia Medica and Department of Pharmaceutics, College of Pharmacy, Army Medical University, Chongqing, 400038, China
| | - Hongyu Quan
- Institute of Materia Medica and Department of Pharmaceutics, College of Pharmacy, Army Medical University, Chongqing, 400038, China
| | - Wenying Fu
- Institute of Materia Medica and Department of Pharmaceutics, College of Pharmacy, Army Medical University, Chongqing, 400038, China
| | - Xiaohui Li
- Institute of Materia Medica and Department of Pharmaceutics, College of Pharmacy, Army Medical University, Chongqing, 400038, China
| | - Dongfeng Zeng
- Department of Haematology, Daping Hospital of Army Medical University, Chongqing, 400042, China.
| | - Yi Jia
- Institute of Materia Medica and Department of Pharmaceutics, College of Pharmacy, Army Medical University, Chongqing, 400038, China.
| |
Collapse
|
9
|
Sohn M, Lim S. The Role of Cilostazol, a Phosphodiesterase-3 Inhibitor, in the Development of Atherosclerosis and Vascular Biology: A Review with Meta-Analysis. Int J Mol Sci 2024; 25:2593. [PMID: 38473840 DOI: 10.3390/ijms25052593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/07/2024] [Accepted: 02/14/2024] [Indexed: 03/14/2024] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD) stands as the leading global cause of mortality. Addressing this vital and pervasive condition requires a multifaceted approach, in which antiplatelet intervention plays a pivotal role, together with antihypertensive, antidiabetic, and lipid-lowering therapies. Among the antiplatelet agents available currently, cilostazol, a phosphodiesterase-3 inhibitor, offers a spectrum of pharmacological effects. These encompass vasodilation, the impediment of platelet activation and aggregation, thrombosis inhibition, limb blood flow augmentation, lipid profile enhancement through triglyceride reduction and high-density lipoprotein cholesterol elevation, and the suppression of vascular smooth muscle cell proliferation. However, the role of cilostazol has not been clearly documented in many guidelines for ASCVD. We comprehensively reviewed the cardiovascular effects of cilostazol within randomized clinical trials that compared it to control or active agents and involved individuals with previous coronary artery disease or stroke, as well as those with no previous history of such conditions. Our approach demonstrated that the administration of cilostazol effectively reduced adverse cardiovascular events, although there was less evidence regarding its impact on myocardial infarction. Most studies have consistently reported its favorable effects in reducing intermittent claudication and enhancing ambulatory capacity in patients with peripheral arterial disease. Furthermore, cilostazol has shown promise in mitigating restenosis following coronary stent implantation in patients with acute coronary syndrome. While research from more diverse regions is still needed, our findings shed light on the broader implications of cilostazol in the context of atherosclerosis and vascular biology, particularly for individuals at high risk of ASCVD.
Collapse
Affiliation(s)
- Minji Sohn
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam 13620, Republic of Korea
| | - Soo Lim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam 13620, Republic of Korea
| |
Collapse
|
10
|
Maqsood MH, Levine GN, Kleiman ND, Hasdai D, Uretsky BF, Birnbaum Y. Do We Still Need Aspirin in Coronary Artery Disease? J Clin Med 2023; 12:7534. [PMID: 38137601 PMCID: PMC10743767 DOI: 10.3390/jcm12247534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
Aspirin has for some time been used as a first-line treatment for acute coronary syndromes, including ST-elevation myocardial infarction, for secondary prevention of established coronary disease, and for primary prevention in patients at risk of coronary artery disease. Although aspirin has been in use for decades, the available evidence for its efficacy largely predates the introduction of other drugs, such as statins and P2Y12 inhibitors. Based on recent trials, the recommendation for aspirin use as primary prevention has been downgraded. In addition, P2Y12 inhibitors given as a single antiplatelet therapy have been associated with a lower incidence of bleeding than dual antiplatelet therapy in combination with aspirin in patients with stable and unstable coronary artery disease. The aim of this review is to discuss the role of aspirin considering the available evidence for primary prevention, secondary prevention for stable coronary artery disease or acute coronary syndromes, and after percutaneous coronary intervention or coronary artery bypass revascularization.
Collapse
Affiliation(s)
- Muhammad Haisum Maqsood
- Department of Cardiology, DeBakey Heart and Vascular Center, Methodist Hospital, Houston, TX 77030, USA;
| | - Glenn N. Levine
- The Section of Cardiology, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Neal D. Kleiman
- Department of Cardiology, Section of Interventional Cardiology, Houston Methodist DeBakey Heart Center, Houston, TX 77030, USA;
| | - David Hasdai
- Department of Cardiology, Rabin Medical Center, Tel Aviv University, Petah Tikva 49200, Israel;
| | - Barry F. Uretsky
- Central Arkansas Veterans Health System, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Yochai Birnbaum
- The Section of Cardiology, Baylor College of Medicine, Houston, TX 77030, USA;
| |
Collapse
|
11
|
Kim RB, Li A, Park KS, Kang YS, Kim JR, Navarese EP, Gorog DA, Tantry US, Gurbel PA, Hwang JY, Kwon OY, Jeong YH. Low-Dose Aspirin for Primary Prevention of Cardiovascular Events Comparing East Asians With Westerners: A Meta-Analysis. JACC. ASIA 2023; 3:846-862. [PMID: 38155798 PMCID: PMC10751647 DOI: 10.1016/j.jacasi.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 07/11/2023] [Accepted: 07/14/2023] [Indexed: 12/30/2023]
Abstract
Background East Asians have shown different risk profiles for both thrombophilia and bleeding than Western counterparts. Objectives The authors sought to evaluate the effect of low-dose aspirin for primary prevention between these populations. Methods We searched randomized clinical trials (RCTs) for intervention with low-dose aspirin (≤100 mg once daily) in participants without symptomatic cardiovascular disease until December 31, 2021. The number of events between the arms was extracted for analysis. Pooled risk ratios (RRs) and risk differences (RDs) were analyzed in each population. Outcomes included a major adverse cardiovascular event (MACE), cardiovascular death, myocardial infarction, stroke, and major bleeding (intracranial hemorrhage and major gastrointestinal bleeding). Results Two RCTs included 17,003 East Asians, and 9 RCTs had 117,467 Western participants. Aspirin treatment showed a similar effect in reducing the MACE rate (RR of East Asians: 0.87; 95% CI: 0.71-1.05; RR of Westerners: 0.90; 95% CI: 0.85-0.95) (Pinteraction = 0.721). In contrast, the risk of major bleeding during aspirin vs control was greater in the East Asian population (RR: 2.48; 95% CI: 1.86-3.30) compared with the Western population (RR: 1.45; 95% CI: 1.26-1.66) (Pinteraction = 0.001), which was driven by more frequent gastrointestinal bleeding (RR of East Asians: 3.29; 95% CI: 2.26-4.80 vs RR of Westerners: 1.56; 95% CI: 1.29-1.88) (Pinteraction < 0.001). The net RDs (RD of MACE plus RD of major bleeding) were 8.04 and 0.72 per 1,000 persons in East Asian and Western participants, indicating 124 and 1,389 of the net number needed to harm, respectively. Conclusions Low-dose aspirin for primary prevention in East Asians must be cautiously prescribed because of the increased risk of major bleeding relative to Western counterparts.
Collapse
Affiliation(s)
- Rock Bum Kim
- Regional Cardiocerebrovascular Disease Center, Gyeongsang National University, Jinju, South Korea
| | - Ang Li
- Section of Hematology-Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Ki-Soo Park
- Department of Preventive Medicine and Institute of Health Sciences, Gyeongsang National University College of Medicine, Jinju, South Korea
| | - Yune-Sik Kang
- Department of Preventive Medicine and Institute of Health Sciences, Gyeongsang National University College of Medicine, Jinju, South Korea
| | - Jang-Rak Kim
- Department of Preventive Medicine and Institute of Health Sciences, Gyeongsang National University College of Medicine, Jinju, South Korea
| | - Eliano P. Navarese
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Diana A. Gorog
- Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Udaya S. Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Paul A. Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Jin Yong Hwang
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, South Korea
| | - Oh-Young Kwon
- Department of Neurology, Gyeongsang National University Hospital, Jinju, South Korea
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Heart and Brain Hospital, Chung-Ang University, Gwangmyeong Hospital, Gwangmyeong, South Korea
- Department of Internal Medicine, Chung-Ang University School of Medicine, Seoul, South Korea
| |
Collapse
|
12
|
Laferrière C, Moazzami C, Belley-Côté E, Bainey KR, Marquis-Gravel G, Fama A, Lordkipanidzé M, Potter BJ. Aspirin for the Primary Prevention of Vascular Ischemic Events: An Updated Systematic Review and Meta-analysis to Support Shared Decision-Making. CJC Open 2023; 5:881-890. [PMID: 38204851 PMCID: PMC10774080 DOI: 10.1016/j.cjco.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/25/2023] [Indexed: 01/12/2024] Open
Abstract
Background Since the publication of the 2010 Canadian antiplatelet guidelines, several large randomized controlled trials (RCTs) have evaluated the role of aspirin (ASA) use in primary prevention. We evaluated the effect of ASA use, compared with no ASA, on ischemic and bleeding events in patients without known atherosclerotic cardiovascular diseases. Methods We updated a published systematic review and meta-analysis by searching MEDLINE, Embase, and CENTRAL for the period up to March 2023. We included RCTs that enrolled patients for primary prevention of atherosclerotic cardiovascular diseases, and compared use of ASA to no ASA. We assessed risk of bias (RoB) using the Cochrane RoB tool, and certainty of evidence using the grading recommendations, assessment, development, and evaluation (GRADE) criteria. The primary efficacy outcome was major adverse cardiovascular events (MACE) (death, myocardial infarction, or stroke). The primary safety outcomes were intracranial hemorrhage and extracranial major bleeding events. We used a random-effects model to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs). Results We included 14 RCTs (n = 167,587) at overall low RoB, with a median follow-up of 5 years. Compared to no ASA, ASA use reduced the incidence of MACE (RR 0.90, 95% CI 0.86-0.94), with a higher risk of intracranial hemorrhage (RR 1.33, 95% CI 1.13-1.56) and extracranial major bleeding (RR 1.67, 95% CI 1.36-2.06). In prespecified subgroups of age, sex, and diabetes, effect estimates were consistent. Conclusions ASA use in primary prevention is associated with a consistent reduction in MACE, but at the expense of major bleeding events. Patient values and preferences should be taken into account when considering ASA use for primary prevention.
