CardioSource WorldNews December 2014 - Page 46

ASPIRIN Good Drug Bad Drug Reconsidering the value of ASA in some settings By Debra L. Beck Once a mainstay in the armamentarium of cardiologists, aspirin has morphed into a tricky drug to recommend. The generous response to give it to anyone with cardiovascular risk — acute or not — has proved, shall we say, problematic. Today, clinicians may be as likely to over-use aspirin as they are to under-use it. Aspirin has been getting a bad rap these days … except when it’s heaped with praise. These use it/don’t use it messages seem confusing for sure, but the evidence being accumulated should assist clinical decision making and inform guidelines. Take Two and Call Me… Wait, Don’t Take Any… Certainly, we know about the several settings where the use of aspirin remains quite clear cut. We’ve cleaned up the primary prevention issue in terms of guidance — well, almost, since the Food and Drug Administration (FDA), American Heart Association (AHA), and U.S. Preventive Services Task Force all say something slightly different. In brief, as the FDA stated in May 2014 after reviewing the available data, the evidence does not support “…the general use of aspirin for primary prevention of a heart attack or stroke.” However, as reported recently, self-prescribing still occurs regularly, complicating the situation.1 Hitinder Gurm interview Oops: Forgetting Pre-PCI Aspirin - Outcomes Are Awful com/watch?v=q7zVQIqBrXA It’s hardly news that someone in the throes of a heart attack might want to chew a baby aspirin or two. Well, actually, in Canada, that is news: Just a few weeks ago, Health Canada gave Bayer Inc. the okay to promote their drug as an emergency treatment for myocardial infarction (MI).2 It’s not that Canadians haven’t been using aspirin in acute MI for more than 15 years, but now the packaging can include instruction to consumers to chew two 81 mg aspirin tablets if they suspect they’re having an MI, providing Canucks a jumpstart on platelet inhibition before the paramedics arrive. File this under cutting edge science. Given aspirin’s substantial ability to reduce periprocedural MI caused by thrombotic occlusion, one would also assume that periprocedural aspirin in patients undergoing percutaneous coronary intervention (PCI) also rates as a no brainer. Yes, but surprisingly it’s sometimes not being used prior to PCI when it should be. This is illustrated in a report published at the end of 2013 in the Journal of the American College of Cardiology showing a significant proportion of patients undergoing PCI are not receiving aspirin, and their subsequent rates of death and stroke were significantly higher than those who did receive periprocedural aspirin FIGURE.3 “We thought this would be an infrequent problem, but I was honestly shocked that just over 7% of patients were getting PCI without getting aspirin FIGURE Propensity-Matched In-Hospital Outcomes for PCI With/Without Pre-Procedural Aspirin SOURCE: Ref. 3 44 CardioSource WorldNews December 2014