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• W4221010563 abstract "HomeCirculation: Cardiovascular Quality and OutcomesVol. 15, No. 3Mind the Gap: Primary Prevention Aspirin and the Danger of Suboptimal Implementation of Contemporary Guidelines Into Clinical Practice Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBMind the Gap: Primary Prevention Aspirin and the Danger of Suboptimal Implementation of Contemporary Guidelines Into Clinical Practice Naeif Almagal, MBBS, Miguel Cainzos-Achirica, MD, MPH, PhD and John W. McEvoy, MBBCh, MHS Naeif AlmagalNaeif Almagal Prince Mohammed bin Abdulaziz Medical City, Ministry of Health, Saudi Arabia (N.A.). Division of Cardiology, Department of Medicine, Saolta University Healthcare Group, University Hospital Galway, Ireland (N.A., J.W.M.). Search for more papers by this author , Miguel Cainzos-AchiricaMiguel Cainzos-Achirica https://orcid.org/0000-0002-8073-2337 Division of Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, TX (M.C.-A.). Center for Outcomes Research, Houston Methodist, TX (M.C.-A.). Search for more papers by this author and John W. McEvoyJohn W. McEvoy Correspondence to: John W. McEvoy, MBBCh, MHS, National Institute for Prevention and Cardiovascular Health, School of Medicine, National University of Ireland Galway, Croi House, Moyola Lane, Newcastle, Galway, H91FF68, Ireland. Email E-mail Address: [email protected] https://orcid.org/0000-0001-6530-5479 Division of Cardiology, Department of Medicine, Saolta University Healthcare Group, University Hospital Galway, Ireland (N.A., J.W.M.). National Institute for Prevention and Cardiovascular Health, School of Medicine, National University of Ireland Galway (J.W.M.). Search for more papers by this author Originally published31 Jan 2022https://doi.org/10.1161/CIRCOUTCOMES.121.008799Circulation: Cardiovascular Quality and Outcomes. 2022;15:e008799This article is a commentary on the followingPotential Impact of the 2019 ACC/AHA Guidelines on the Primary Prevention of Cardiovascular Disease Recommendations on the Inappropriate Routine Use of Aspirin and Aspirin Use Without a Recommended Indication for Primary Prevention of Cardiovascular Disease in Cardiology Practices: Insights From the NCDR PINNACLE RegistryOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 31, 2022: Ahead of Print The 2019 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline on the Primary Prevention of Atherosclerotic Cardiovascular Disease (ASCVD) recommends against routine aspirin use in asymptomatic primary prevention adults older than 70 years or at high-risk of bleeding, while a tepid IIb recommendation was included for consideration of primary prevention aspirin among adults 40 to 70 years deemed high risk for ASCVD but low bleeding risk.1See Article by Hira et alEvaluating the implementation of guideline recommendations into routine clinical care can help identify implementation gaps, standardization of care issues, and other opportunities to improve patient outcomes. In this context, the use of aspirin among individuals free of clinically overt ASCVD has become an active area of research given concerns for over-use and the risk of major bleeding associated with aspirin.2 In a survey of patients attending hospital-based cardiology or internal medicine outpatient clinics in the Johns Hopkins Hospital (United States) and the National University of Ireland in Galway (Ireland), Jacobsen et al3 found that 46% of US primary prevention participants were using aspirin, compared with just 26% of Irish participants. Of concern, the majority (84%) of aspirin users in the Hopkins sample reported obtaining aspirin over-the-counter. Also of concern, 47% of participants incorrectly reported that aspirin was routinely indicated for primary prevention. However, selection of a relatively high-risk study population may have contributed to the high use of aspirin observed in the Jacobsen study. In a recent report from the BRFSS (Behavioral Risk Factor Surveillance System) survey, Boakye et al4 also observed a high use of aspirin in primary prevention in the US: 20% to 30%, including among individuals older than 70 and in many without a clear indication.In this issue of Circulation: Cardiovascular Quality Outcomes, Hira et al5 shed further light on the issue of aspirin over-use in primary prevention in the United States. The authors examined the National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) Registry and characterized use of aspirin before publication of the 2019 ACC/AHA Primary Prevention guideline. Started in 2008, PINNACLE is a large and rigorous US registry with an overall population of more than 32 million patients from 1954 different cardiology practices. The authors evaluated 855 366 eligible PINNACLE participants with encounters between