Association of Discharge Aspirin Dose With Outcomes After Acute Myocardial Infarction

Xian, Ying; Wang, Tracy Y.; McCoy, Lisa A.; Effron, Mark B.; Henry, Timothy D.; Bach, Richard G.; Zettler, Marjorie E.; Baker, Brian; Fonarow, Gregg C.; Peterson, Eric D.

doi:10.1161/circulationaha.114.014992

Cited by 48 publications

(12 citation statements)

References 29 publications

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“…This study had some characteristics that might have affected the bleeding rate as follows: (1) there was a high proportion of patients with TRA-PCI in the present study (91.20%); (2) a low percentage of the population received oral triple therapy comprising anticoagulants, aspirin, and a P2Y12 receptor inhibitor ( n = 17, 0.17%); (3) none of the maintenance doses of aspirin were higher than 100 mg; and (4) there was a low rate of using ticagrelor in 2013 in China (only 0.13% in this study). Previous studies showed that the use of the TRA[ 11 ] and a low maintenance dose of aspirin may decrease the incidence of bleeding,[ 14 15 16 ] triple therapy,[ 17 18 ] and the use of strong P2Y12 receptor inhibitors may increase the bleeding risk. [ 19 ] All of the above factors might affect the PARIS bleeding score's predictive value in this study.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of the Patterns of Non-Adherence to Anti-Platelet Regimens in Stented Patients Bleeding Score for Predicting the Long-term Out-of-hospital Bleeding Risk in Chinese Patients after Percutaneous Coronary Intervention

Zhao

Tang

et al. 2018

Chinese Medical Journal

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Background:The Patterns of Non-Adherence to Anti-Platelet Regimens in Stented Patients (PARIS) bleeding score is a novel score for predicting the out-of-hospital bleeding risk after percutaneous coronary intervention (PCI). However, whether this score has the same value in non-European and American populations is unclear. This study aimed to assess the PARIS bleeding score's predictive value of bleeding in patients after PCI in the Chinese population.Methods:We performed a prospective, observational study of 10,724 patients who underwent PCI from January to December 2013, in Fuwai Hospital, China. We defined the primary end point as major bleeding (MB) according to Bleeding Academic Research Consortium definition criteria including Type 2, 3, or 5. The predictive value of the PARIS bleeding score was assessed with the area under the receiver operating characteristic (AUROC) curve.Results:Of 9782 patients, 245 (2.50%) MB events occurred during the 2 years of follow-up. The PARIS bleeding score was significantly higher in the MB group than that of non-MB group (4.00 [3.00, 5.00] vs. 3.00 [2.00, 5.00], Z = 3.71, P < 0.001). According to risk stratification of the PARIS bleeding score, the bleeding risk in the intermediate- and high-risk groups was 1.50 times (hazard ratio [HR]: 1.50; 95% confidence interval [CI]: 1.160–1.950; P = 0.002) and 2.27 times higher (HR: 2.27; 95% CI: 1.320–3.900; P = 0.003) than that in the low-risk group. The PARIS bleeding score showed a moderate predictive value for MB in the overall population (AUROC: 0.568, 95% CI: 0.532–0.605; P < 0.001) and acute coronary syndrome (ACS) subgroup (AUROC: 0.578, 95% CI: 0.530–0.626; P = 0.001) and tended to be predictive in the non-ACS subgroup (AUROC: 0.556, 95% CI: 0.501–0.611; P = 0.054).Conclusion:The PARIS bleeding score shows good clinical value for risk stratification and has a significant, but relatively limited, prognostic value for out-of-hospital bleeding in the Chinese population after PCI.

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Section: Discussionmentioning

confidence: 99%

Evaluation of the Patterns of Non-Adherence to Anti-Platelet Regimens in Stented Patients Bleeding Score for Predicting the Long-term Out-of-hospital Bleeding Risk in Chinese Patients after Percutaneous Coronary Intervention

Zhao

Tang

et al. 2018

Chinese Medical Journal

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“…4 After the initial loading dose, subsequent administration of low-dose aspirin (ie, 81 mg daily) is associated with lower gastrointestinal bleeding with the same cardiovascular benefit as higher daily doses. 5,6 Per the 2013 ACC/AHA STEMI guidelines, after an initial aspirin loading dose of 162 to 325 mg, a daily dose of 81 mg is often continued indefinitely for secondary prevention. 7 Likewise, the 2017 ESC STEMI guidelines recommend aspirin administration for all patients without contraindications (class I recommendation).…”

Section: Maintaining Myocardial Perfusion During St-segment Elevationmentioning

confidence: 99%

Do We Need Potent Intravenous Antiplatelet Inhibition at the Time of Reperfusion During ST-Segment Elevation Myocardial Infarction?

