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 https://www.youtube.
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