Collapse
Affiliation(s)
- Chloë Laferrière
- Université de Montréal, Faculté de médecine, Montréal, Quebec, Canada
| | - Chloé Moazzami
- Université de Montréal, Faculté de médecine, Montréal, Quebec, Canada
| | - Emilie Belley-Côté
- Population Health Research Institute (PHRI), Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
| | - Kevin R. Bainey
- Faculty of Medicine. University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Guillaume Marquis-Gravel
- Université de Montréal, Faculté de médecine, Montréal, Quebec, Canada
- Centre de recherche de l’Institut de cardiologie de Montréal, Montréal, Quebec, Canada
| | - Alexa Fama
- Population Health Research Institute (PHRI), Hamilton, Ontario, Canada
| | - Marie Lordkipanidzé
- Université de Montréal, Faculté de médecine, Montréal, Quebec, Canada
- Faculté de pharmacie, Université de Montréal, Montréal, Quebec, Canada
| | - Brian J. Potter
- Université de Montréal, Faculté de médecine, Montréal, Quebec, Canada
- Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montréal, Quebec, Canada
| |
Collapse
|
13
|
Brooker C, Compton R, Babineau T, Normeshie CA, Li L, Blackstone SR. Identifying and reducing inappropriate aspirin use in primary care. BMJ Open Qual 2023; 12:e002457. [PMID: 37931985 PMCID: PMC10632878 DOI: 10.1136/bmjoq-2023-002457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/21/2023] [Indexed: 11/08/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Christa Brooker
- Department of Family Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Rebekah Compton
- Department of Family Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Terri Babineau
- Department of Family Medicine, University of Virginia, Charlottesville, Virginia, USA
| | | | - Li Li
- Department of Family Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Sarah Rachel Blackstone
- Office of Planning, Analytics & Institutional Research, James Madison University, Harrisonburg, Virginia, USA
| |
Collapse
|
14
|
Karavasili C, Babaee S, Kutty S, Chu JN, Min S, Fitzgerald N, Morimoto J, Inverardi N, Traverso G. Modular Titratable Polypills for Personalized Medicine and Simplification of Complex Medication Regimens. Adv Healthc Mater 2023; 12:e2301101. [PMID: 37526266 PMCID: PMC10836191 DOI: 10.1002/adhm.202301101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Indexed: 08/02/2023]
Abstract
Simplification of complex medication regimens in polypharmacy positively contributes to treatment adherence and cost-effective improved health outcomes. Even though fixed dose combination (FDC) drug products are the only currently available single dose poly-pill regimens, the lack of flexibility in dose adjustment of a single drug in the combination limits their efficacy. To fill the existing gap in drug dose personalization and simplification of complex medication regimens commonly encountered in the treatment of cardiovascular disease, tuberculosis, and tapering of corticosteroid therapy, a modular titratable polypill approach that simultaneously addresses both aspects is proposed. The polypill consists of modular units that contain different drugs at incremental or decremental doses to be assembled in a single titratable polypill at the required dose for each drug through a stacking or interlocking process. The variable dose (VD) modular tablets are subjected to quality control tests and found to comply to pharmacopeia's acceptance criteria and requirements specified in the respective drug monographs. A cost-effectiveness analysis is conducted supporting the VD strategy as cost-effective compared to the FDC strategy and more effective and less expensive than standard of care. The VD approach stands to enable pill burden reduction, ease of administration, enhancement of treatment adherence, and potential cost-saving benefits.
Collapse
Affiliation(s)
- Christina Karavasili
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Sahab Babaee
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Shruti Kutty
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Jacqueline N Chu
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
- Integrated Gastroenterology Consultants, N. Chelmsford, MA, 01863, USA
| | - Seokkee Min
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Nina Fitzgerald
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Joshua Morimoto
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Nicoletta Inverardi
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Giovanni Traverso
- David H. Koch Institute for Integrative Cancer Research and Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| |
Collapse
|
15
|
Clerici B, Cattaneo M. Pharmacological Efficacy and Gastrointestinal Safety of Different Aspirin Formulations for Cardiovascular Prevention: A Narrative Review. J Cardiovasc Dev Dis 2023; 10:jcdd10040137. [PMID: 37103016 PMCID: PMC10145431 DOI: 10.3390/jcdd10040137] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/18/2023] [Accepted: 03/20/2023] [Indexed: 04/28/2023] Open
Abstract
Aspirin inhibits platelet function by irreversibly inhibiting the synthesis of thromboxane A2 (TxA2). Aspirin, at low doses, is widely used for cardiovascular prevention. Gastrointestinal discomfort, mucosal erosions/ulcerations and bleeding are frequent complications of chronic treatment. To reduce these adverse effects, different formulations of aspirin have been developed, including enteric-coated (EC) aspirin, the most widely used aspirin formulation. However, EC aspirin is less effective than plain aspirin in inhibiting TxA2 production, especially in subjects with high body weight. The inadequate pharmacological efficacy of EC aspirin is mirrored by lower protection from cardiovascular events in subjects weighing >70 kg. Endoscopic studies showed that EC aspirin causes fewer erosions of the gastric mucosa compared to plain aspirin (which is absorbed in the stomach) but causes mucosal erosions in the small intestine, where it is absorbed. Several studies demonstrated that EC aspirin does not reduce the incidence of clinically relevant gastrointestinal ulceration and bleeding. Similar results were found for buffered aspirin. Although interesting, the results of experiments on the phospholipid-aspirin complex PL2200 are still preliminary. Considering its favorable pharmacological profile, plain aspirin should be the preferred formulation to be used for cardiovascular prevention.
Collapse
Affiliation(s)
- Bianca Clerici
- Divisione di Medicina Generale II, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Via Di Rudinì 8, 20142 Milano, Italy
| | - Marco Cattaneo
- Fondazione Arianna Anticoagulazione, Via Paolo Fabbri 1/3, 40138 Bologna, Italy
| |
Collapse
|
16
|
Kim SP, Ryu J, Kim SH, Yoon HJ. Low-dose aspirin in the primary prevention of cardiovascular diseases: A retrospective, propensity score matched study. Atherosclerosis 2023; 371:54-60. [PMID: 37004474 DOI: 10.1016/j.atherosclerosis.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 03/02/2023] [Accepted: 03/14/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND AND AIMS Although the guidelines have been revised recently, the effect of aspirin for the primary prevention of cardiovascular disease (CVD) is still controversial. Thus, we aimed to evaluate the effect of aspirin on primary prevention in the real world. METHODS Among the 4,266,268 participants without a history of CVD or previous prescription of aspirin and other antiplatelet agents who were screened between 2002 and 2008, 268,963 persons who were prescribed low-dose aspirin (≤100 mg/day) over 90 days in 2002-2008 and 1,075,852 persons who did not receive aspirin were selected after propensity score matching. A Cox proportional-hazards model was used to evaluate the effect of low-dose aspirin on the development of CVD and bleeding episodes. RESULTS Aspirin showed a protective effect on total CVD events (hazard ratio (HR); 0.737, 95% confidence interval; 0.729-0.745). The protective effect of aspirin on total CVD events was significant in men, women and even in young participants (<65 years). Aspirin had a protective effect in participants with diabetes or hypertension against all subcategories of CVD. The HR of bleeding risk was 1.4-1.5 in aspirin group. CONCLUSIONS Low-dose aspirin generally showed a protective effect against CVD regardless of age, sex, and underlying comorbidities in the real world. Though, the effect of aspirin was evident at a young age, the risk of bleeding was also high (1.4-1.5 times), and thus, careful prescription is required.
Collapse
Affiliation(s)
- Seong Pyo Kim
- Interdisciplinary Program of Medical Informatics, Seoul National University College of Medicine, Seoul, Republic of Korea; Integrated Major in Innovative Medical Science, Seoul National University Graduate School, Republic of Korea
| | - Jiwon Ryu
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Su Hwan Kim
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyung-Jin Yoon
- Medical Bigdata Research Center, Seoul National University College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
17
|
Khan SU, Lone AN, Kleiman NS, Arshad A, Jain V, Al Rifai M, Arshad HB, Dani SS, Khera A, Morris PB, Bittner V, Nasir K, Virani SS. Aspirin With or Without Statin in Individuals Without Atherosclerotic Cardiovascular Disease Across Risk Categories. JACC. ADVANCES 2023; 2:100197. [PMID: 38938315 PMCID: PMC11198672 DOI: 10.1016/j.jacadv.2022.100197] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/21/2022] [Accepted: 11/28/2022] [Indexed: 06/29/2024]
Abstract
Background The effects of aspirin in adults without atherosclerotic cardiovascular disease (ASCVD), stratified by statin use across different ASCVD risks, remain uncertain. Objectives The purpose of this study was to examine the effects of aspirin in adults without ASCVD, stratified by statin use across different ASCVD risks. Methods We searched databases through March 2022 and selected randomized controlled trials of aspirin without ASCVD and follow-up of ≥1 year. We used random-effects models and estimated relative and absolute risks for cardiovascular outcomes, major bleeding, and mortality over 5 years. We calculated absolute risk differences assuming constant relative risks (RRs) across statin use and ASCVD risks. The Cholesterol Treatment Trialists Collaboration, and the ASCEND (A Study of Cardiovascular Events in Diabetes) trial were used to estimate baseline risks. Results In 16 trials [171,215 individuals; median age, 64 (Q1-Q3: 60-65) years], aspirin vs control reduced myocardial infarction (MI) [RR: 0.85 (95% CI: 0.77-0.95)] but increased major bleeding [RR: 1.48 (95% CI: 1.32-1.66)]. Aspirin did not reduce mortality. Statin vs no statin was associated with lower bleeding and MI risk; the bleeding and MI risk were proportional to ASCVD risk. For every 10,000 adults, aspirin reduced MI (very low risk: 3 events as monotherapy or 1 event with statin; very high risk: 49 events as monotherapy or 37 events with statin) and increased major bleeding (very low risk: 21 events as monotherapy or 20 events with statin; very high risk: 98 events as monotherapy or 94 events with statin) proportional to baseline ASCVD risk. Conclusions In adults without ASCVD, concomitant statin appeared to significantly reduce absolute risk reduction for MI associated with aspirin without influencing bleeding risk. The anticipated absolute risk of major bleeding with aspirin exceeds absolute MI benefits for every level of ASCVD risk.
Collapse
Affiliation(s)
- Safi U. Khan
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Ahmad N. Lone
- Department of Cardiology, Guthrie Health System/Robert Packer Hospital, Sayre, Pennsylvania, USA
| | - Neal S. Kleiman
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Adeel Arshad
- Department of Medical Oncology, Ohio State University Comprehensive Cancer Care Center, Columbus, Ohio, USA
| | - Vardhmaan Jain
- Department of Cardiology, Emory Heart and Vascular Center, Atlanta, Georgia, USA
| | - Mahmoud Al Rifai
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Hassaan B. Arshad
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Sourbha S. Dani
- Division of Cardiology, Lahey Hospital, and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Amit Khera
- Section of Preventive Cardiology, Department of Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Pamela B. Morris
- Department of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Vera Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Khurram Nasir
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas, USA
| | - Salim S. Virani
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Department of Medicine, The Aga Khan University, Karachi, Pakistan
| |
Collapse
|
18
|
Brown MT, Bortfeld KS, Sperling LS, Wenger NK. Redefining the Roles of Aspirin across the Spectrum of Cardiovascular Disease Prevention. Curr Cardiol Rev 2023; 19:9-22. [PMID: 37132104 PMCID: PMC10636801 DOI: 10.2174/1573403x19666230502163828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 03/21/2023] [Accepted: 03/28/2023] [Indexed: 05/04/2023] Open
Abstract
Even before its role in platelet inhibition was fully characterized in the 1980s, aspirin had been incorporated into the cardiovascular disease care algorithm. Early trials examining its use in unstable angina and acute myocardial infarction revealed evidence of its protective role in the secondary prevention of atherosclerotic cardiovascular disease (ASCVD). Large trials assessing use in the primary prevention setting and optimal dosing regimens were studied in the late 1990s and early 2000s. As a cornerstone of cardiovascular care, aspirin was incorporated into primary and secondary ASCVD prevention guidelines in the United States and mechanical heart valve guidelines. However, in recent years, with significant advances in medical and interventional ASCVD therapies, scrutiny has been placed on the bleeding profile of aspirin, and guidelines have adapted to new evidence. Updates in primary prevention guidelines reserve aspirin only for patients at higher ASCVD risk and low bleeding risk - though questions remain in ASCVD risk assessment as risk-enhancing factors have proven difficult to incorporate on a population level. New thoughts regarding aspirin use in secondary prevention - especially with the concomitant use of anticoagulants - have altered recommendations as additional data accrued. Finally, a recommendation for aspirin and vitamin K antagonists with mechanical heart valves has been modified. Despite aspirin losing a foothold in cardiovascular care, new evidence has strengthened claims for its use in women at high risk for preeclampsia.