January 2018 and March 2019, from 400 practices. Individuals who were prescribed aspirin for secondary prevention were excluded, and the authors focused their attention on 2 subgroups of asymptomatic individuals. The first included patients <40 or >70 years who were prescribed aspirin, defined by the authors as inappropriate use, and the second consisted of patients 40 to 70 years prescribed aspirin who had low, borderline, or intermediate 10-year risk for ASCVD (ie, <20%) according to the ACC/AHA Pooled Cohort Equations, whom the authors defined as aspirin use without a recommended indication.According to those definitions, aspirin was inappropriately prescribed in 28% of participants aged <40 or >70 years. Similarly, 26% of PINNACLE participants aged between 40 to 70 years who had <20% 10-year risk for ASCVD were found to be taking aspirin without a recommended indication. There was also significant practice-level variation in both outcomes, indicating an opportunity to better standardize preventive care across the United States. Because the ACC/AHA Primary Prevention guideline was released in March 2019, these PINACCLE data precede that date and cannot be used to assess the real-world implementation of the 2019 aspirin recommendations. Nonetheless, the results by Hira et al help characterize the baseline context and the dramatic changes in aspirin use patterns that implementation of those guidelines could require. Specifically, these PINNACLE data suggest that approximately 1 in 4 patients attending cardiology clinics in the United States were eligible for aspirin discontinuation after March 2019.We note, however, that the authors’ results may be subject to some overestimation. First, the 2019 ACC/AHA guideline recommended against relying solely on the Pooled Cohort Equations to identify high-risk primary prevention persons suitable for aspirin.1 Therefore, there may be other reasons why PINNACLE participants with estimated ASCVD risk <20% may have been considered sufficiently high in actual ASCVD risk by their physicians to warrant primary prevention aspirin, for example by virtue of a strong family history of premature ASCVD,6 diabetes with target organ damage, or imaging evidence of extensive coronary atherosclerosis.7 Information about these variables were not available in PINNACLE and; therefore, not accommodated by the authors in their definitions. Second, the 2019 ACC/AHA guideline recommended against routine use of aspirin for primary prevention among adults <40 and >70 years, but the emphasis of this recommendation was on routine use, and the writers acknowledged that there may be individual circumstances where aspirin use for primary prevention in the very young and very old may be reasonable.1 Third, the results from PINNACLE practices might not translate to primary care practices in the United States, and generalizability to the general population is unknown—although the overall consistency with the BRFSS study is reassuring.4 Finally, bleeding risk was not ascertained comprehensively in PINNACLE.Despite these limitations, this study of PINNACLE data, together with other recent research, suggests a widespread use (often over-the-counter) of aspirin for primary prevention among persons without a clear guideline indication.3–5 But, why is this? A better understanding of the drivers of this phenomenon is needed in the United States. In the aftermath of the classic aspirin trials, which reported dramatic reductions in fatal and nonfatal ASCVD events in an era (1970s to early 2000s) when statin use was zero/low and the study populations were higher risk than contemporary Western adults, aspirin was heavily marketed as a wonder drug.8 Thirty years later, this perception may persist with many patients and physicians, and efforts should be made to make sure that, in primary prevention, aspirin is restricted to the highly select group of asymptomatic individuals at high absolute ASCVD risk and low risk of bleeding.1,2 The decision to provide primary prevention aspirin should also be regularly reviewed and aspirin should never be considered for life.9 In particular, trial data indicate that primary prevention aspirin has no net benefit in adults over 70, and may even be harmful2; therefore, efforts to consider discontinuation of primary prevention aspirin in most of these older adults should be prioritized.In contrast to aspirin over-use, in an important secondary analysis Hira et al also observed that statins were underused in primary prevention: specifically, they were prescribed in only half of patients with a guideline recommendation for such therapy.6 Available information on the reasons for this low use was, once again, limited; however, cost would not be expected to be a relevant barrier for a generic medication and it is hard to blame musculoskeletal symptoms for a 50% implementation gap. The need to more effectively communicate and bridge the implementation gap between evidence-based guidelines and clinical practice are arguably the greatest unsolved problems in modern medicine, including in preventive cardiology. Many lives depend on our collective efforts to solve this challenge, and the report by Hira et al adds to the major imperative to fix implementation gaps in ASCVD prevention.Article InformationDisclosuresNone.