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Use of Antiplatelet Agents for Primary and Secondary Prevention of Cardiovascular Disease Amongst Type 2 Diabetes Patients
Abstract and Figures
Background. A retrospective observational study was conducted to study the use of antiplatelet agents for primary and secondary prevention of cardiovascular disease among hospitalized type 2 diabetes mellitus patients.
Method. A total of 355 patients were included in the study. The compliance with the American Diabetes Association recommendation on the use of antiplatelet therapy for prevention of cardiovascular disease was studied.
Results. For the primary prevention group, type 2 diabetes mellitus, patients with known dyslipidemia were more likely to receive antiplatelet therapy than those without dyslipidemia (P = 0.023). The rate of adherence to the American Diabetes Association recommendations on the use of antiplatelet therapy for secondary prevention of cardiovascular disease was higher than for primary prevention of cardiovascular disease (P = 0.001).
Conclusion. In conclusion, many of the eligible patients still do not receive antiplatelet therapy, particularly in primary prevention of cardiovascular disease. Measures should be taken to ensure that type 2 diabetes mellitus patients receive the antiplatelet therapy and hence prevent macrovascular complications.
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... Antiplatelet therapy for patients with previous CVD is highly recommended for secondary prevention. The current recommendation for primary prevention of CVD has been changed to be selective to women above 60 years of age with one additional risk factor [12,19]. ...
... Interestingly, the lack of association of aspirin use among cases with dyslipidemia adds further need for proper management of dyslipidemia among diabetes management. Consistent with other studies, the primary prevention of CVD among type 2 diabetes patients is still an area of development [19]. ...
Introduction. Prescription for diabetes care is an important practice in primary care. Methods. This is a descriptive study carried out on at primary care clinics over a five-month period at Al Imam Medical Complex, Riyadh, Saudi Arabia. It was cross-sectional study of 160 female diabetic patients, who visited the services between January and May, 2012. Data were collected from the medical records on the clinical characteristics and drugs prescribed for their diabetic management. Results. The majority of the sample population (82%) was older than 40 years old. Half of them had concomitant hypertension, hyperlipidemia, and obesity. There were 500 prescriptions for diabetes management. More than 57% of participants were on two or more drugs for hyperglycemia. Metformin was the most common drug prescribed. Metformin and sulphonylurea were the most common combined medications. Most of cases ( 70%) were on a combination of antihypertensive drugs. ACE or ARBs and diuretic was the most common combined prescriptions. Statins and aspirin were used by 41% and 23.8% of the research population, respectively. Conclusion. Polypharmacy is a feature in diabetes care. Most of the prescription practice for diabetic care follows the recommended guidelines for hyperglycemia and hypertension. Management of dyslipidemia among diabetic patients, however, is an area that needs to be developed.
... Anti-platelet therapy for patients with previous cardiovascular disease (CVD) is highly recommended for secondary prevention. The current recommendation for primary prevention of CVD has been changed to be selective to women above 60 years of age with one additional risk factor [11,17]. ...
Methods: This is a cross-sectional retrospective study in adult T2DM patients. A total number of 343 patient’s records was randomly selected from the patient medical records section. Among the 343 T2DM patients, all were hyperlipidemics, and only 228 patients were Hypertensive. The collected raw data were recorded and statistically analyzed with Windows Microsoft Excel 2007. Descriptive statistics of mean, standard deviation, and frequencies were performed on the sample, one-way ANOVA was used to analyze the continuous data by using Graphpad software version-5; p≤0.05 was considered statistically significant.
... The outcome of the study could be due to small number of patients with low event rates. A study on the utilization of antiplatelet therapy in type 2 diabetes patients revealed that many of the eligible patients did not receive the drugs as primary prevention strategy for CVD (Huri et al., 2008). Therefore, the recommendations on aspirin usage in primary prevention of CVD in type 2 diabetes patients must be fully justified after taking consideration against the benefit versus risk of its use. ...
... The outcome of the study could be due to small number of patients with low event rates. A study on the utilization of antiplatelet therapy in type 2 diabetes patients revealed that many of the eligible patients did not receive the drugs as primary prevention strategy for CVD (Huri et al., 2008). Therefore, the recommendations on aspirin usage in primary prevention of CVD in type 2 diabetes patients must be fully justified after taking consideration against the benefit versus risk of its use. ...