Collapse
Affiliation(s)
- Matthew T. Brown
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Laurence S. Sperling
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Nanette K. Wenger
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| |
Collapse
|
19
|
Fijałkowski Ł, Skubiszewska M, Grześk G, Koech FK, Nowaczyk A. Acetylsalicylic Acid-Primus Inter Pares in Pharmacology. Molecules 2022; 27:molecules27238412. [PMID: 36500502 PMCID: PMC9738180 DOI: 10.3390/molecules27238412] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 11/24/2022] [Accepted: 11/27/2022] [Indexed: 12/05/2022] Open
Abstract
Acetylsalicylic acid (ASA) is one of the first drugs to be obtained by synthesis while being the most used. It has experienced the longest lasting commercial success and is considered the most popular drug of the modern era. ASA, originally used as an anti-inflammatory medication, nowadays is predominantly used as an antiplatelet agent for prophylaxis in cardiac patients. Many studies show that the benefits of using ASA far outweigh the potential risk of side effects. With particular emphasis on the possibility of ASA repositioning for new therapies, extending the indications for use beyond the diseases from the spectrum of atherosclerotic diseases, such as cancer, requires shifting the benefit-risk ratio, although very good, even more towards safety. Interesting activities consisting not only of changing the formulation but also modifying the drug molecule seem to be an important goal of the 21st century. ASA has become a milestone in two important fields: pharmacy and medicine. For a pharmacist, ASA is a long-used drug for which individual indications are practically maintained. For a doctor, acetylsalicylic acid is primarily an antiplatelet drug that saves millions of lives of patients with coronary heart disease or after a stroke. These facts do not exempt us from improving therapeutic methods based on ASA, the main goal of which is to reduce the risk of side effects, as well as to extend effectiveness. Modified acetylsalicylic acid molecules already seem to be a promising therapeutic option.
Collapse
Affiliation(s)
- Łukasz Fijałkowski
- Department of Pharmacometrics and Molecular Modeling, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 2 dr. A. Jurasza St., 85-094 Bydgoszcz, Poland
| | - Magdalena Skubiszewska
- Department of Pharmacometrics and Molecular Modeling, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 2 dr. A. Jurasza St., 85-094 Bydgoszcz, Poland
| | - Grzegorz Grześk
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 75 Ujejskiego St., 85-168 Bydgoszcz, Poland
| | | | - Alicja Nowaczyk
- Department of Pharmacometrics and Molecular Modeling, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 2 dr. A. Jurasza St., 85-094 Bydgoszcz, Poland
- Correspondence: ; Tel.: +48-52-585-3904
| |
Collapse
|
20
|
Cao Y, DiPiro ND, Krause JS. Staying Pressure Injury Free: The Role of Modifiable Behaviors. Arch Phys Med Rehabil 2022; 103:2138-2144. [PMID: 35257678 DOI: 10.1016/j.apmr.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 02/08/2022] [Accepted: 02/08/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate the association of behavioral factors with retrospective reports of staying free from pressure injuries (PIs) during a 12-month period for people with chronic spinal cord injury (SCI). DESIGN Cross-sectional survey. SETTING Data collection was completed at an academic medical center in the Southeastern United States in collaboration with a specialized treatment center and 2 public health registries that use population-based approaches to identify all incident cases of SCI within the state. PARTICIPANTS The participant cohort was composed of 3817 adults (N=3817) with traumatic SCI of at least 1-year duration. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Self-reported recall of staying PI-free for 12 months vs having 1 or more PIs. RESULTS Among the 3817 participants, 74% were male, 76% were non-Hispanic White, and mean age was 48 years, with an average of 12 years post SCI. Based on self-report assessment, 67% reported being PI-free in the past year. After controlling for the demographic and injury characteristics, we found that those in the clinical cohort and those who reported healthy diets and planned exercise at least once a week were more likely to be PI-free; being underweight and high frequency of prescription medication use for spasticity, pain, and depression were negatively associated with being PI-free. Smoking, alcohol use, nonmedical substance use, and prescription medication misuse were not statistically significant in the multivariate model. CONCLUSIONS There are several significant behavioral predictors of being PI-free, and consideration of these factors may be used to develop tailored strategies to promote healthy skin maintenance and the prevention of multiple, severe, and recurrent PI.
Collapse
Affiliation(s)
- Yue Cao
- College of Health Professions, Medical University of South Carolina, Charleston, South Carolina.
| | - Nicole D DiPiro
- College of Health Professions, Medical University of South Carolina, Charleston, South Carolina
| | - James S Krause
- College of Health Professions, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
21
|
Cofer LB, Barrett TJ, Berger JS. Aspirin for the Primary Prevention of Cardiovascular Disease: Time for a Platelet-Guided Approach. Arterioscler Thromb Vasc Biol 2022; 42:1207-1216. [PMID: 36047408 PMCID: PMC9484763 DOI: 10.1161/atvbaha.122.318020] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 08/10/2022] [Indexed: 11/17/2022]
Abstract
Aspirin protects against atherothrombosis while increasing the risk of major bleeding. Although it is widely used to prevent cardiovascular disease (CVD), its benefit does not outweigh its risk for primary CVD prevention in large population settings. The recent United States Preventive Services Task Force guidelines on aspirin use to prevent CVD reflect this clinical tradeoff as well as the persistent struggle to define a population that would benefit from prophylactic aspirin therapy. Past clinical trials of primary CVD prevention with aspirin have not included consideration of a biomarker relevant to aspirin's mechanism of action, platelet inhibition. This approach is at odds with the paradigm used in other key areas of pharmacological CVD prevention, including antihypertensive and statin therapy, which combine cardiovascular risk assessment with the measurement of mechanistic biomarkers (eg, blood pressure and LDL [low-density lipoprotein]-cholesterol). Reliable methods for quantifying platelet activity, including light transmission aggregometry and platelet transcriptomics, exist and should be considered to identify individuals at elevated cardiovascular risk due to a hyperreactive platelet phenotype. Therefore, we propose a new, platelet-guided approach to the study of prophylactic aspirin therapy. We think that this new approach will reveal a population with hyperreactive platelets who will benefit most from primary CVD prevention with aspirin and usher in a new era of precision-guided antiplatelet therapy.
Collapse
|
22
|
Orozco-Beltrán D, Brotons Cuixart C, Banegas Banegas JR, Gil Guillén VF, Cebrián Cuenca AM, Martín Rioboó E, Jordá Baldó A, Vicuña J, Navarro Pérez J. [Cardiovascular preventive recommendations. PAPPS 2022 thematic updates. Working groups of the PAPPS]. Aten Primaria 2022; 54 Suppl 1:102444. [PMID: 36435583 PMCID: PMC9705225 DOI: 10.1016/j.aprim.2022.102444] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 07/21/2022] [Indexed: 11/24/2022] Open
Abstract
The recommendations of the semFYC's Program for Preventive Activities and Health Promotion (PAPPS) for the prevention of cardiovascular diseases (CVD) are presented. The following sections are included: epidemiological review, where the current morbidity and mortality of CVD in Spain and its evolution as well as the main risk factors are described; cardiovascular (CV) risk and recommendations for the calculation of CV risk; main risk factors such as arterial hypertension, dyslipidemia and diabetes mellitus, describing the method for their diagnosis, therapeutic objectives and recommendations for lifestyle measures and pharmacological treatment; indications for antiplatelet therapy, and recommendations for screening of atrial fibrillation, and recommendations for management of chronic conditions. The quality of testing and the strength of the recommendation are included in the main recommendations.
Collapse
Affiliation(s)
- Domingo Orozco-Beltrán
- Medicina Familiar y Comunitaria, Unidad de Investigación Centro de Salud Cabo Huertas, Departamento San Juan de Alicante. Departamento de Medicina Clínica, Universidad Miguel Hernández, San Juan de Alicante, España.