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Disclosures, see page 187.Correspondence to: John W. McEvoy, MBBCh, MHS, National Institute for Prevention and Cardiovascular Health, School of Medicine, National University of Ireland Galway, Croi House, Moyola Lane, Newcastle, Galway, H91FF68, Ireland. Email johnwilliam.[email protected]ieReferences1. Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Circulation. 2019; 140:e596–e646. doi: 10.1161/CIR.0000000000000678LinkGoogle Scholar2. Raber I, McCarthy CP, Vaduganathan M, Bhatt DL, Wood DA, Cleland JGF, Blumenthal RS, McEvoy JW. The rise and fall of aspirin in the primary prevention of cardiovascular disease.Lancet. 2019; 393:2155–2167. doi: 10.1016/S0140-6736(19)30541-0CrossrefMedlineGoogle Scholar3. Jacobsen AP, Lim ZL, Chang B, Lambeth KD, Das TM, Gorry C, McCague M, Wijns W, Serruys PWJC, Blumenthal RS, et al. A transatlantic comparison of patient-reported access to and use of aspirin in contemporary preventive cardiology.J Am Coll Cardiol. 2021; 78:1193–1195. doi: 10.1016/j.jacc.2021.07.015CrossrefMedlineGoogle Scholar4. Boakye E, Uddin SMI, Obisesan OH, Osei AD, Dzaye O, Sharma G, McEvoy JW, Blumenthal R, Blaha MJ. Aspirin for cardiovascular disease prevention among adults in the United States: Trends, prevalence, and participant characteristics associated with use.Am J Prev Cardiol. 2021; 8:100256. doi: 10.1016/j.ajpc.2021.100256CrossrefMedlineGoogle Scholar5. Hira RS, Gosch KL, Kazi DS, Yeh RW, Kataruka A, Maddox TM, Shah T, Jneid H, Bhatt DL, Virani SS. Potential Impact of the 2019 American College of Cardiology/American Heart Association Guidelines on the Primary Prevention of Cardiovascular Disease Recommendations on the Inappropriate Routine Use of Aspirin and Aspirin Use Without a Recommended Indication for Primary Prevention of Cardiovascular Disease in Cardiology Practices: Insights From the National Cardiovascular Disease Registry Practice Innovation and Clinical Excellence Registry.Circ Cardiovasc Qual Outcomes. 2022; 15:175–185. doi: 10.1161/CIRCOUTCOMES.121.007979Google Scholar6. Sesso HD, Lee IM, Gaziano JM, Rexrode KM, Glynn RJ, Buring JE. Maternal and paternal history of myocardial infarction and risk of cardiovascular disease in men and women.Circulation. 2001; 104:393–398. doi: 10.1161/hc2901.093115LinkGoogle Scholar7. Cainzos-Achirica M, Miedema MD, McEvoy JW, Al Rifai M, Greenland P, Dardari Z, Budoff M, Blumenthal RS, Yeboah J, Duprez DA, et al. Coronary artery calcium for personalized allocation of aspirin in primary prevention of cardiovascular disease in 2019: The MESA Study (Multi-Ethnic Study of Atherosclerosis).Circulation. 2020; 141:1541–1553. doi: 10.1161/CIRCULATIONAHA.119.045010LinkGoogle Scholar8. Los Angeles Times. Aspirin Starts 2nd Century as a Wonder Drug. Medicine: An Old Remedy Turns Out to Have Surprising Importance. Its Regular Use Can Prevent Heart Attack, Stroke and Other Ailments.Accessed December 21, 2021. https://www.latimes.com/archives/la-xpm-1992-01-26-mn-1389-story.htmlGoogle Scholar9. Fernandes A, McEvoy JW, Halvorsen S. “Doctor, Should I Keep Taking an Aspirin a Day?”.N Engl J Med. 2019; 380:1967–1970. doi: 10.1056/NEJMclde1903004CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Murphy E and McEvoy J (2022) Does Stopping Aspirin Differ Fundamentally From Not Starting Aspirin in the Primary Prevention of Cardiovascular Disease Among Older Adults?, Annals of Internal Medicine, 10.7326/M22-0550, 175:5, (757-758), Online publication date: 1-May-2022. Related articlesPotential Impact of the 2019 ACC/AHA Guidelines on the Primary Prevention of Cardiovascular Disease Recommendations on the Inappropriate Routine Use of Aspirin and Aspirin Use Without a Recommended Indication for Primary Prevention of Cardiovascular Disease in Cardiology Practices: Insights From the NCDR PINNACLE RegistryRavi S. Hira, et al. Circulation: Cardiovascular Quality and Outcomes. 2022;15 March 2022Vol 15, Issue 3 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.121.008799PMID: 35098726 Originally publishedJanuary 31, 2022 KeywordsEditorialsprimary preventionattentionaspirininternal medicinecardiovascular diseasePDF download Advertisement SubjectsCardiovascular DiseasePharmacologyPrimary Prevention" @default.
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