2013. Aspirin for Primary Prevention of Cardiovascular Events. Just another day in clinic. Roadmap. Epidemiology (a.k.a

1/7/2013 Aspirin for Primary Prevention of Cardiovascular Events Just another day in clinic…  69 yo Filipina woman, non-smoker    ALI BLOCK, R2...
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1/7/2013

Aspirin for Primary Prevention of Cardiovascular Events

Just another day in clinic…  69 yo Filipina woman, non-smoker   

ALI BLOCK, R2 GERIATRICS TALK JANUARY 2013

DM on metformin, hgb A1c 7.1 Hyperlipidemia on atorva, TC 190, TG 199, LDL 81, HDL 69 HTN on benazepril, BP 146/84

 80 yo Eritrean man, non-smoker  

HTN on lisinopril, BP 159/85 HLD not on meds, TC 241, TG 102, LDL 165, HDL 56

 49 yo Latino man, non-smoker   

Roadmap

DM on metformin and insulin, s/p amputation, A1C 7.9 HLD starting meds, TC 366, TG 351, LDL 243, HDL 53 HTN on benaz, 138/82

Epidemiology (a.k.a. Why We Care)

 Epidemiology

 CV disease leading cause of death in U.S.

 Pathophysiology and Dosing

 1 out of 2.8 deaths

 Contraindications

 Aspirin known to work for secondary prevention

 Guidelines and Evidence for:    

 LOTS of trials for 1˚prevention  mixed results

General population Diabetes Very elderly Colon cancer prevention

  

 Simple approach + resources



 Cases revisited



MI Stroke Mortality GI bleeds Hemorrhagic stroke

Mechanism of Action and Dosing  Low dose: blocks thromboxane A2  blocks platelet

aggregation 

 Absolute: 

75-300mg/day



 Higher dose can block prostacyclin  thrombosis 

Contraindications

 

500mg/day



 Cumulative effect if taken daily  Reduces C-reactive protein – anti-inflammatory  U.S. use 81mg/day

  

Miser, AFP, 2011

Active peptic ulcer Allergy/intolerance Bleeding disorder Recent GI bleed Recent intracranial bleed Renal failure Severe liver Disease Thrombocytopenia

 Relative:    

harm (A)  Women 55-79 for ischemic stroke reduction when

benefit > harm (A)

 Potential harm: GI bleed, hemorrhagic stroke

 Insufficient evidence for men/women >80 (I)

 Lowest dose (81mg for us)

 Men benefit Berger, JAMA, 2006

Effect of Aspirin by Risk Category: Women and Stroke

Summary: Harms ≈ Benefits

Berger, JAMA, 2006 Bold typeface  harms > benefit Assume net strokes prevented (ischemic prevented – hemorrhagic incurred)

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1/7/2013

Geriatrics – USPSTF

Geriatrics – Beers Criteria

 >80 yo: insufficient evidence

 “Potentially Inappropriate Medications” in older

adults

 Stroke/MI and GI bleed risks all go up

 No aspirin >325mg/day, esp if h/o GI ulcer

 Consider aspirin if:  

No risk factors for GI bleed Good potential to tolerate GI bleed: normal hgb, good renal function, easy access to emergency care

 Asa for primary prevention >80yo may do more

harm than good  use with caution 

Low quality evidence, weak recommendation

 Counsel on signs/symptoms GI bleed  Discuss harms/benefits

What about in Diabetes?  2-4x increased risk CV events

Diabetes Continued  2010 Meta-analysis 7 RCTs

 68% deaths from CAD, 16% from stroke



 Mixed data on efficacy of asa for 1˚ prevention



 Guidelines:    

Yes for >10% risk, No for 50 or Women > 60 with another risk factor No for Men 10% risk, no for 50 or women >60 with additional risk factor

 Geriatrics (>80)

 81mg is sufficient  Calculate 10-year risk to



determine whether pt should be on aspirin – lower threshold at younger age



Consider GI bleed risk factors, physiologic reserve Shared decision-making

 Colon cancer prevention 

Some evidence, could tip the balance

References  



  



“Aspirin for the Prevention of Cardiovascular Disease: Recommendation Statement.” U.S. Preventive Services Task Force, March 2009. Berger, JS et al. “Aspirin for the Primary Prevention of Cardiovascular Events in Women and Men: A Sex-Specific Meta-analysis of Randomized Controlled Trials.” JAMA. 2006; 295(3):306-313. “American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults.” American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc. 2012 Apr, 60(4):616-31. Rothwell PM et al. “Long-term effect of aspirin on colorectal cancer incidence and mortality: 20-year follow-up of five randomised trials.” Lancet. 2010 Nov 20; 376(9754): 1741-50. Stavrakis, S, et al. “Low-dose aspirin for primary prevention of cardiovascular events in patients with diabetes: a meta-analysis.” Am J Med Sci. 2011 Jan; 341(1):1-9. Pignone, M et al. “Aspirin for Primary Prevention of Cardiovascular Events in People with Diabetes: A position statement of the American Diabetes Association, a scientific statement of the American Heart Association, and an expert consensus document of the American College of Cardiology Foundation.” Diabetes Care June 2010 vol. 33 no. 6 1395-1402. Miser, WF. “Appropriate Aspirin Use for Primary Prevention of Cardiovascular Disease.” Am Fam Physician. 2011 Un 15;83(12):1380-1390.

Thank You!

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