| | - Carlos Brotons Cuixart
- Medicina Familiar y Comunitaria. Instituto de Investigación Biomédica (IIB) Sant Pau. Equipo de Atención Primaria Sardenya, Barcelona, España
| | - Jose R Banegas Banegas
- Medicina Preventiva y Salud Pública, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, España
| | - Vicente F Gil Guillén
- Medicina Familiar y Comunitaria, Hospital Universitario de Elda. Departamento de Medicina Clínica. Universidad Miguel Hernández, San Juan de Alicante, España
| | - Ana M Cebrián Cuenca
- Medicina Familiar y Comunitaria, Centro de Salud Cartagena Casco Antiguo, Instituto Murciano de Investigación Biosanitaria (IMIB), 30120 Murcia, España
| | - Enrique Martín Rioboó
- Medicina Familiar y Comunitaria, Especialista en Medicina Familiar y Comunitaria, Centro de Salud Poniente, Córdoba, IMIBIC Hospital Reina Sofía Córdoba. Colaborador del grupo PAPPS
| | - Ariana Jordá Baldó
- Medicina Familiar y Comunitaria, Centro de Salud San Miguel, Plasencia, Badajoz, España
| | - Johanna Vicuña
- Medicina Preventiva y Salud Pública, Hospital de la Sant Creu i Sant Pau, Barcelona, España
| | - Jorge Navarro Pérez
- Medicina Familiar y Comunitaria, Hospital Clínico Universitario. Departamento de Medicina. Universidad de Valencia. Instituto de Investigación INCLIVA, Valencia, España
| |
Collapse
|
23
|
Li XY, Li L, Na SH, Santilli F, Shi Z, Blaha M. Implications of the heterogeneity between guideline recommendations for the use of low dose aspirin in primary prevention of cardiovascular disease. Am J Prev Cardiol 2022; 11:100363. [PMID: 35757317 PMCID: PMC9214826 DOI: 10.1016/j.ajpc.2022.100363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 06/02/2022] [Accepted: 06/05/2022] [Indexed: 11/30/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Xiao-Ying Li
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Li Li
- Medical Affairs & Pharmacovigilance, Pharmaceuticals, Bayer AG, Berlin, Germany
| | - Sang-Hoon Na
- Seoul National University Hospital, Seoul, Republic of Korea
| | - Francesca Santilli
- Department of Medicine and Aging and Center for Advanced Studies and Technology, D'Annunzio University of Chieti–Pescara, Chieti, Italy
| | - Zhongwei Shi
- Department of Cardiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Michael Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University Medical Center, Baltimore, MD, United States
| |
Collapse
|
24
|
Abstract
BACKGROUND The main complications of elevated systemic blood pressure (BP), coronary heart disease, ischaemic stroke, and peripheral vascular disease, are related to thrombosis rather than haemorrhage. Therefore, it is important to investigate if antithrombotic therapy may be useful in preventing thrombosis-related complications in patients with elevated BP. OBJECTIVES To conduct a systematic review of the role of antiplatelet therapy and anticoagulation in patients with elevated BP, including elevations in systolic or diastolic BP alone or together. To assess the effects of antiplatelet agents on total deaths or major thrombotic events or both in these patients versus placebo or other active treatment. To assess the effects of oral anticoagulants on total deaths or major thromboembolic events or both in these patients versus placebo or other active treatment. SEARCH METHODS The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials (RCTs) up to January 2021: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 12), Ovid MEDLINE (from 1946), and Ovid Embase (from 1974). The World Health Organization International Clinical Trials Registry Platform and the US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) were searched for ongoing trials. SELECTION CRITERIA: RCTs in patients with elevated BP were included if they were ≥ 3 months in duration and compared antithrombotic therapy with control or other active treatment. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data for inclusion criteria, our prespecified outcomes, and sources of bias. They assessed the risks and benefits of antiplatelet agents and anticoagulants by calculating odds ratios (OR), accompanied by the 95% confidence intervals (CI). They assessed risks of bias and applied GRADE criteria. MAIN RESULTS: Six trials (61,015 patients) met the inclusion criteria and were included in this review. Four trials were primary prevention (41,695 patients; HOT, JPAD, JPPP, and TPT), and two secondary prevention (19,320 patients, CAPRIE and Huynh). Four trials (HOT, JPAD, JPPP, and TPT) were placebo-controlled and two studies (CAPRIE and Huynh) included active comparators. Four studies compared acetylsalicylic acid (ASA) versus placebo and found no evidence of a difference for all-cause mortality (OR 0.97, 95% CI 0.87 to 1.08; 3 studies, 35,794 participants; low-certainty evidence). We found no evidence of a difference for cardiovascular mortality (OR 0.98, 95% CI 0.82 to 1.17; 3 studies, 35,794 participants; low-certainty evidence). ASA reduced the risk of all non-fatal cardiovascular events (OR 0.63, 95% CI 0.45 to 0.87; 1 study (missing data in 3 studies), 2540 participants; low-certainty evidence) and the risk of all cardiovascular events (OR 0.86, 95% CI 0.77 to 0.96; 3 studies, 35,794 participants; low-certainty evidence). ASA increased the risk of major bleeding events (OR 1.77, 95% CI 1.34 to 2.32; 2 studies, 21,330 participants; high-certainty evidence). One study (CAPRIE; ASA versus clopidogrel) included patients diagnosed with hypertension (mean age 62.5 years, 72% males, 95% Caucasians, mean follow-up: 1.91 years). It showed no evidence of a difference for all-cause mortality (OR 1.02, 95% CI 0.91 to 1.15; 1 study, 19,143 participants; high-certainty evidence) and for cardiovascular mortality (OR 1.08, 95% CI 0.94 to 1.26; 1 study, 19,143 participants; high-certainty evidence). ASA probably reduced the risk of non-fatal cardiovascular events (OR 1.10, 95% CI 1.00 to 1.22; 1 study, 19,143 participants; high-certainty evidence) and the risk of all cardiovascular events (OR 1.08, 95% CI 1.00 to 1.17; 1 study, 19,143 participants; high-certainty evidence) when compared to clopidogrel. Clopidogrel increased the risk of major bleeding events when compared to ASA (OR 1.35, 95% CI 1.14 to 1.61; 1 study, 19,143 participants; high-certainty evidence). In one study (Huynh; ASA verus warfarin) patients with unstable angina or non-ST-segment elevation myocardial infarction, with prior coronary artery bypass grafting (CABG) were included (mean age 68 years, 79.8% males, mean follow-up: 1.1 year). There was no evidence of a difference for all-cause mortality (OR 0.98, 95% CI 0.06 to 16.12; 1 study, 91 participants; low-certainty evidence). Cardiovascular mortality, non-fatal cardiovascular events, and all cardiovascular events were not available. There was no evidence of a difference for major bleeding events (OR 0.13, 95% CI 0.01 to 2.60; 1 study, 91 participants; low-certainty evidence). AUTHORS' CONCLUSIONS: There is no evidence that antiplatelet therapy modifies mortality in patients with elevated BP for primary prevention. ASA reduced the risk of cardiovascular events and increased the risk of major bleeding events. Antiplatelet therapy with ASA probably reduces the risk of non-fatal and all cardiovascular events when compared to clopidogrel. Clopidogrel increases the risk of major bleeding events compared to ASA in patients with elevated BP for secondary prevention. There is no evidence that warfarin modifies mortality in patients with elevated BP for secondary prevention. The benefits and harms of the newer drugs glycoprotein IIb/IIIa inhibitors, clopidogrel, prasugrel, ticagrelor, and non-vitamin K antagonist oral anticoagulants for patients with high BP have not been studied in clinical trials. Further RCTs of antithrombotic therapy including newer agents and complete documentation of all benefits and harms are required in patients with elevated BP.
Collapse
Affiliation(s)
- Eduard Shantsila
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Monika Kozieł-Siołkowska
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- 1st Department of Cardiology and Angiology, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| |
Collapse
|
25
|
Dimitriadis K, Lazarou E, Tsioufis P, Soulaidopoulos S, Tsioufis K. Aspirin for Primary Prevention of Cardiovascular Diseases: "WALTZ" with the Evidence. Curr Cardiol Rep 2022; 24:1139-1147. [PMID: 35857202 PMCID: PMC9297059 DOI: 10.1007/s11886-022-01740-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW In this review article, a detailed analysis of the current literature is provided, along with a "glimpse" into what the future holds for aspirin in the context of primary prevention. RECENT FINDINGS The role of aspirin in primary prevention of cardiovascular diseases (CVD) has been extensively evaluated; however, the results provided over the years have been controversial. Identification of individual subgroups who may benefit from aspirin administration at an acceptable risk of bleeding complications is of paramount importance. Additionally, questions emerge at everyday clinical practice regarding the optimal use of aspirin in different phenotypes of patients due to age, sex, obesity status, frailty and diabetes mellitus. Until further data become available, the effective management of the well-established CV risk factors constitutes the milestone in the primary prevention of CVD. Moreover, based on the available evidence, the beneficial addition of aspirin in the modern era of lifestyle and pharmacological interventions for primary CVD prevention remains largely undetermined and further research is needed.
Collapse
Affiliation(s)
- Kyriakos Dimitriadis
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 114 Vassilissis Sofias Ave 11527, Athens, Greece
| | - Emilia Lazarou
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 114 Vassilissis Sofias Ave 11527, Athens, Greece
| | - Panagiotis Tsioufis
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 114 Vassilissis Sofias Ave 11527, Athens, Greece
| | - Stergios Soulaidopoulos
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 114 Vassilissis Sofias Ave 11527, Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, 114 Vassilissis Sofias Ave 11527, Athens, Greece.
| |
Collapse
|
26
|
O'Connor EA, Evans CV, Ivlev I, Rushkin MC, Thomas RG, Martin A, Lin JS. Vitamin and Mineral Supplements for the Primary Prevention of Cardiovascular Disease and Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2022; 327:2334-2347. [PMID: 35727272 DOI: 10.1001/jama.2021.15650] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Cardiovascular disease and cancer are the 2 leading causes of death in the US, and vitamin and mineral supplementation has been proposed to help prevent these conditions. OBJECTIVE To review the benefits and harms of vitamin and mineral supplementation in healthy adults to prevent cardiovascular disease and cancer to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, PubMed (publisher-supplied records only), Cochrane Library, and Embase (January 2013 to February 1, 2022); prior reviews. STUDY SELECTION English-language randomized clinical trials (RCTs) of vitamin or mineral use among adults without cardiovascular disease or cancer and with no known vitamin or mineral deficiencies; observational cohort studies examining serious harms. DATA EXTRACTION AND SYNTHESIS Single extraction, verified by a second reviewer. Quantitative pooling methods appropriate for rare events were used for most analyses. MAIN OUTCOMES AND MEASURES Mortality, cardiovascular disease events, cancer incidence, serious harms. RESULTS Eighty-four studies (N=739 803) were included. In pooled analyses, multivitamin use was significantly associated with a lower incidence of any cancer (odds ratio [OR], 0.93 [95% CI, 0.87-0.99]; 4 RCTs [n=48 859]; absolute risk difference [ARD] range among adequately powered trials, -0.2% to -1.2%) and lung cancer (OR, 0.75 [95% CI, 0.58-0.95]; 2 RCTs [n=36 052]; ARD, 0.2%). However, the evidence for multivitamins had important limitations. Beta carotene (with or without vitamin A) was significantly associated with an increased risk of lung cancer (OR, 1.20 [95% CI, 1.01-1.42]; 4 RCTs [n=94 830]; ARD range, -0.1% to 0.6%) and cardiovascular mortality (OR, 1.10 [95% CI, 1.02-1.19]; 5 RCTs [n=94 506] ARD range, -0.8% to 0.8%). Vitamin D use was not significantly associated with all-cause mortality (OR, 0.96 [95% CI, 0.91-1.02]; 27 RCTs [n=117 082]), cardiovascular disease (eg, composite cardiovascular disease event outcome: OR, 1.00 [95% CI, 0.95-1.05]; 7 RCTs [n=74 925]), or cancer outcomes (eg, any cancer incidence: OR, 0.98 [95% CI, 0.92-1.03]; 19 RCTs [n=86 899]). Vitamin E was not significantly associated with all-cause mortality (OR, 1.02 [95% CI, 0.97-1.07]; 9 RCTs [n=107 772]), cardiovascular disease events (OR, 0.96 [95% CI, 0.90-1.04]; 4 RCTs [n=62 136]), or cancer incidence (OR, 1.02 [95% CI, 0.98-1.08]; 5 RCTs [n=76 777]). Evidence for benefit of other supplements was equivocal, minimal, or absent. Limited evidence suggested some supplements may be associated with higher risk of serious harms (hip fracture [vitamin A], hemorrhagic stroke [vitamin E], and kidney stones [vitamin C, calcium]). CONCLUSIONS AND RELEVANCE Vitamin and mineral supplementation was associated with little or no benefit in preventing cancer, cardiovascular disease, and death, with the exception of a small benefit for cancer incidence with multivitamin use. Beta carotene was associated with an increased risk of lung cancer and other harmful outcomes in persons at high risk of lung cancer.
Collapse
Affiliation(s)
- Elizabeth A O'Connor
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Corinne V Evans
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Ilya Ivlev
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Megan C Rushkin
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
- Center for Evidence-based Policy, Oregon Health & Science University, Portland
| | - Rachel G Thomas
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Allea Martin
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Jennifer S Lin
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| |
Collapse
|
27
|
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. Am J Cardiovasc Drugs 2022; 22:657-675. [PMID: 35570250 DOI: 10.1007/s40256-022-00537-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 12/22/2022]
Abstract
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.
