Aspirin

Aspirin for primary prevention of cardiovascular disease (Updated January 2016 )

Facilitator: Erin Goss


Goal
: To make informed clinical decisions about chemoprophylaxis for primary prevention

Learning Objectives:
  1. Describe the available clinical evidence to balance risk and benefits of aspirin for chemoprophylaxis. 
  2. Explain why USPSTF recommendations for aspirin differ for men and women in primary prevention. 
  3. Practice using risk calculators for coronary heart disease and stroke. 
  4. Recognize when to utilize the shared decision making process for patients with similar levels of potential risk vs. benefit (and/or when there is not enough evidence available). 
  5. Contrast the conclusions of the ATT meta-analysis with USPTSF recommendations. 

** Click 
here for a word document of the pre-session assignment below. **

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Part 1: Understanding the literature

Read the following articles and answer the questions below.

Steering Committee of the Physicians’ Health Study Research Group. Final report on the aspirin component of the ongoing Physicians’ Health Study. N Engl J Med 1989;321:129-35. (PHS)

Ridker PM, Cook NR, Lee IM, Gordon D et al. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med 2005;352 (13):1293-1304. (WHS)

 

Compare the study design, study populations and methods for the Physican’s Health Study (PHS) to those of the Women’s Health Study (WHS)?



How did each study define events or outcomes?



What conclusions were made based on the results of PHS vs. WHS?



What did each study find about the harms of aspirin use?

 

Part 2: Apply the USPSTF Aspirin guidelines to case vignettes

Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement.  Annals of Internal Medicine 2009;150 (6):396-404.

For the following vignettes, utilize the appropriate risk calculator to calculate the 10 year risk of CHD or CVA based on the appropriate calculator below. Calculate the 10 year ASCVD risk for all vignettes. Compare the results of these 2 scores to determine the harms and benefits of aspirin prescription for the patient in each vignette.

Coronary heart disease: Risk calculator -  http://www.mcw.edu/calculators/CoronaryHeartDiseaseRisk.htm

Reference: Wilson PW, et al. Prediction of coronary heart disease using risk factor categories. Circulation 1998; 97 (18): 1837-1847.


Stroke: UCLA Risk calculator (based on same reference as risk calculator recommended by USPSTF guidelines) http://stroke.ucla.edu/body.cfm?id=66

Reference: Stroke,1994;25: 40-43

ASCVD risk calculator:

Questions:

1a. A 60 year old man with a history of HTN presents to your clinic for a routine follow-up visit. He tells you that he recently saw a TV commercial about aspirin and wonders if he should be taking aspirin on a daily basis to prevent cardiovascular disease. Today his BP is 150/90. He is 70 inches tall and weighs 190 lbs. He has a a total cholesterol of 230 and HDL 60. His medications include chlorthalidone 25mg daily and nifedipine 60mg daily. He dose not take NSAIDs, smoke cigarettes, and has no history of GI bleeding. 

What would you advise?

 

10 year risk

Benefit of ASA

Harm of ASA

CHD vs. CVA risk

 

 

 

ASCVD risk

 

 

 

1b. What if this patient was 45 yrs old?  

 

10 year risk

Benefit of ASA

Harm of ASA

CHD vs. CVA risk

 

 

 

ASCVD risk

 

 

 

1c. What if this patient was 60 yrs old and diabetic?

 

10 year risk

Benefit of ASA

Harm of ASA

CHD vs. CVA risk

 

 

 

ASCVD risk

 

 

 

1d. What if the original patient used naproxen daily for arthritis pain?  

 

10 year risk

Benefit of ASA

Harm of ASA

CHD vs. CVA risk

 

 

 

ASCVD risk

 

 

 

1e. What if the original patient was a woman?  

 

10 year risk

Benefit of ASA

Harm of ASA

CHD vs. CVA risk

 

 

 

ASCVD risk

 

 

 

 1f. What if this 60 year old woman also smoked cigarettes?  

 

10 year risk

Benefit of ASA

Harm of ASA

CHD vs. CVA risk

 

 

 

ASCVD risk

 

 

 

1g. How would your recommendation differ if this 60 year old woman had LVH on EKG?  

 

10 year risk

Benefit of ASA

Harm of ASA

CHD vs. CVA risk

 

 

 

ASCVD risk

 

 

 

1h. What if the woman was 52yrs old?  

 

10 year risk

Benefit of ASA

Harm of ASA

CHD vs. CVA risk

 

 

 

ASCVD risk

 

 

 

1i. What if she was 80 yrs old? 

 

10 year risk

Benefit of ASA

Harm of ASA

CHD vs. CVA risk

 

 

 

ASCVD risk

 

 

 

 

Part 3

Read the following article and answer the questions below.

Antithrombotic Trialists’ Collaboration. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomized trials. Lancet 2009;373:1849-60. (ATT)

What were the inclusion criteria for primary prevention trials?

 

How did the Antithrombotic Trialists’ study (ATT) define events or outcomes and how does this differ from the PHS and WHS?

 

Describe the results of the ATT study.

 

What conclusion did the ATT authors reach about the use of aspirin for primary prevention?