Underutilization of Aspirin Persists in US Ambulatory Care for the Secondary and Primary Prevention of Cardiovascular Disease

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Cardiovascular disease (CVD), including myocardial infarction and stroke, is the leading cause of morbidity and mortality in the US. A broad array of randomized trials have demonstrated the benefits of low doses of aspirin (75-325mg)1,2 for both the primary3-7 and secondary8-11 prevention of CVD. Most trials demonstrate a 15-40% reduction in cardiovascular events with chronic aspirin use.Aspirin is unequivocally recommended as a secondary prevention strategy in non-contraindicated patients with known CVD.12,13 As for primary prevention, the American Diabetic Association recommends regular aspirin for men and women with diabetes mellitus (DM) who are older than 40 years or have additional cardiovascular risk factors.14 In addition, aspirin is indicated for apparently healthy individuals without CVD or DM but with an increased cardiovascular risk, which is defined as a 3% or greater risk in five years by the US Preventive Services Task Force2 or a 10% or greater risk in 10 years by the American Heart Association.1 However, the latest results from the WomenÔÇÖs Health Study7 suggest that careful ascertainment of the absolute benefit and risk on a case-by-case basis is essential to deciding on the use of aspirin therapy in men and, even more so, in women who have shown no clinical manifestations of CVD or diabetes.

Despite the proven benefits of aspirin therapy for reducing cardiovascular risk, aspirin use falls considerably short of recommendations. National surveys of the prescribing of cardiac medications found that aspirin use in visits by patients with coronary heart disease (CHD) increased significantly from 5% in 1980 to 32% in 1995, but then remained unchanged or even declined in subsequent years.15,16 The Third National Health and Nutrition Examination Survey (NHANES III) data showed that among patients with DM, only 37% of those with CHD and 13% of those with risk factors for CHD were regular aspirin users.17 While aspirin underutilization is also present in other countries,18,19 some evidence suggests that the problem is more prominent in the US. For instance, outpatient use of aspirin for secondary prevention ranged from approximately 40 to 90% in many European countries, in comparison with approximately 24% in the US.15,20-23 Greater aspirin use is associated with middle to older age (55-75 years old), male gender, diagnosis of hyperlipidemia, smoking, having medical insurance, revascularization or coronary angioplasty, and use of other medications.24-28

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References
  1. Berg AO, Atkins D, Aspirin for the primary prevention of cardiovascular events. US Preventive Services Task Force , Ann Intern Med (2002); 136: pp. 157-160.
    Crossref | PubMed
  2. Pearson TA, Blair SN, Daniels SR, et al., AHA guidelines for primary prevention of cardiovascular disease and stroke: 2002 update. Consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases.American Heart Association Science Advisory and Coordinating Committee , Circulation (2002); 106: pp. 388-391.
    Crossref | PubMed
  3. Hansson L, Zanchetti A, Carruthers S, et al., Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomized trial. HOT Study Group Lancet (1998); 351: pp. 1755-1762.
    Crossref | PubMed
  4. Steering Committee for the Physician's Health Study Research Group, Final report on the aspirin component of the ongoing Physician's Health Study , N Engl J Med (1989); 321: pp. 129-135.
    Crossref | PubMed
  5. Medical Research Council's General Practice Research Framework, Thrombosis prevention trial: Randomized trial of lowintensity oral anticoagulation with warfarin and low-dose aspirin in the primary prevention of ischaemic heart disease in men at increased risk , Lancet (1998); 351: pp. 233-241.
    Crossref | PubMed
  6. Collaborative Group of the Primary Prevention Project, Low-dose aspirin and vitamin E in people at cardiovascular risk:A randomized trial in general practice , Lancet (2001); 357: pp. 89-95.
    Crossref | PubMed
  7. Ridker PM, Cook NR, Lee IM, et al., A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women , N Engl J Med (2005); 352: pp. 1293-1304.
    Crossref | PubMed
  8. ISIS-2 Collaborative Group, Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2: Second International Study of Infarct Survival, Collaborative Group , Lancet (1988); 2: pp. 349-360.