Collapse
|
28
|
Guirguis-Blake JM, Evans CV, Perdue LA, Bean SI, Senger CA. Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2022; 327:1585-1597. [PMID: 35471507 DOI: 10.1001/jama.2022.3337] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Low-dose aspirin is used for primary cardiovascular disease prevention and may have benefits for colorectal cancer prevention. OBJECTIVE To review the benefits and harms of aspirin in primary cardiovascular disease prevention and colorectal cancer prevention to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, PubMed, Embase, and the Cochrane Central Register of Controlled Trials through January 2021; literature surveillance through January 21, 2022. STUDY SELECTION English-language randomized clinical trials (RCTs) of low-dose aspirin (≤100 mg/d) compared with placebo or no intervention in primary prevention populations. DATA EXTRACTION AND SYNTHESIS Single extraction, verified by a second reviewer. Quantitative synthesis using Peto fixed-effects meta-analysis. MAIN OUTCOMES AND MEASURES Cardiovascular disease events and mortality, all-cause mortality, colorectal cancer incidence and mortality, major bleeding, and hemorrhagic stroke. RESULTS Eleven RCTs (N = 134 470) and 1 pilot trial (N = 400) of low-dose aspirin for primary cardiovascular disease prevention were included. Low-dose aspirin was associated with a significant decrease in major cardiovascular disease events (odds ratio [OR], 0.90 [95% CI, 0.85-0.95]; 11 RCTs [n = 134 470]; I2 = 0%; range in absolute effects, -2.5% to 0.1%). Results for individual cardiovascular disease outcomes were significant, with similar magnitude of benefit. Aspirin was not significantly associated with reductions in cardiovascular disease mortality or all-cause mortality. There was limited trial evidence on benefits for colorectal cancer, with the findings highly variable by length of follow-up and statistically significant only when considering long-term observational follow-up beyond randomized trial periods. Low-dose aspirin was associated with significant increases in total major bleeding (OR, 1.44 [95% CI, 1.32-1.57]; 10 RCTs [n = 133 194]; I2 = 4.7%; range in absolute effects, 0.1% to 1.0%) and in site-specific bleeding, with similar magnitude. CONCLUSIONS AND RELEVANCE Low-dose aspirin was associated with small absolute risk reductions in major cardiovascular disease events and small absolute increases in major bleeding. Colorectal cancer results were less robust and highly variable.
Collapse
Affiliation(s)
- Janelle M Guirguis-Blake
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
- Department of Family Medicine, University of Washington, Tacoma
| | - Corinne V Evans
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Leslie A Perdue
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Sarah I Bean
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Caitlyn A Senger
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| |
Collapse
|
29
|
Zareef R, Diab M, Al Saleh T, Makarem A, Younis NK, Bitar F, Arabi M. Aspirin in COVID-19: Pros and Cons. Front Pharmacol 2022; 13:849628. [PMID: 35370686 PMCID: PMC8965577 DOI: 10.3389/fphar.2022.849628] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 02/21/2022] [Indexed: 01/08/2023] Open
Abstract
Since its emergence, the COVID-19 pandemic has been ravaging the medical and economic sectors even with the significant vaccination advances. In severe presentations, the disease of SARS-CoV-2 can manifest with life-threatening thromboembolic and multi-organ repercussions provoking notable morbidity and mortality. The pathogenesis of such burdensome forms has been under extensive investigation and is attributed to a state of immune dysfunction and hyperinflammation. In light of these extraordinary circumstances, research efforts have focused on investigating and repurposing previously available agents that target the inflammatory and hematological cascades. Aspirin, due to its well-known properties and multiple molecular targets, and ought to its extensive clinical use, has been perceived as a potential therapeutic agent for COVID-19. Aspirin acts at multiple cellular targets to achieve its anti-inflammatory and anti-platelet effects. Although initial promising clinical data describing aspirin role in COVID-19 has appeared, evidence supporting its use remains fragile and premature. This review explores the notion of repurposing aspirin in COVID-19 infection. It delves into aspirin as a molecule, along with its pharmacology and clinical applications. It also reviews the current high-quality clinical evidence highlighting the role of aspirin in SARS-CoV-2 infection.
Collapse
Affiliation(s)
- Rana Zareef
- Pediatric and Adolescent Medicine Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Marwa Diab
- Pediatric and Adolescent Medicine Department, American University of Beirut Medical Center, Beirut, Lebanon
| | - Tala Al Saleh
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Adham Makarem
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nour K. Younis
- Brigham and Women’s Hospital-Harvard Medical School, Boston, MA, United States
| | - Fadi Bitar
- Pediatric and Adolescent Medicine Department, American University of Beirut Medical Center, Beirut, Lebanon
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Pediatric Department, Division of Pediatric Cardiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mariam Arabi
- Pediatric and Adolescent Medicine Department, American University of Beirut Medical Center, Beirut, Lebanon
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Pediatric Department, Division of Pediatric Cardiology, American University of Beirut Medical Center, Beirut, Lebanon
| |
Collapse
|
30
|
Alghadeer S, Alwhaibi AM, Alhossan A, Babelghaith SD, Mubarak AM, Samreen S, Alameel NN, Aljabali NN, Al-Arifi MN. Aspirin Use among Saudi Adults: The Prevalence and Users’ Characteristics. Saudi Pharm J 2022; 30:340-346. [PMID: 35527833 PMCID: PMC9068572 DOI: 10.1016/j.jsps.2022.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 02/06/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Despite the public routine use of aspirin as cardio-prophylaxis agent, its use is only recommended in particular situations, and not as usual primary prevention. Only few local studies investigate the use of aspirin in patients with certain diseases, but not within the public population. The purpose of this study was to evaluate the prevalence of aspirin use and identify the demographic and clinical characteristics among Saudi users. Methodology A cross-sectional study targeting Saudi adults in Saudi Arabia was conducted over a period of four months in 2021 using online Google forms. The study collected data to assess the prevalence of use, use of aspirin according to prevention type, users’ characteristics and comorbidities. Additionally, a self-assessment of knowledge, perception, reasons and attitude towards aspirin use among Saudi adults was conducted. A chi-square test was used to determine the association between the variables. A P-value ≤ 0.05 was considered statistically significant. Results The prevalence of aspirin use was 47%. Regarding the self-assessed aspirin knowledge, the majority of the respondents (n = 481; 62.4 %) found to have good knowledge. Less than half of the participants (n = 341; 44%) use aspirin as primary prevention agent while only 23 participants (2.9%) use aspirin as secondary prevention agent. There was a significant difference between gender and user type (p = 0.001). With regards to comorbidities, hypertension, hyperlipidemia, diabetes, and obesity were common among the primary users of aspirin. Significant associations were found (p = 0.001) between participant’s user type and the following characteristics such as smoking status, past medical history, presence of comorbidities. Conclusion Aspirin use is commonly prevalent Saudi population with good level of knowledge of the therapy; however, its popular use as primary preventive agent for CVD may necessitate medical advice based on the level of cardiovascular risk.
Collapse
Affiliation(s)
- Sultan Alghadeer
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Corresponding author at: P.O.Box 2454, Riyadh 11451, Saudi Arabia.
| | - Abdulrahman M. Alwhaibi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz Alhossan
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Salmeen D. Babelghaith
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah M. Mubarak
- Department of Basic Sciences, PSCEMS, King Saud University, Riyadh, Saudi Arabia
| | - Sana Samreen
- Volunteering Researcher in the Drug and Poison Information Center (DPIC), Clinical Pharmacy Department, College of Pharmacy, King Saud University
| | - Nouf N. Alameel
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Noura N. Aljabali
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mohamed N. Al-Arifi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| |
Collapse
|
31
|
Violi F, Nocella C, Loffredo L, Carnevale R, Pignatelli P. Interventional study with vitamin E in cardiovascular disease and meta-analysis. Free Radic Biol Med 2022; 178:26-41. [PMID: 34838937 DOI: 10.1016/j.freeradbiomed.2021.11.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/27/2021] [Accepted: 11/12/2021] [Indexed: 12/15/2022]
Abstract
Cardiovascular disease (CVD) is one of the major causes of morbidity and mortality and atherosclerosis is the common root to most of the CVD. Oxidative stress is one of the most important factors driving atherosclerosis and its complications. Thus, strategies for the prevention and treatment of cardiovascular events had oxidative changes as a potential target. Natural vitamin E consists of a family of eight different compounds, four tocopherols and four tocotrienols. All tocopherols and tocotrienols are potent antioxidants with lipoperoxyl radical-scavenging activities. In addition, α-tocopherol possesses also anti-inflammatory as well as anti-atherothrombotic effects by modulating platelet and clotting system. Experimental and in vitro studies described molecular and cellular signalling pathways regulated by vitamin E antithrombotic and antioxidant properties. While observational studies demonstrated an inverse association between vitamin E serum levels and CVD, interventional trials with vitamin supplements provided negative results. This review focus on the impact of vitamin E in the atherothrombotic process and describes the results of experimental and clinical studies with the caveats related to the interventional trials with vitamin E to prevent CVD.
Collapse
Affiliation(s)
- Francesco Violi
- Mediterranea Cardiocentro, Napoli, Italy; Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy.
| | - Cristina Nocella
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - Lorenzo Loffredo
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - Roberto Carnevale
- Mediterranea Cardiocentro, Napoli, Italy; Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100, Latina, Italy
| | - Pasquale Pignatelli
- Mediterranea Cardiocentro, Napoli, Italy; Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy
| |
Collapse
|
32
|
Calderone D, Ingala S, Mauro MS, Angiolillo DJ, Capodanno D. Appraising the contemporary role of aspirin for primary and secondary prevention of atherosclerotic cardiovascular events. Expert Rev Cardiovasc Ther 2021; 19:1097-1117. [PMID: 34915778 DOI: 10.1080/14779072.2021.2020100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
Collapse
Affiliation(s)
- Dario Calderone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco" University of Catania, Catania, Italy
| | - Salvatore Ingala
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco" University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco" University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco" University of Catania, Catania, Italy
| |
Collapse
|
33
|
Abstract
Coronary artery disease is the leading cause of death in both men and women, yet adequate control of risk factors can largely reduce the incidence and recurrence of cardiac events. In this review, we discuss various life style and pharmacological measures for both the primary and secondary prevention of coronary artery disease. With a clear understanding of management options, health care providers have an excellent opportunity to educate patients and ameliorate a significant burden of morbidity and mortality.
Collapse
Affiliation(s)
- Lindsay Short
- Cardiology, University of California, Riverside, School of Medicine of California Riverside School of Medicine, Riverside, California,St Bernadine Medical Center, Cardiology, Internal Medicine, San Bernardino, California
| | - Van T. La
- Cardiology, University of California, Riverside, School of Medicine of California Riverside School of Medicine, Riverside, California,St Bernadine Medical Center, Cardiology, Internal Medicine, San Bernardino, California
| | - Mandira Patel
- Cardiology, University of California, Riverside, School of Medicine of California Riverside School of Medicine, Riverside, California,St Bernadine Medical Center, Cardiology, Internal Medicine, San Bernardino, California
| | - Ramdas G. Pai
- Cardiology, University of California, Riverside, School of Medicine of California Riverside School of Medicine, Riverside, California,St Bernadine Medical Center, Cardiology, Internal Medicine, San Bernardino, California,Address for correspondence Ramdas G. Pai, MD UCR School of MedicineRiversideCalifornia
| |
Collapse
|
34
|
Kumar G, Saini M, Kundu S. Therapeutic enzymes as non-conventional targets in cardiovascular impairments:A Comprehensive Review. Can J Physiol Pharmacol 2021; 100:197-209. [PMID: 34932415 DOI: 10.1139/cjpp-2020-0732] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Over the last few decades, substantial progress has been made towards the understanding of cardiovascular diseases (CVDs). In-depth mechanistic insights have also provided opportunities to explore novel therapeutic targets and treatment regimens to be discovered. Therapeutic enzymes are an example of such opportunities. The balanced functioning of such enzymes protects against a variety of CVDs while on the other hand, even a small shift in the normal functioning of these enzymes may lead to deleterious outcomes. Owing to the great versatility of these enzymes, inhibition and activation are key regulatory approaches to counter the onset and progression of several cardiovascular impairments. While cardiovascular remedies are already available in excess and of course they are efficacious, a comprehensive description of novel therapeutic enzymes to combat CVDs is the need of the hour. In light of this, the regulation of the functional activity of these enzymes also opens a new avenue for the treatment approaches to be employed. This review describes the importance of non-conventional enzymes as potential candidates in several cardiovascular disorders while highlighting some of the recently targeted therapeutic enzymes in CVDs.
