Update on aspirin in the treatment and prevention of cardiovascular disease

doi:10.1016/S0002-8703(99)70391-1

American Heart Journal

Volume 137, Issue 4, Supplement, April 1999, Pages S9-S13

https://doi.org/10.1016/S0002-8703(99)70391-1 Get rights and content

Abstract

The effects of low-dose aspirin on cardiovascular disease have been tested in randomized trials in 3 types of populations: (1) patients with a history of cardiovascular disease; (2) patients with evolving acute myocardial infarction (MI), and (3) apparently healthy subjects. In a very wide range of patients with prior occlusive cardiovascular disease, aspirin reduces the risks of nonfatal MI, nonfatal stroke, and vascular death. Initiating aspirin therapy within 24 hours after the onset of symptoms of an acute MI also confers conclusive reductions in the risk of nonfatal reinfarction, nonfatal stroke, and total cardiovascular death. In primary prevention trials, aspirin has been shown to reduce the risk of a first MI in men, but the data on stroke and total cardiovascular death are not sufficient to allow firm conclusions to be drawn; randomized data from studies in women are not yet available. The Women’s Health Study, an ongoing large-scale trial in female health care professionals, will provide the data necessary to assess the balance of benefits and risks of aspirin in primary prevention. Until then, the decision to use aspirin in primary prevention should be based on the clinical judgment of the physician and considered as an adjunct in the management of other cardiovascular disease risk factors. (Am Heart J 1999;137:S9-S13.)

Section snippets

Secondary prevention

The evidence to support the use of aspirin in secondary prevention of cardiovascular events comes from more than 100 randomized trials, which have been combined into 2 meta-analyses, one published in 1988⁵ and the other in 1994. ⁶

The first report was based on 25 trials of antiplatelet therapy conducted in approximately 29,000 patients with a history of MI, stroke, transient ischemic attack (TIA), or unstable angina pectoris. ⁵ These trials evaluated the effects of aspirin, dipyridamole, or

Acute evolving MI

Evidence on the benefits of aspirin administered during an evolving acute MI comes chiefly from the Second International Study of Infarct Survival (ISIS-2), a large-scale, randomized, double-blind, placebo-controlled trial that used a 2 × 2 factorial design to assess the effects of aspirin, streptokinase, or both, in suspected acute MI. ⁹ In ISIS-2, 17,187 patients with suspected evolving MI within 24 hours after symptom onset were randomly assigned to either 162.5 mg/d aspirin for 1 month, a

Primary prevention trials

In contrast to patients at high risk (ie, those with a history of cardiovascular disease or an evolving acute MI), in whom the benefits of aspirin in primary prevention clearly outweigh the risks, in subjects at a low baseline risk of cardiovascular events, the risk-to-benefit ratio of long-term administration of aspirin assumes particular importance. Potential risks of long-term aspirin therapy include gastrointestinal effects, such as bleeding, heartburn, and nausea, all of which have clearly

Summary

There are clear benefits of aspirin use in the secondary prevention of cardiovascular disease in patients who have survived a cardiovascular event. A recently updated overview of antiplatelet trials investigating secondary prevention indicates that these benefits extend to a much broader range of patients than previously demonstrated, with significant benefits accruing not only for survivors of an MI or stroke but also in patients with PVD, atrial fibrillation, chronic stable angina, valvular

References (23)

IAG Reilly et al.
Inhibition of thromboxane formation in vivo and ex vivo: implications for therapy and platelet inhibitory drugs
Blood
(1987)
JR Vane
Inhibition of prostaglandin synthesis as a mechanism of action for aspirin-like drugs
Nat New Biol
(1971)
CH Hennekens et al.
Aspirin and other antiplatelet agents in the secondary and primary prevention of cardiovascular disease
Circulation
(1989)
V Fuster et al.
Aspirin as a therapeutic agent in cardiovascular disease
Circulation
(1993)
CH Hennekens et al.
Aspirin as a therapeutic agent in cardiovascular disease
Circulation
(1997)
Antiplatelet Trialists’ Collaboration
Secondary prevention of vascular disease by prolonged antiplatelet therapy
BMJ
(1988)
Antiplatelet Trialists’ Collaboration
Collaborative overview of randomized trials of antiplatelet therapy, I: prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients
BMJ
(1994)
Aspirin for heart patients
FDA Drug Bull
(1985)
Aspirin for TIAs
FDA Drug Bull
(1980)
ISIS-2 (Second International Study of Infarct Survival) Collaborative Group
Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2
Lancet
(1988)

US Food and Drug Administration

Internal analgesic, antipyretic, and antirheumatic drug products for over-the-counter human use: proposed amendment to the tentative Final Monograph

Federal Register

(June 13, 1996)

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The consequences of these findings are that individuals who may be particularly sensitive to sodium retention (e.g., because of a history of congestive heart failure) or who have compromised renal function should be treated with these agents cautiously and with periodic monitoring, similar to the recommendations for traditional NSAIDs. Other measures of renal function have been examined (creatinine, electrolytes) and found to be largely unchanged from prior treatment.4,19 Small changes in both diastolic and systolic blood pressure are seen with COX-2 inhibitors compared with baseline “off-treatment” values but are similar to levels measured while the patients were taking traditional NSAIDs.
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^☆: Reprint requests: Charles H. Hennekens, MD, DrPH, Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 900 Commonwealth Ave E, Boston, MA 02215.

^☆☆: 0002-8703/99/$8.00 + 0 4/0/97096

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Update on aspirin in the treatment and prevention of cardiovascular disease☆,☆☆

Abstract

Section snippets

Secondary prevention

Acute evolving MI

Primary prevention trials

Summary

Blood

Inhibition of prostaglandin synthesis as a mechanism of action for aspirin-like drugs

Nat New Biol

Aspirin and other antiplatelet agents in the secondary and primary prevention of cardiovascular disease

Circulation

Aspirin as a therapeutic agent in cardiovascular disease

Circulation

Aspirin as a therapeutic agent in cardiovascular disease

Circulation

Secondary prevention of vascular disease by prolonged antiplatelet therapy

BMJ

Collaborative overview of randomized trials of antiplatelet therapy, I: prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients

BMJ

Aspirin for heart patients

FDA Drug Bull

Aspirin for TIAs

FDA Drug Bull

Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2

Lancet

Internal analgesic, antipyretic, and antirheumatic drug products for over-the-counter human use: proposed amendment to the tentative Final Monograph

Federal Register