Background
Despite treatment, there is often a higher incidence of cardiovascular complications in patients with hypertension than in normotensive individuals. Inadequate reduction of their blood pressure is a likely cause, but the optimum target blood pressure is not known. The impact of acetylsalicylic acid (aspirin) has never been investigated in patients with hypertension. We aimed to assess the optimum target diastolic blood pressure and the potential benefit of a low dose of acetylsalicylic acid in the treatment of hypertension.
Methods
18 790 patients, from 26 countries, aged 50–80 years (mean 61·5 years) with hypertension and diastolic blood pressure between 100 mm Hg and 115 mm Hg (mean 105 mm Hg) were randomly assigned a target diastolic blood pressure. 6264 patients were allocated to the target pressure ⩽90 mm Hg, 6264 to ⩽85 mm Hg, and 6262 to ⩽80 mm Hg. Felodipine was given as baseline therapy with the addition of other agents, according to a five-step regimen. In addition, 9399 patients were randomly assigned 75 mg/day acetylsalicylic acid (Bamycor, Astra) and 9391 patients were assigned placebo.
Findings
Diastolic blood pressure was reduced by 20·3 mm Hg, 22·3 mm Hg, and 24·3 mm Hg, in the ⩽90 mm Hg, ⩽85 mm Hg, and ⩽80 mm Hg target groups, respectively. The lowest incidence of major cardiovascular events occurred at a mean achieved diastolic blood pressure of 82·6 mm Hg; the lowest risk of cardiovascular mortality occurred at 86·5 mm Hg. Further reduction below these blood pressures was safe. In patients with diabetes mellitus there was a 51% reduction in major cardiovascular events in target group ⩽80 mm Hg compared with target group ⩽90 mm Hg (p for trend=0·005). Acetylsalicylic acid reduced major cardiovascular events by 15% (p=0·03) and all myocardial infarction by 36% (p=0·002), with no effect on stroke. There were seven fatal bleeds in the acetylsalicylic acid group and eight in the placebo group, and 129 versus 70 non-fatal major bleeds in the two groups, respectively (p<0·001).
Interpretation
Intensive lowering of blood pressure in patients with hypertension was associated with a low rate of cardiovascular events. The HOT Study shows the benefits of lowering the diastolic blood pressure down to 82·6 mm Hg. Acetylsalicylic acid significantly reduced major cardiovascular events with the greatest benefit seen in all myocardial infarction. There was no effect on the incidence of stroke or fatal bleeds, but non-fatal major bleeds were twice as common.
Several observational studies document a considerably increased risk of advanced renal disease, cardiovascular disease, and early mortality in persons with diabetes. Both epidemiologic and observational studies indicate that progression of cardiovascular disease and renal disease is associated not only with high blood glucose levels, but also with hypertension and dyslipidemia. In persons with type 1 diabetes, hypoglycemic and antihypertensive therapy are important in the prevention of cardiovascular and renal disease. In those with type 2 diabetes, hypoglycemic therapy can help to prevent microvascular disease in the retina and in the kidney, and recent studies show that antihypertensive treatment is important in preventing cardiovascular disease. Thus, a multifactorial intervention program is key to preventing complications of hyperglycemia and, equally important, elevated blood pressure and dyslipidemia. (C) 1998 by Excerpta Medica, Inc.
The Physicians' Health Study is a randomized, double-blind, placebo-controlled trial designed to determine whether low-dose aspirin (325 mg every other day) decreases cardiovascular mortality and whether beta carotene reduces the incidence of cancer. The aspirin component was terminated earlier than scheduled, and the preliminary findings were published. We now present detailed analyses of the cardiovascular component for 22,071 participants, at an average follow-up time of 60.2 months. There was a 44 percent reduction in the risk of myocardial infarction (relative risk, 0.56; 95 percent confidence interval, 0.45 to 0.70; P < 0.00001) in the aspirin group (254.8 per 100,000 per year as compared with 439.7 in the placebo group). A slightly increased risk of stroke among those taking aspirin was not statistically significant; this trend was observed primarily in the subgroup with hemorrhagic stroke (relative risk, 2.14; 95 percent confidence interval, 0.96 to 4.77; P = 0.06). No reduction in mortality from all cardiovascular causes was associated with aspirin (relative risk, 0.96; 95 percent confidence interval, 0.60 to 1.54). Further analyses showed that the reduction in the risk of myocardial infarction was apparent only among those who were 50 years of age and older. The benefit was present at all levels of cholesterol, but appeared greatest at low levels. The relative risk of ulcer in the aspirin group was 1.22 (169 in the aspirin group as compared with 138 in the placebo group; 95 percent confidence interval, 0.98 to 1.53; P = 0.08), and the relative risk of requiring a blood transfusion was 1.71. This trial of aspirin for the primary prevention of cardiovascular disease demonstrates a conclusive reduction in the risk of myocardial infarction, but the evidence concerning stroke and total cardiovascular deaths remains inconclusive because of the inadequate numbers of physicians with these end points.