Collapse
Affiliation(s)
- Gaurav Kumar
- University of Delhi - South Campus, 93081, Biochemistry, New Delhi, Delhi, India;
| | - Manisha Saini
- University of Delhi - South Campus, 93081, Biochemistry, New Delhi, Delhi, India;
| | - Suman Kundu
- University of Delhi - South Campus, 93081, Biochemistry, New Delhi, Delhi, India;
| |
Collapse
|
35
|
Kim K, Hennekens CH, Martinez L, Gaziano JM, Pfeffer MA, Biglione B, Gitin A, McCabe JB, Cook TD, DeMets DL, Wood SK. Primary care providers should prescribe aspirin to prevent cardiovascular disease based on benefit-risk ratio, not age. Fam Med Community Health 2021; 9:e001475. [PMID: 34952844 PMCID: PMC8710906 DOI: 10.1136/fmch-2021-001475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Recent guidelines restricted aspirin (ASA) in primary prevention of cardiovascular disease (CVD) to patients <70 years old and more recent guidance to <60.In the most comprehensive prior meta-analysis, the Antithrombotic Trialists Collaboration reported a significant 12% reduction in CVD with similar benefit-risk ratios at older ages. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, four trials were added to an updated meta-analysis.ASA produced a statistically significant 13% reduction in CVD with 95% confidence limits (0.83 to 0.92) with similar benefits at older ages in each of the trials.Primary care providers should make individual decisions whether to prescribe ASA based on benefit-risk ratio, not simply age. When the absolute risk of CVD is >10%, benefits of ASA will generally outweigh risks of significant bleeding. ASA should be considered only after implementation of therapeutic lifestyle changes and other drugs of proven benefit such as statins, which are, at the very least, additive to ASA. Our perspective is that individual clinical judgements by primary care providers about prescription of ASA in primary prevention of CVD should be based on our evidence-based solution of weighing all the absolute benefits and risks rather than age. This strategy would do far more good for far more patients as well as far more good than harm in both developed and developing countries. This new and novel strategy for primary care providers to consider in prescribing ASA in primary prevention of CVD is the same as the general approach suggested by Professor Geoffrey Rose decades ago.
Collapse
Affiliation(s)
- Kyungmann Kim
- Biostatistics and Medical Informatics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Charles H Hennekens
- Medicine and Population Health and Social Medicine, Florida Atlantic University, Charles E Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Lisa Martinez
- Medicine and Population Health and Social Medicine, Florida Atlantic University, Charles E Schmidt College of Medicine, Boca Raton, Florida, USA
| | | | - Marc A Pfeffer
- Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Bianca Biglione
- Medicine and Population Health and Social Medicine, Florida Atlantic University, Charles E Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Alexander Gitin
- Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jeanne Bell McCabe
- Biostatistics and Medical Informatics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Thomas D Cook
- Biostatistics and Medical Informatics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - David L DeMets
- Biostatistics and Medical Informatics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Sarah K Wood
- Medicine and Population Health and Social Medicine, Florida Atlantic University, Charles E Schmidt College of Medicine, Boca Raton, Florida, USA
| |
Collapse
|
36
|
Murphy E, Curneen JMG, McEvoy JW. Aspirin in the Modern Era of Cardiovascular Disease Prevention. Methodist Debakey Cardiovasc J 2021; 17:36-47. [PMID: 34824680 PMCID: PMC8588762 DOI: 10.14797/mdcvj.293] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 04/18/2021] [Indexed: 12/20/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Ella Murphy
- National University of Ireland, Galway, Ireland
| | | | | |
Collapse
|
37
|
Joshi A, Schmidt LE, Burnap SA, Lu R, Chan MV, Armstrong PC, Baig F, Gutmann C, Willeit P, Santer P, Barwari T, Theofilatos K, Kiechl S, Willeit J, Warner TD, Mathur A, Mayr M. Neutrophil-Derived Protein S100A8/A9 Alters the Platelet Proteome in Acute Myocardial Infarction and Is Associated With Changes in Platelet Reactivity. Arterioscler Thromb Vasc Biol 2021; 42:49-62. [PMID: 34809447 PMCID: PMC8691374 DOI: 10.1161/atvbaha.121.317113] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Supplemental Digital Content is available in the text. Objective: Platelets are central to acute myocardial infarction (MI). How the platelet proteome is altered during MI is unknown. We sought to describe changes in the platelet proteome during MI and identify corresponding functional consequences. Approach and Results: Platelets from patients experiencing ST-segment–elevation MI (STEMI) before and 3 days after treatment (n=30) and matched patients with severe stable coronary artery disease before and 3 days after coronary artery bypass grafting (n=25) underwent quantitative proteomic analysis. Elevations in the proteins S100A8 and S100A9 were detected at the time of STEMI compared with stable coronary artery disease (S100A8: FC, 2.00; false discovery rate, 0.05; S100A9: FC, 2.28; false discovery rate, 0.005). During STEMI, only S100A8 mRNA and protein levels were correlated in platelets (R=0.46, P=0.012). To determine whether de novo protein synthesis occurs, activated platelets were incubated with 13C-labeled amino acids for 24 hours and analyzed by mass spectrometry. No incorporation was confidently detected. Platelet S100A8 and S100A9 was strongly correlated with neutrophil abundance at the time of STEMI. When isolated platelets and neutrophils were coincubated under quiescent and activated conditions, release of S100A8 from neutrophils resulted in uptake of S100A8 by platelets. Neutrophils released S100A8/A9 as free heterodimer, rather than in vesicles or extracellular traps. In the community-based Bruneck study (n=338), plasma S100A8/A9 was inversely associated with platelet reactivity—an effect abrogated by aspirin. Conclusions: Leukocyte-to-platelet protein transfer may occur in a thromboinflammatory environment such as STEMI. Plasma S100A8/A9 was negatively associated with platelet reactivity. These findings highlight neutrophils as potential modifiers for thrombotic therapies in coronary artery disease.
Collapse
Affiliation(s)
- Abhishek Joshi
- King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, United Kingdom (A.J., L.E.S., S.A.B., R.L., F.B., C.G., T.B., K.T., M.M.).,Department of Cardiology, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom (A.J., A.M.)
| | - Lukas E Schmidt
- King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, United Kingdom (A.J., L.E.S., S.A.B., R.L., F.B., C.G., T.B., K.T., M.M.)
| | - Sean A Burnap
- King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, United Kingdom (A.J., L.E.S., S.A.B., R.L., F.B., C.G., T.B., K.T., M.M.)
| | - Ruifang Lu
- King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, United Kingdom (A.J., L.E.S., S.A.B., R.L., F.B., C.G., T.B., K.T., M.M.)
| | - Melissa V Chan
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom (M.V.C., P.C.A., T.D.W.)
| | - Paul C Armstrong
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom (M.V.C., P.C.A., T.D.W.)
| | - Ferheen Baig
- King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, United Kingdom (A.J., L.E.S., S.A.B., R.L., F.B., C.G., T.B., K.T., M.M.)
| | - Clemens Gutmann
- King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, United Kingdom (A.J., L.E.S., S.A.B., R.L., F.B., C.G., T.B., K.T., M.M.)
| | - Peter Willeit
- Department of Neurology, Medical University of Innsbruck, Austria (P.W., S.K., J.W.)
| | - Peter Santer
- Department of Laboratory Medicine, Bruneck Hospital, Italy (P.S.)
| | - Temo Barwari
- King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, United Kingdom (A.J., L.E.S., S.A.B., R.L., F.B., C.G., T.B., K.T., M.M.)
| | - Konstantinos Theofilatos
- King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, United Kingdom (A.J., L.E.S., S.A.B., R.L., F.B., C.G., T.B., K.T., M.M.)
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Austria (P.W., S.K., J.W.).,Research Centre on Vascular Ageing and Stroke, Innsbruck, Austria (S.K., J.W.)
| | - Johann Willeit
- Department of Neurology, Medical University of Innsbruck, Austria (P.W., S.K., J.W.).,Research Centre on Vascular Ageing and Stroke, Innsbruck, Austria (S.K., J.W.)
| | - Timothy D Warner
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom (M.V.C., P.C.A., T.D.W.)
| | - Anthony Mathur
- Department of Cardiology, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom (A.J., A.M.)
| | - Manuel Mayr
- King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, United Kingdom (A.J., L.E.S., S.A.B., R.L., F.B., C.G., T.B., K.T., M.M.).,Centre for Cardiovascular Medicine and Devices, Queen Mary's University, London, United Kingdom (A.M.)
| |
Collapse
|
38
|
Hirai S, Miwa H, Tanaka T, Toriumi K, Kunii Y, Shimbo H, Sakamoto T, Hino M, Izumi R, Nagaoka A, Yabe H, Nakamachi T, Shioda S, Dan T, Miyata T, Nishito Y, Suzuki K, Miyashita M, Tomoda T, Hikida T, Horiuchi J, Itokawa M, Arai M, Okado H. High-sucrose diets contribute to brain angiopathy with impaired glucose uptake and psychosis-related higher brain dysfunctions in mice. SCIENCE ADVANCES 2021; 7:eabl6077. [PMID: 34757783 PMCID: PMC8580307 DOI: 10.1126/sciadv.abl6077] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 09/21/2021] [Indexed: 05/30/2023]
Abstract
Metabolic dysfunction is thought to contribute to the severity of psychiatric disorders; however, it has been unclear whether current high–simple sugar diets contribute to pathogenesis of these diseases. Here, we demonstrate that a high-sucrose diet during adolescence induces psychosis-related behavioral endophenotypes, including hyperactivity, poor working memory, impaired sensory gating, and disrupted interneuron function in mice deficient for glyoxalase-1 (GLO1), an enzyme involved in detoxification of sucrose metabolites. Furthermore, the high-sucrose diet induced microcapillary impairments and reduced brain glucose uptake in brains of Glo1-deficient mice. Aspirin protected against this angiopathy, enhancing brain glucose uptake and preventing abnormal behavioral phenotypes. Similar vascular damage to our model mice was found in the brains of randomly collected schizophrenia and bipolar disorder patients, suggesting that psychiatric disorders are associated with angiopathy in the brain caused by various environmental stresses, including metabolic stress.