Allencherril

Alam

Levine

et al. 2018

J Cardiovasc Pharmacol Ther

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Acute myocardial infarction (MI) is still a large source of morbidity and mortality worldwide. Although early reperfusion therapy has been prioritized in the modern era of percutaneous coronary intervention and thrombolysis, attempts at incremental improvements in clinical outcomes by reducing MI size have not been successful so far. Herein, we review the studies that have evaluated immediate-onset antiplatelet therapy as attempts to improve meaningful clinical outcomes in ST-segment elevation MI (STEMI). Unfortunately, many of the adjunctive pharmacotherapies have proven to be disappointing. Recent studies performed in the background of routine oral administration of P2Y 12 adenosine receptor inhibitors, which may take several hours to take full effect, and aspirin have largely shown no improvement in outcomes, despite an earlier onset of antiplatelet activity of the investigative agents. Further progress in improving outcomes during STEMI may depend on exploring therapeutics that modulate the pathophysiology of microvascular damage during ischemia-reperfusion injury, a phenomenon whose effects evolve over hours to days. We speculate that the dynamic nature of the no-reflow phenomenon may be an explanation for these disappointing results with the intravenous antiplatelet agents. We hope that appreciation for what has not worked in this domain may direct future research efforts to focus on novel pathways. Myocardial ischemia and reperfusion injury are very much still a lingering issue. Despite significant improvements in door-to-balloon times, rates of in-hospital mortality for STEMI remain unchanged. Outcomes following successfully reperfused STEMI are likely determined by the initial size of myocardial necrosis (ie, cardiomyocyte death during the period of ongoing ischemia), patency of the infarct-related epicardial coronary artery, possible reperfusion injury, the microvascular no-reflow phenomenon, and adverse remodeling after infarction.

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“…While there is strong evidence to support aspirin treatment for the secondary prevention of ASCVD in contemporary practice guidelines, registries and post hoc analyses from randomized clinical trials have shown discordant results with respect to aspirin dosage on ischemic events in the post-ACS setting . Moreover, variable use of aspirin in low or high dosages for post-ACS treatment in clinical practice exists, reflecting the uncertainty among clinicians regarding the optimal dosage for long-term secondary prevention.…”

Section: Introductionmentioning

confidence: 99%

Rationale and Design of the Aspirin Dosing—A Patient-Centric Trial Assessing Benefits and Long-term Effectiveness (ADAPTABLE) Trial

et al. 2020

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BACKGROUNDThe appropriate dose of aspirin to lower the risk of death, myocardial infarction, and stroke and to minimize major bleeding in patients with established atherosclerotic cardiovascular disease is a subject of controversy. METHODSUsing an open-label, pragmatic design, we randomly assigned patients with established atherosclerotic cardiovascular disease to a strategy of 81 mg or 325 mg of aspirin per day. The primary effectiveness outcome was a composite of death from any cause, hospitalization for myocardial infarction, or hospitalization for stroke, assessed in a time-to-event analysis. The primary safety outcome was hospitalization for major bleeding, also assessed in a time-to-event analysis. RESULTSA total of 15,076 patients were followed for a median of 26.2 months (interquartile range [IQR], 19.0 to 34.9). Before randomization, 13,537 (96.0% of those with available information on previous aspirin use) were already taking aspirin, and 85.3% of these patients were previously taking 81 mg of daily aspirin. Death, hospitalization for myocardial infarction, or hospitalization for stroke occurred in 590 patients (estimated percentage, 7.28%) in the 81-mg group and 569 patients (estimated percentage, 7.51%) in the 325-mg group (hazard ratio, 1.02; 95% confidence interval [CI], 0.91 to 1.14). Hospitalization for major bleeding occurred in 53 patients (estimated percentage, 0.63%) in the 81-mg group and 44 patients (estimated percentage, 0.60%) in the 325-mg group (hazard ratio, 1.18; 95% CI, 0.79 to 1.77). Patients assigned to 325 mg had a higher incidence of dose switching than those assigned to 81 mg (41.6% vs. 7.1%) and fewer median days of exposure to the assigned dose (434 days [IQR, 139 to 737] vs. 650 days [IQR, 415 to 922]). CONCLUSIONSIn this pragmatic trial involving patients with established cardiovascular disease, there was substantial dose switching to 81 mg of daily aspirin and no significant differences in cardiovascular events or major bleeding between patients assigned to 81 mg and those assigned to 325 mg of aspirin daily. (Funded by the Patient-Centered Outcomes Research Institute; ADAPTABLE ClinicalTrials.gov number, NCT02697916.

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Association of Discharge Aspirin Dose With Outcomes After Acute Myocardial Infarction

Cited by 48 publications

References 29 publications

Evaluation of the Patterns of Non-Adherence to Anti-Platelet Regimens in Stented Patients Bleeding Score for Predicting the Long-term Out-of-hospital Bleeding Risk in Chinese Patients after Percutaneous Coronary Intervention

Evaluation of the Patterns of Non-Adherence to Anti-Platelet Regimens in Stented Patients Bleeding Score for Predicting the Long-term Out-of-hospital Bleeding Risk in Chinese Patients after Percutaneous Coronary Intervention

Do We Need Potent Intravenous Antiplatelet Inhibition at the Time of Reperfusion During ST-Segment Elevation Myocardial Infarction?

Rationale and Design of the Aspirin Dosing—A Patient-Centric Trial Assessing Benefits and Long-term Effectiveness (ADAPTABLE) Trial

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