Objectives.
—This report presents information on the effects of aspirin on mortality, the occurrence of cardiovascular events, and the incidence of kidney disease in the patients enrolled in the Early Treatment Diabetic Retinopathy Study (ETDRS).Study Design.
—This multicenter, randomized clinical trial of aspirin vs placebo was sponsored by the National Eye Institute.Patients.
—Patients (N=3711) were enrolled in 22 clinical centers between April 1980 and July 1985. Men and women between the ages of 18 and 70 years with a clinical diagnosis of diabetes mellitus were eligible. Approximately 30% of all patients were considered to have type I diabetes mellitus, 31% type II, and in 39% type I or II could not be determined definitely.Intervention.
—Patients were randomly assigned to aspirin or placebo (two 325-mg tablets once per day).Main Outcome Measures.
—Mortality from all causes was specified as the primary outcome measure for assessing the systemic effects of aspirin. Other outcome variables included cause-specific mortality and cardiovascular events.Results.
—The estimate of relative risk for total mortality for aspirin-treated patients compared with placebo-treated patients for the entire study period was 0.91 (99% confidence interval, 0.75 to 1.11). Larger differences were noted for the occurrence of fatal and nonfatal myocardial infarction; the estimate of relative risk was 0.83 for the entire follow-up period (99% confidence interval, 0.66 to 1.04).Conclusions.
—The effects of aspirin on any of the cardiovascular events considered in the ETDRS were not substantially different from the effects observed in other studies that included mainly nondiabetic persons. Furthermore, there was no evidence of harmful effects of aspirin. Aspirin has been recommended previously for persons at risk for cardiovascular disease. The ETDRS results support application of this recommendation to those persons with diabetes at increased risk of cardiovascular disease.(JAMA. 1992;268:1292-1300)
Data Synthesis: Meta-analysis was performed, and the quantitative results of the review were then used to model the consequences of treating patients with different levels of baseline risk for coronary heart disease. Five trials examined the effect of aspirin on cardiovascular events in patients with no previous cardiovascular disease. For patients similar to those enrolled in the trials, aspirin reduces the risk for the combined end point of nonfatal myocardial infarction and fatal coronary heart disease (summary odds ratio, 0.72 [95% CI, 0.60 to 0.87]). Aspirin increased the risk for hemorrhagic strokes (summary odds ratio, 1.4 [CI, 0.9 to 2.0]) and major gastrointestinal bleeding (summary odds ratio, 1.7 [CI, 1.4 to 2.1]). All-cause mortality (summary odds ratio, 0.93 [CI, 0.84 to 1.02]) was not significantly affected. For 1000 patients with a 5% risk for coronary heart disease events over 5 years, aspirin would prevent 6 to 20 myocardial infarctions but would cause 0 to 2 hemorrhagic strokes and 2 to 4 major gastrointestinal bleeding events. For patients with a risk of 1% over 5 years, aspirin would prevent 1 to 4 myocardial infarctions but would cause 0 to 2 hemorrhagic strokes and 2 to 4 major gastrointestinal bleeding events. Conclusions: The net benefit of aspirin increases with increasing cardiovascular risk. In the decision to use aspirin chemoprevention, the patient’s cardiovascular risk and relative utility for the different clinical outcomes prevented or caused by aspirin use must be considered.
Background
In addition to the treatment of specific cardiovascular risk factors, intervention which interferes with the general mechanisms of atherosclerosis could further reduce the incidence of cardiovascular events. We aimed to investigate in general practice the efficacy of antiplatelets and antioxidants in primary prevention of cardiovascular events in people with one or more major cardiovascular risk factors.
Methods
We did a randomised controlled open 2·2 factorial trial to investigate low-dose aspirin (100 mg/day) and vitamin E (300 mg/day) in the prevention of cardiovascular events, in people with one or more of the following: hypertension, hypercholesterolaemia, diabetes, obesity, family history of premature myocardial infarction, or individuals who were elderly.