Collapse
Affiliation(s)
- Shinobu Hirai
- Sleep Disorders Project, Department of Psychiatry and Behavioral Sciences, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
| | - Hideki Miwa
- Sleep Disorders Project, Department of Psychiatry and Behavioral Sciences, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
- Molecular Neuropsychopharmacology Section, Department of Neuropsychopharmacology, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo 187-8553, Japan
| | - Tomoko Tanaka
- Department of Basic Medical Sciences, Tokyo Metropolitan Institute of Medical Science, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
| | - Kazuya Toriumi
- Schizophrenia Research Project, Department of Psychiatry and Behavioral Sciences, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
| | - Yasuto Kunii
- Department of Neuropsychiatry, School of Medicine, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Hiroko Shimbo
- Sleep Disorders Project, Department of Psychiatry and Behavioral Sciences, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
| | - Takuya Sakamoto
- Department of Applied Biological Science, Faculty of Science and Technology, Tokyo University of Science, 2641 Yamazaki, Noda, Chiba 278-8510, Japan
| | - Mizuki Hino
- Department of Neuropsychiatry, School of Medicine, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Ryuta Izumi
- Department of Neuropsychiatry, School of Medicine, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Atsuko Nagaoka
- Department of Neuropsychiatry, School of Medicine, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Hirooki Yabe
- Department of Neuropsychiatry, School of Medicine, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Tomoya Nakamachi
- Laboratory of Regulatory Biology, Graduate School of Science and Engineering, University of Toyama, Toyama 930-8555, Japan
| | - Seiji Shioda
- Department of Clinical Pharmacy, Shonan University of Medical Sciences, Yokohama 244-0806, Japan
| | - Takashi Dan
- Division of Molecular Medicine and Therapy, Tohoku University Graduate School of Medicine, Miyagi 980-8575, Japan
| | - Toshio Miyata
- Division of Molecular Medicine and Therapy, Tohoku University Graduate School of Medicine, Miyagi 980-8575, Japan
| | - Yasumasa Nishito
- Center for Basic Technology Research, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
| | - Kazuhiro Suzuki
- Schizophrenia Research Project, Department of Psychiatry and Behavioral Sciences, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
| | - Mitsuhiro Miyashita
- Schizophrenia Research Project, Department of Psychiatry and Behavioral Sciences, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
| | - Toshifumi Tomoda
- Centre for Addiction and Mental Health, Campbell Family Mental Health Research Institute, University of Toronto, Toronto, ON M5T 1R8, Canada
| | - Takatoshi Hikida
- Laboratory for Advanced Brain Functions, Institute for Protein Research, Osaka University, Osaka 565-0871, Japan
| | - Junjiro Horiuchi
- Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
| | - Masanari Itokawa
- Schizophrenia Research Project, Department of Psychiatry and Behavioral Sciences, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
| | - Makoto Arai
- Schizophrenia Research Project, Department of Psychiatry and Behavioral Sciences, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
| | - Haruo Okado
- Sleep Disorders Project, Department of Psychiatry and Behavioral Sciences, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
| |
Collapse
|
39
|
Gassanov N, Eicke M, Er F. [Aspirin in primary prevention of cardiovascular and cerebrovascular diseases]. Dtsch Med Wochenschr 2021; 146:1353-1359. [PMID: 34644796 DOI: 10.1055/a-1578-6802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Acetylsalicylic acid (aspirin) is one of the most used medications worldwide. The antithrombotic agent acts mainly through inhibition of cyclooxygenase-1 and consequently thromboxane A2 synthesis, causing an irreversible suppression of platelet function. Despite of its proven benefit in the treatment and secondary prevention of atherosclerotic diseases, its use for the primary prevention remains controversial due to an unclear balance between the benefits and risks of aspirin. Moreover, the recent evidence indicates that the risk of major bleeding outweighs the potential to reduce ischemic events in patients without atherosclerotic diseases, thus, precluding the general use of aspirin for the primary prevention.
Collapse
Affiliation(s)
- Natig Gassanov
- Medizinische Klinik II, Klinikum Idar-Oberstein, Idar-Oberstein
| | - Martin Eicke
- Klinik für Neurologie, Klinikum Idar-Oberstein, Idar-Oberstein
| | - Fikret Er
- Klinik I für Innere Medizin, Klinikum Gütersloh, Gütersloh
| |
Collapse
|
40
|
Calderone D, Greco A, Ingala S, Agnello F, Franchina G, Scalia L, Buccheri S, Capodanno D. Efficacy and Safety of Aspirin for Primary Cardiovascular Risk Prevention in Younger and Older Age: An Updated Systematic Review and Meta-analysis of 178,310 Subjects from 21 Randomized Studies. Thromb Haemost 2021; 122:445-455. [PMID: 34638150 DOI: 10.1055/a-1667-7427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2021] [Indexed: 01/04/2023]
Abstract
AIMS The efficacy and safety of aspirin for primary cardiovascular disease (CVD) prevention is controversial. The aim of this study was to investigate the efficacy and safety of aspirin in subjects with no overt CVD, with a focus on age as a treatment modifier. METHODS AND RESULTS Randomized trials comparing aspirin use versus no aspirin use or placebo were included. The primary efficacy outcome was all-cause death. The primary safety outcome was major bleeding. Secondary ischemic and bleeding outcomes were explored. Subgroup analyses were conducted to investigate the consistency of the effect sizes in studies including younger and older individuals, using a cut-off of 65 years. A total of 21 randomized trials including 173,810 individuals at a mean follow-up of 5.3 years were included. Compared with control, aspirin did not reduce significantly the risk of all-cause death (risk ratio: 0.96; 95% confidence interval: 0.92-1.00, p = 0.057). Major adverse cardiovascular events were significantly reduced by 11%, paralleled by significant reductions in myocardial infarction and transient ischemic attack. Major bleeding, intracranial hemorrhage, and gastrointestinal bleeding were significantly increased by aspirin. There was a significant age interaction for death (p for interaction = 0.007), with aspirin showing a statistically significant 7% relative benefit on all-cause death in studies including younger patients. CONCLUSION The use of aspirin in subjects with no overt CVD was associated with a neutral effect on all-cause death and a modest lower risk of major cardiovascular events at the price of an increased risk in major bleeding. The benefit of aspirin might be more pronounced in younger individuals.
Collapse
Affiliation(s)
- Dario Calderone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
| | - Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
| | - Salvatore Ingala
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
| | - Gabriele Franchina
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
| | - Lorenzo Scalia
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
| | - Sergio Buccheri
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Catania, Italy
| |
Collapse
|
41
|
Li PC, Yang YC, Wang JH, Lin SZ, Ding DC. Endometriosis Is Associated with an Increased Risk of Coronary Artery Disease in Asian Women. J Clin Med 2021; 10:4173. [PMID: 34575282 PMCID: PMC8472678 DOI: 10.3390/jcm10184173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 11/20/2022] Open
Abstract
Endometriosis is a common systemic chronic inflammatory disease. Inflammation is the key mechanism responsible for the development of endothelial dysfunction and atherosclerosis. We aimed to investigate the risk of coronary artery disease (CAD) among Asian women with endometriosis. This retrospective population-based cohort study included patients with endometriosis diagnosed from 2000 to 2012 and registered in the Longitudinal Health Insurance Database, Taiwan. The comparison cohort (those without endometriosis) were selected (1:4) by matching the age frequency and the index year. We followed up the patients until the diagnosis of CAD (ICD-9-CM codes: 410-414, A270, and A279), withdrawal from the National Health Insurance system, death, or the end of the study. We used a multivariable-adjusted Cox proportional hazard model for evaluating the risk of CAD. We included 19,454 patients with endometriosis and 77,816 women as a comparison group. The mean age of the women at the diagnosis of endometriosis was 37.4 years. A total of 3245 women developed CAD in both groups during a median follow-up of 7 years. The incidence of CAD was higher in women with endometriosis than in those without (5.96 vs. 4.38 per 10,000 person-years; adjusted hazard ratio [95% confidence interval], 1.34 [1.22-1.47]). In conclusion, Asian women with endometriosis had a significantly higher risk of CAD. Further large-scale studies are needed to elucidate the cause-effect relationship between endometriosis and CAD.
Collapse
Affiliation(s)
- Pei-Chen Li
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien 970, Taiwan;
| | - Yu-Cih Yang
- Management Office for Health Data, China Medical University Hospital, Taichung 404, Taiwan;
- College of Medicine, China Medical University, Taichung 404, Taiwan
| | - Jen-Hung Wang
- Department of Research, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien 970, Taiwan;
| | - Shinn-Zong Lin
- Department of Neurosurgery, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien 970, Taiwan;
| | - Dah-Ching Ding
- Department of Obstetrics and Gynecology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien 970, Taiwan;
- Institute of Medical Sciences, Tzu Chi University, Hualien 970, Taiwan
| |
Collapse
|
42
|
Ojo OO, Leake DS. Vitamins E and C do not effectively inhibit low density lipoprotein oxidation by ferritin at lysosomal pH. Free Radic Res 2021; 55:525-534. [PMID: 34396869 DOI: 10.1080/10715762.2021.1964494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Low density lipoprotein (LDL) might be oxidized by iron in the lysosomes of macrophages in atherosclerotic lesions. We have shown previously that the iron-storage proteinferritin can oxidize LDL at lysosomal pH. We have now investigated the roles of the most important antioxidant contained in LDL, α-tocopherol (the main form of vitamin E) and of ascorbate (vitamin C), a major water-soluble antioxidant, on LDL oxidation by ferritin at lysosomal pH (pH 4.5). We incubated LDL with ferritin at pH 4.5 and 37 °C and measured its oxidation by monitoring the formation of conjugated dienes at 234 n min a spectrophotometer. α-Tocopherol is well known to inhibit LDL oxidation at pH 7.4, but enrichment of LDL with α-tocopherol was unable to inhibit LDL oxidation by ferritin at pH 4.5. Ascorbate had a complex effect on LDL oxidation by ferritin at lysosomal pH and exhibited both antioxidant and pro-oxidant effects. It had no antioxidant effect on partially oxidized LDL, only a pro-oxidant effect. Ascorbate completely inhibited LDL oxidation by copper at pH 7.4 for a long period, but in marked contrast did not inhibit LDL oxidation by copper at lysosomal pH. Dehydroascorbate, the oxidation product of ascorbate, had a pronounced pro-oxidant effect on LDL incubated with ferritin at pH 4.5. The inability of α-tocopherol and ascorbate to effectively inhibit LDL oxidation by ferritin at lysosomal pH might help to explain why the large clinical trials with these vitamins failed to show protection against cardiovascular diseases.
