Response to Naunton and Duyvendak re “Appropriate use of antiplatelets: is prescription in daily practice influenced by the global cardiovascular risk?”

Abstract

We thank Drs. Naunton and Duyvendak for their useful comments and criticism. As we mentioned, the study was a feasibility phase for a large intervention trial (Risk and Prevention trial) on cardiovascular risk prevention in highrisk patients, aimed at describing how general practitioners (GPs) perceive and treat cardiovascular risk in everyday practice and was not focused specifically on antiplatelet drug treatment. Data on chronic prescriptions were collected during the patient’s visit from the physician’s documentation or directly from the patients. We decided to exclude atrial fibrillation because the purpose of the study was to evaluate antiplatelet treatment in high-risk subjects for the prevention of atherosclerotic events, but not in patients with atrial fibrillation, where the goal is to prevent embolic events. In our study, the current use of anticoagulants, nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids—relative contraindications to antiplatelet prescription—accounted for 3.4% of the total population (2% of patients in primary prevention and 7% in the secondary prevention). Therefore, the low rate of aspirin prescription is unlikely to be due to the concomitant use of these drugs. As already noted in our “Discussion”, the lack of information on other contraindications to antiplatelets could be a limit of the study. Nevertheless in the first 5,000 patients at high cardiovascular risk enrolled in the Risk and Prevention trial, the rates of any contraindication or intolerance were 8 and 4%, respectively. The original aim of the study was to see whether prescription of preventive drugs varied on the basis of the level of risk “subjectively” perceived by GPs. The SCORE risk chart was used to estimate the risk a posteriori as an “objective” method. Indeed, this is a recent and accurate tool to apply to a population of Southern Europeans, like ours. Anyway, using the previously recommended risk charts, such as the European one [1], or simply using the number of risk factors, did not materially change the results. At the time of the study, most evidence on the benefit of aspirin treatment in primary prevention had already been published [2–4], but no national or international guideline yet recommended using antiplatelets in primary prevention. However, we are not convinced that everyday practice could be so promptly influenced by guidelines. Indeed, preliminary data from the population enrolled in the Risk and Prevention trial show that even today aspirin is prescribed to only one-fourth of high-risk patients. These data show clearly that 3 years after the publication of the U.S. Preventive Services Task Force recommendations on aspirin prophylaxis [5] this effective measure is still largely underused in current practice. As correctly underlined by Naunton and Duyvendak, beside low aspirin use, there is also inappropriate aspirin prescription in low-risk patients. This is another piece of evidence, as we already noted, that shows the need for “general practice-based studies to explore the reasons for the gap between recommended behaviour and real practice, including GPs’ and patients’ perspectives” in order to improve prescribing practice and patient care.