Findings
4495 people (2583 female, mean age 64·4 years) were included in the trial. After a mean follow-up of 3·6 years the trial was prematurely stopped on ethical grounds when newly available evidence from other trials on the benefit of aspirin in primary prevention was strictly consistent with the results of the second planned interim analysis. Aspirin lowered the frequency of all the endpoints, being significant for cardiovascular death (from 1·4 to 0·8%; relative risk 0·56 [95% CI 0·31–0·99]) and total cardiovascular events (from 8·2 to 6·3%; 0·77 [0·62–0·95]). Severe bleedings were more frequent in the aspirin group than the no-aspirin group (1·1% vs 0·3%; p<0·0008). Vitamin E showed no effect on any prespecified endpoint. Analyses were by intention-to-treat.
Interpretation
In women and men at risk of having a cardiovascular event because of the presence of at least one major risk factor, low-dose aspirin given in addition to treatment of specific risk factors contributes an additional preventive effect, with an acceptable safety profile. The results on vitamin E's cardiovascular primary preventive efficacy are not conclusive per se, although our results are consistent with the negative results of other large published trials on secondary prevention.
Objective:
To determine the effects of antiplatelet therapy among patients at high risk of occlusive vascular events.
Design:
Collaborative meta-analyses (systematic overviews).
Inclusion criteria:
Randomised trials of an antiplatelet regimen versus control or of one antiplatelet regimen versus another in high risk patients (with acute or previous vascular disease or some other predisposing condition) from which results were available before September 1997. Trials had to use a method of randomisation that precluded prior knowledge of the next treatment to be allocated and comparisons had to be unconfounded-that is, have study groups that differed only in terms of antiplatelet regimen.
Studies reviewed:
287 studies involving 135 000 patients in comparisons of antiplatelet therapy versus control and 77 000 in comparisons of different antiplatelet regimens.
Main outcome measure:
"Serious vascular event": non-fatal myocardial infarction, non-fatal stroke, or vascular death.
Results:
Overall, among these high risk patients, allocation to antiplatelet therapy reduced the combined outcome of any serious vascular event by about one quarter; non-fatal myocardial infarction was reduced by one third, non-fatal stroke by one quarter, and vascular mortality by one sixth (with no apparent adverse effect on other deaths). Absolute reductions in the risk of having a serious vascular event were 36 (SE 5) per 1000 treated for two years among patients with previous myocardial infarction; 38 (5) per 1000 patients treated for one month among patients with acute myocardial infarction; 36 (6) per 1000 treated for two years among those with previous stroke or transient ischaemic attack; 9 (3) per 1000 treated for three weeks among those with acute stroke; and 22 (3) per 1000 treated for two years among other high risk patients (with separately significant results for those with stable angina (P=0.0005), peripheral arterial disease (P=0.004), and atrial fibrillation (P=0.01)). In each of these high risk categories, the absolute benefits substantially outweighed the absolute risks of major extracranial bleeding. Aspirin was the most widely studied antiplatelet drug, with doses of 75-150 mg daily at least as effective as higher daily doses. The effects of doses lower than 75 mg daily were less certain. Clopidogrel reduced serious vascular events by 10% (4%) compared with aspirin, which was similar to the 12% (7%) reduction observed with its analogue ticlopidine. Addition of dipyridamole to aspirin produced no significant further reduction in vascular events compared with aspirin alone. Among patients at high risk of immediate coronary occlusion, short term addition of an intravenous glycoprotein IIb/IIIa antagonist to aspirin prevented a further 20 (4) vascular events per 1000 (P<0.0001) but caused 23 major (but rarely fatal) extracranial bleeds per 1000.
Conclusions:
Aspirin (or another oral antiplatelet drug) is protective in most types of patient at increased risk of occlusive vascular events, including those with an acute myocardial infarction or ischaemic stroke, unstable or stable angina, previous myocardial infarction, stroke or cerebral ischaemia, peripheral arterial disease, or atrial fibrillation. Low dose aspirin (75-150 mg daily) is an effective antiplatelet regimen for long term use, but in acute settings an initial loading dose of at least 150 mg aspirin may be required. Adding a second antiplatelet drug to aspirin may produce additional benefits in some clinical circumstances, but more research into this strategy is needed.