    Crossref | PubMed
  9. Anti-Platelet Trialists' Collaboration, Collaborative meta-analysis of randomized trials of anti platelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients , Br Med J (2002); 324: pp. 71-86.
    Crossref | PubMed
  10. Weisman SM, Graham DY, Evaluation of the benefits and risks of low-dose aspirin in the secondary prevention of cardiovascular and cerebrovascular events , Arch Intern Med (2002); 162: pp. 2197-2202.
    Crossref | PubMed
  11. Chen Z, Sandercock P, Pan H, et al., Indications for early aspirin use in acute ischemic stroke.A combined analysis of 40,000 randomized patients from the Chinese Acute Stroke Trial and the International Stroke Trial , Stroke (2000); 31: pp. 1240-1249.
    Crossref | PubMed
  12. Harrington RA, Becker RC, Ezekowitz M, et al., Antithrombotic therapy for coronary artery disease:The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy , Chest (2004); 126: pp. 513S-548S.
    Crossref | PubMed
  13. Albers GW, Amarenco P, Easton JD, et al., Antithrombotic and thrombolytic therapy for ischemic stroke:The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest (2004); 126: pp. 483S-512S.
    Crossref | PubMed
  14. American Diabetes Association, Aspirin therapy in diabetes , Diabetes Care (2004); 27: pp. S72-S73.
    Crossref | PubMed
  15. Stafford RS, Radley DC, The underutilization of cardiac medications of proven benefit, 1990 to 2002 , J Am Coll Cardiol (2003); 41: pp. 69-72.
  16. Stafford RS, Aspirin use is low among United States outpatients with coronary artery disease , Circulation (2000); 101: pp. 1097-1101.
    Crossref | PubMed
  17. Rolka DB, Fagot-Campagna A, Narayan KM, Aspirin use among adults with diabetes. Estimates from the Third National Health and Nutrition Examination Survey , Diabetes Care (2001); 24: pp. 197-201.
    Crossref | PubMed
  18. Kramer JM, Newby LK, Chang WC, et al., International variation in the use of evidence based medicines for acute coronary syndromes , Eur Heart J (2003); 24: pp. 2133-2141.
    Crossref | PubMed
  19. Venturini F, Romero M,Tognoni G, Patterns of practice for acute myocardial infarction in a population from ten countries , Eur J Clin Pharmacol (1999); 54: pp. 877-886.
    Crossref | PubMed
  20. O'Connor GT, Quinton HB,Traven ND, et al., Geographic variation in the treatment of acute myocardial infarction:The Cooperative Cardiovascular Project , JAMA (1999); 281: pp. 627-633.
    Crossref | PubMed
  21. Bennett KE, Williams D, Feely J, Under-prescribing of cardiovascular therapies for diabetes in primary care , Eur J Clin Pharmacol (2003); 58: pp. 835-841.
    Crossref | PubMed
  22. EUROASPIRE II Study Group, Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries: Principal results from EUROASPIRE II Euro Heart Survey Programme , Eur Heart J (2001); 22: pp. 526-528.
  23. Steffenino G, Galliasso M, Gastaldi C, et al., Nurses' observational study on the practice of secondary prevention in a cardiovascular department , Ital Heart J (2003); 4: pp. 473-478.
    PubMed
  24. Avezum A, Makdisse M, Spencer F, et al., Impact of age on management and outcome of acute coronary syndrome: observations from the Global Registry of Acute Coronary Events (GRACE) , Am Heart J (2005); 149: pp. 67-73.
    Crossref | PubMed
  25. Meigs JB, Stafford RS, Cardiovascular disease prevention practices by U.S. physicians for patients with diabetes , J Gen Intern Med (2000); 15: pp. 220-228.
    Crossref | PubMed
  26. Califf RM, DeLong ER, Ostbye T, et al., Underuse of aspirin in a referral population with documented coronary artery disease , Am J Cardiol (2002); 89: pp. 653-661.
    Crossref | PubMed
  27. Ganz DA, Lamas GA, Orav EJ, et al., Age related differences in management of heart disease: A study of cardiac medication use in an older cohort. Pacemaker Selection in the Elderly (PASE) Investigators , J Am Geriat Soc (1999); 47: pp. 145-150.