Collapse
Affiliation(s)
- Oluwatosin O Ojo
- School of Biological Sciences and Institute for Cardiovascular and Metabolic Research, University of Reading, Reading, Berkshire, UK
| | - David S Leake
- School of Biological Sciences and Institute for Cardiovascular and Metabolic Research, University of Reading, Reading, Berkshire, UK
| |
Collapse
|
43
|
Toualbi LA, Mounir A, Wafa B, Medina A, Abderrezak K, Chahine T, Henni C, Abdelghani B, Atmane S. Implications of advanced oxidation protein products and vitamin E in atherosclerosis progression. Arch Med Sci Atheroscler Dis 2021; 6:e135-e144. [PMID: 34381915 PMCID: PMC8336440 DOI: 10.5114/amsad.2021.107823] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/30/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Advanced oxidation protein products (AOPP) are considered as markers of oxidative stress and inflammation, and highly predictive of atherosclerosis. Vitamin E (Vit-E) is a powerful antioxidant, but no consensus on its effectiveness at the level of AOPP or the process of atherosclerosis has been made. Hence this was the aim of the present study. MATERIAL AND METHODS A longitudinal study was conducted on 205 patients with chronic kidney disease (CKD) and 40 controls. The correlations between AOPP and glomerular filtration rate (GFR) and different biological markers were analyzed. Supra-aortic trunk echo-Doppler was conducted to assess the correlation of AOPP with intima-media thickness. The effects of Vit-E treatment on AOPP levels and atherosclerosis progression were also investigated. RESULTS AOPP levels increased in parallel to the alteration of renal functions in CKD patients, compared to the control group (p < 0.05). The mean value of AOPP increased concomitantly with the intima-media thickness (p < 0.05). Furthermore, AOPP mean value was higher in patients with atherosclerotic plaques (p < 0.05) compared to those without plaques. Vit-E treatment stabilized the levels of AOPP but had no effect on the atherosclerotic progression. CONCLUSIONS AOPP were proved to be effective markers of oxidative stress and their high levels help to predict the progression of atherosclerosis. As a powerful antioxidant, Vit-E stabilized the AOPP levels.
Collapse
Affiliation(s)
- Leila Azouaou Toualbi
- Hospital CHU Parnet Universite Algiers, Algeria
- Department of Nephrology, Parnet Hospital, Faculty of Medicine Algiers, Algeria
| | - Adnane Mounir
- Department of Biomedicine, Institute of Veterinary Sciences, University of Tiaret, Tiaret, Algeria
| | - Ballouti Wafa
- Department of Biochemistry, Hospital of Parnet, Faculty of Medicine Algiers, Algeria
| | - Arab Medina
- Department of Biochemistry, Hospital of CPMC, Faculty of Pharmacy, Algiers, Algeria
| | - Khelfi Abderrezak
- Department of Toxicology, Hospital of Bab el oued, Faculty of Pharmacy Algiers, Algeria
| | - Toualbi Chahine
- Department of Orthopedic Surgery, Hospital of Bejaia, Faculty of Medicine, Bejaia, Algeria
| | - Chader Henni
- Department of Pharmacology, Pastor Institute, Faculty of Pharmacy, Algiers, Algeria
| | | | - Seba Atmane
- Hospital CHU Parnet Universite Algiers, Algeria
| |
Collapse
|
44
|
Tan SY, Cronin H, Byrne S, O’Donovan A, Tuthill A. Appropriateness of aspirin prescribing for primary and secondary prevention of cardiovascular disease in type 2 diabetes in different care settings. Ir J Med Sci 2021; 191:1185-1191. [PMID: 34156663 PMCID: PMC9135889 DOI: 10.1007/s11845-021-02649-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 05/10/2021] [Indexed: 12/22/2022]
Abstract
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.
Collapse
Affiliation(s)
- Shi Ying Tan
- School of Medicine, University College Cork, College Road, Cork, Ireland
| | - Heather Cronin
- Department of Endocrinology and Diabetes, Cork University Hospital, Wilton, Cork, Ireland
| | - Stephen Byrne
- School of Pharmacy, University College Cork, College Road, Cork, Ireland
| | | | - Antoinette Tuthill
- Department of Endocrinology and Diabetes, Cork University Hospital, Wilton, Cork, Ireland
| |
Collapse
|
45
|
Jhaveri A, Sibley RA, Spatz ES, Dodson J. Aspirin, Statins, and Primary Prevention: Opportunities for Shared Decision Making in the Face of Uncertainty. Curr Cardiol Rep 2021; 23:67. [PMID: 33961154 DOI: 10.1007/s11886-021-01499-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW The utility of aspirin and statins for primary prevention of atherosclerotic cardiovascular disease remains ambiguous in older adults. Current guidelines and recent data are vague and inconclusive. This review seeks to summarize the landscape of primary prevention of cardiovascular disease in older adults and explore the role of shared decision making. RECENT FINDINGS Observational data suggest potential benefit of statin therapy in older adults. Aspirin is presently not recommended for primary prevention based on evidence from recent clinical trials. The implementation of shared decision making and decision aids in routine clinical practice remains challenging but may rise in coming years. Clinical trial data on the horizon may aid in solidifying guideline therapy for statin use. However, in the face of uncertainty, shared decision making between provider and patient should be utilized to determine whether pharmacotherapy may benefit older adults. Decision aids are an effective tool to guide this process.
Collapse
Affiliation(s)
- Amit Jhaveri
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Rachel A Sibley
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Erica S Spatz
- Divison of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - John Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, 227 East 30th Street, TRB 851, New York, NY, 10016, USA. .,Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York, NY, USA.
| |
Collapse
|
46
|
Yue Y, Creed JH, Cote DJ, Stampfer MJ, Wang M, Midttun Ø, McCann A, Ueland PM, Furtado J, Egan KM, Smith-Warner SA. Pre-diagnostic circulating concentrations of fat-soluble vitamins and risk of glioma in three cohort studies. Sci Rep 2021; 11:9318. [PMID: 33927267 PMCID: PMC8084971 DOI: 10.1038/s41598-021-88485-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 04/05/2021] [Indexed: 12/31/2022] Open
Abstract
Few prospective studies have evaluated the relation between fat-soluble vitamins and glioma risk. Using three cohorts-UK Biobank (UKB), Nurses' Health Study (NHS), and Health Professionals Follow-Up Study (HPFS), we investigated associations of pre-diagnostic concentrations of fat-soluble vitamins D, A, and E with incident glioma. In 346,785 participants (444 cases) in UKB, associations with vitamin D (25-hydroxyvitamin D [25(OH)D]) were evaluated by Cox proportional hazards regression. In NHS (52 cases, 104 controls) and HPFS (32 cases, 64 controls), associations with 25(OH)D, vitamin A (retinol), and vitamin E (α- and γ-tocopherol) were assessed using conditional logistic regression. Our results suggested plasma concentrations of 25(OH)D and retinol were not associated with glioma risk. Comparing the highest to lowest tertile, the multivariable hazard ratio (MVHR) for 25(OH)D was 0.87 (95% confidence interval [CI] 0.68-1.11) in UKB and the multivariable risk ratio (MVRR) was 0.97 (95% CI 0.51-1.85) in NHS and HPFS. In NHS and HPFS, the MVRR for the same comparison for retinol was 1.16 (95% CI 0.56-2.38). Nonsignificant associations were observed for α-tocopherol (MVRRtertile3vs1 = 0.61, 95% CI 0.29-1.32) and γ-tocopherol (MVRR tertile3vs1 = 1.30, 95% CI 0.63-2.69) that became stronger in 4-year lagged analyses. Further investigation is warranted on a potential association between α- and γ-tocopherol and glioma risk.
Collapse
Affiliation(s)
- Yiyang Yue
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jordan H Creed
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center, Tampa, FL, USA
| | - David J Cote
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Boston, MA, USA
| | - Meir J Stampfer
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Molin Wang
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | - Per Magne Ueland
- Department of Clinical Science, University of Bergen, 5021, Bergen, Norway
- Laboratory of Clinical Biochemistry, Haukeland University Hospital, Bergen, Norway
| | - Jeremy Furtado
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Kathleen M Egan
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center, Tampa, FL, USA.
| | - Stephanie A Smith-Warner
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
47
|
Angiolillo DJ, Capodanno D. Aspirin for Primary Prevention of Cardiovascular Disease in the 21 st Century: A Review of the Evidence. Am J Cardiol 2021; 144 Suppl 1:S15-S22. [PMID: 33706985 DOI: 10.1016/j.amjcard.2020.12.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 12/11/2020] [Indexed: 12/21/2022]
Abstract
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.
Collapse
Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida.
| | - Davide Capodanno
- Division of Cardiology, A.O.U. "Policlinico-Vittorio Emanuele," University of Catania, Catania, Italy
| |
Collapse
|
48
|
Abstract
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.
Collapse
Affiliation(s)
- Emanuela Ricciotti
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA; , .,Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Garret A FitzGerald
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA; , .,Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| |
Collapse
|
49
|
Impact of acetylsalicylic acid in patients undergoing cerebral aneurysm surgery - should the neurosurgeon really worry about it? Neurosurg Rev 2021; 44:2889-2898. [PMID: 33495921 PMCID: PMC8490225 DOI: 10.1007/s10143-021-01476-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/16/2020] [Accepted: 01/08/2021] [Indexed: 11/03/2022]
Abstract
There has been an increase in the use of acetylsalicylic acid (ASA, Aspirin®) among patients with stroke and heart disease as well as in aging populations as a means of primary prevention. The potentially life-threatening consequences of a postoperative hemorrhagic complication after neurosurgical operative procedures are well known. In the present study, we evaluate the risk of continued ASA use as it relates to postoperative hemorrhage and cardiopulmonary complications in patients undergoing cerebral aneurysm surgery. We retrospectively analyzed 200 consecutive clipping procedures performed between 2008 and 2018. Two different statistical models were applied. The first model consisted of two groups: (1) group with No ASA impact - patients who either did not use ASA at all as well as those who had stopped their use of the ASA medication in time (> = 7 days prior to operation); (2) group with ASA impact - all patients whose ASA use was not stopped in time. The second model consisted of three groups: (1) No ASA use; (2) Stopped ASA use (> = 7 days prior to operation); (3) Continued ASA use (did not stop or did not stop in time, <7 days prior to operation). Data collection included demographic information, surgical parameters, aneurysm characteristics, and all hemorrhagic/thromboembolic complications. A postoperative hemorrhage was defined as relevant if a consecutive operation for hematoma removal was necessary. An ASA effect has been assumed in 32 out of 200 performed operations. A postoperative hemorrhage occurred in one out these 32 patients (3.1%). A postoperative hemorrhage in patients without ASA impact was detected and treated in 5 out of 168 patients (3.0%). The difference was statistically not significant in either model (ASA impact group vs. No ASA impact group: OR = 1.0516 [0.1187; 9.3132], p = 1.000; RR = 1.0015 [0.9360; 1.0716]). Cardiopulmonary complications were significantly more frequent in the group with ASA impact than in the group without ASA impact (p = 0.030). In this study continued ASA use was not associated with an increased risk of a postoperative hemorrhage. However, cardiopulmonary complications were significantly more frequent in the ASA impact group than in the No ASA impact group. Thus, ASA might relatively safely be continued in patients with increased cardiovascular risk and cases of emergency cerebrovascular surgery.
Collapse
|
50
|
Zhao B, Wu Q, Wang L, Liao C, Dong Y, Xu J, Wei Y, Zhang W. Pros and Cons of Aspirin for the Primary Prevention of Cardiovascular Events: A Secondary Study of Trial Sequential Analysis. Front Pharmacol 2021; 11:592116. [PMID: 33519452 PMCID: PMC7845480 DOI: 10.3389/fphar.2020.592116] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/24/2020] [Indexed: 01/13/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Binghao Zhao
- Department of Cardio-Thoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- Departments of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qian Wu
- Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Li Wang
- Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Chen Liao
- Jiangxi Medical College, Nanchang University, Nanchang, China
| | - Yifei Dong
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Jingsong Xu
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yiping Wei
- Department of Cardio-Thoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wenxiong Zhang
- Department of Cardio-Thoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| |
Collapse
|