Aspirin is the best known and most widely used preventive therapy. A century of clinical experience and randomized trials in over 250,000 patients have proved its benefit in preventing cardiovascular events, and it costs pennies a day. So how can it be that not everyone who needs it gets it?<\/p>\n
In a new report, we used prospective, longitudinal data from REduction of Atherothrombosis for Continued Health<\/a>, a unique registry of outpatients with established atherothrombosis or multiple risk factors, to look at current, \u201creal world\u201d practices of cardiovascular protection. Of more than 25,000 U.S. participants, we found that approximately one quarter of those with vascular disease are not treated with aspirin for secondary prevention, and 15% are not treated with any antithrombotic agent (i.e., aspirin, warfarin, or other antiplatelet agents). Of patients who had risk factors only (i.e, no history of MI, stroke, or peripheral arterial disease), one third were not taking any antithrombotic agent.<\/p>\n So, I see two issues here:<\/p>\n we need to try to make sure that all patients with vascular disease get aspirin (or another antithrombotic agent), and Aspirin is the best known and most widely used preventive therapy. A century of clinical experience and randomized trials in over 250,000 patients have proved its benefit in preventing cardiovascular events, and it costs pennies a day. So how can it be that not everyone who needs it gets it? In a new report, we […]<\/p>\n","protected":false},"author":118,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1,7],"tags":[],"class_list":["post-1441","post","type-post","status-publish","format-standard","hentry","category-general","category-prevention"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/1441","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/118"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=1441"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/1441\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=1441"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=1441"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=1441"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
\n we need o determine which patients who are at risk for \u2014 but have not yet developed \u2014 vascular disease should also be receiving such treatment.<\/p>\n
\n1. Secondary prevention.<\/strong> We didn\u2019t ask investigators why they were not treating individual patients with aspirin. Asking that question would be the next step in a quality-improvement initiative to try and extend aspirin treatment to 100% of eligible patients (understanding that some have contraindications). One option for clinicians who use electronic medical records would be to get an automatic reminder that the patient should be on aspirin or another antithrombotic agent whenever we enter a diagnosis of MI, stroke, or PAD or performance of PCI or CABG.
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\n2. Primary prevention.<\/strong> Here, the data are more mixed. A recent analysis by the Antithrombotic Trialists Collaboration <\/a>found that although patients with only risk factors benefit from treatment, the benefit is very small in low-risk patients: just an 0.25% absolute reduction in cardiovascular death, MI, or stroke per year of treatment. The ATT investigators also reported an increase in bleeding of about half the amount of absolute reduction in occlusive events. Thus, the key question remains: how many patients who do not have cardiovascular disease should be treated with aspirin?
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\nI agree with Drs. Tapp, Shansila, and Lip, the editorialists who commented on the REACH report<\/a>, who call for a reconsideration of international guidelines regarding aspirin in primary prevention.
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\nWhat do you do in your practice? Do you prescribe aspirin for 100% of your patients with vascular disease? How do you handle primary prevention? What does your institution need to do to improve antithrombotic use?
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