    Crossref | PubMed
  28. Krumholz HM, Radford MJ, Ellerbeck EF, et al., Aspirin in the treatment of acute myocardial infarction in elderly Medicare beneficiaries. Patterns of use and outcomes , Circulation (1995); 92: pp. 2841-2847.
    Crossref | PubMed
  29. Zell ER, McCaig LF, Kupronis BA, et al., A comparison of the National Disease and Therapeutic Index and the National Ambulatory Medical Care Survey to evaluate antibiotic usage . In: Proceedings of the survey research methods section, Alexandria (Virginia):American Statistical Association (2000); pp 840-845.
  30. Gilchrist VJ, Stange KC, Flocke SA, et al., A comparison of the National Ambulatory Medical Care Survey (NAMCS) measurement approach with direct observation of outpatient visits , Medical Care (2004); 42: pp. 276-280.
    Crossref | PubMed
  31. Wilson PWF, D'Agostino RB, Levy D, et al., Prediction of coronary heart disease using risk factor categories , Circulation (1998); 97: pp. 1837-1847.
    Crossref | PubMed
  32. Colwell JA, Aspirin therapy in diabetes is underutilized , Diabetes Care (2001); 24: pp. 194-196.
    Crossref | PubMed
  33. Devereaux PJ,Anderson DR, Gardner MJ, et al. , Differences between perspectives of physicians and patients on anticoagulation in patients with atrial fibrillation: Observational study Br Med J (2001); 323: pp. 1218-1222.
  34. Laine L, The gastrointestinal effects of nonselective NSAIDs and COX-2-selective inhibitors , Semin Arthritis Rheum (2002); 32: pp. 25-32.
    Crossref | PubMed
  35. ETDRS Investigators, Aspirin effects on mortality and morbidity in patients with diabetes mellitus. Early Treatment Diabetic Retinopathy Study report 14 , JAMA (1992); 268: pp. 1292-1300.
    Crossref | PubMed
  36. Short D, Frischer M, Bashford J, Ashcroft D, Why are eligible patients not prescribed aspirin in primary care? A qualitative study indicating measures for improvement , BMC Fam Pract (2003); 4: p. 9.
  37. Martin CP,Talbert RL, Aspirin resistance: an evaluation of current evidence and measurement methods , Pharmacotherapy (2005); 25: pp. 942-953.
    Crossref | PubMed
  38. Lee PY, Chen WH, Ng W, et al., Low-dose aspirin increases resistance in patients with coronary artery disease , Am J Med (2005); 118: pp. 723-727.
    Crossref | PubMed
  39. Marshall T, Coronary heart disease prevention: Insights from modelling incremental cost effectiveness , Br Med J (2003); 327: pp. 1-5.
  40. Drummond A, Kwok S, Morgan J, Durrington PN, Costs of aspirin and statins in general practice , QJM (2001); 95: pp. 23-26.
    Crossref | PubMed
  41. Probstfield JF, How cost-effective are new preventive strategies for cardiovascular disease? , Am J Cardiol (2003); 91: pp. 22G-27G.
    Crossref | PubMed
  42. Hennekens CH, Sacks FM,Tonkin A, et al., Additive benefits of pravastatin and aspirin to decrease risks of cardiovascular disease , Arch Intern Med (2004); 164: pp. 40-44.
    Crossref | PubMed
  43. Ma J, Stafford RS, Cockburn IM, Finkelstein SN, A statistical analysis of the magnitude and composition of drug promotion in the United States in 1998 , Clin Ther (2003); 25: pp. 1503-1517.
    Crossref | PubMed
  44. Frances CD, Go AS, Dauterman KW, et al., Outcome following acute myocardial infarction: Are differences among physician specialties the result of quality of care or case mix? , Arch Intern Med (1999); 159: pp. 1429-1436.
    Crossref | PubMed
  45. Akosah KO, Larson DE, Brown WM, et al., Using a systemwide care path to enhance compliance with guidelines for acute myocardial infarction , Jt Comm J Qual Saf (2003); 29: pp. 245-259.
    PubMed