Acetylsalicylic Acid In Primary Prevention Research Articles

Prevalence of Acetylsalicylic Acid Use for Primary Prevention of Cardiovascular Disease Amongst Older Adults From 2017-2021: a Retrospective Cross-Sectional Study.

Three landmark trials on the use of acetylsalicylic acid (ASA) for primary prevention of cardiovascular disease (CVD) were published in 2018. Since then, major clinical practice guidelines have been updated with recommendations against the routine use of ASA for primary CVD prevention, particularly in older adults. However, little is known about the uptake of this evidence into real world practice. The purpose of this study was to assess the change in ASA usage for primary prevention of CVD in older adults between 2017 and 2021. A retrospective cross-sectional study of ASA use for primary prevention in ambulatory older adults without known CVD in an urban Canadian city was conducted. Seven hundred and fifty-six participants were included. The mean age was 78.9 years (standard deviation 7.9) and 64.8% were female. One hundred and thirty (17.2%) participants used ASA for primary prevention, including 20.3% in 2017, 17.0% in 2018, 21.8% in 2019, 16.3% in 2020, and 11.0% in 2021 (p = .061). Female sex was associated with lower ASA use (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.29-0.68) and hypertension was associated with higher ASA use (OR 2.72, 95% CI 1.73-4.29). Use of ASA for primary CVD prevention in older Canadians decreased between 2017 and 2021, suggesting an uptake of clinical trial data and practice guideline recommendations. Focusing on deprescribing of ASA for primary CVD prevention continues to be warranted, given the risks associated with ASA in this population.

Modern concepts of the place of acetylsalicylic acid in the treatment of patients with various manifestations of atherothrombosis

The review is devoted to the analysis of the significance of acetylsalicylic acid (ASA) in the primary and secondary prevention of various manifestations of atherothrombosis. The results of the ARRIVE, ASPREE and ASCEND studies are considered, based on which the evidence base for the use of reduced low-dose ASA (75-100 mg) for primary prevention of cardiovascular diseases (CVD), including patients with diabetes mellitus is formed. Nevertheless, the question of the significance of ASA in primary prevention of CVDs has not been finally resolved, because the results of the latest TIPS-3 study, published in 2020, showed that the combination of enteric-coated ASA with a polypill consisting of a statin and three hypotensive drugs, compared with placebo, reduces the frequency of cardiovascular episodes (CVEs) in individuals without CVDs but with average cardiovascular risk. ASA is an immutable component of dual antiplatelet therapy (DAPT) in patients with acute coronary syndromes (ACS), in patients with coronary heart disease, subjected to planned stenting. Recently, evidence has been obtained about the impact of bleeding on prognostic outcomes, so there is a clear trend to reduce the duration of aspirin therapy in patients with atrial fibrillation and ACS or undergoing planned stenting. A new trend is enhancement of ASA therapy with a second antithrombotic drug in patients with stable manifestations of atherothrombosis with high risk of thrombotic complications. Thus, modern recommendations suggest to enhance ASA therapy with a vascular dose of rivaroxaban (2.5 mg 2 p/day) or a P2Y12-receptor platelet inhibitor. ASA appears to be a classic antiaggregant and an essential partner for new antithrombotic drugs.

Potential role of acetylsalicilic acid and other non-steroidal anti-inflammatory drugs in cancer risk reduction (literature review)

The aim of this review is to analyze and summarize the existing evidence regarding the possibilities of using acetylsalicylic acid (ASA) and other non-steroidal anti-inflammatory drugs (NSAIDs) to reduce cancer risk. Conclusions. Chronic inflammation facilitates the onset and progress of tumour growth. Anti-cancer properties of acetylsalicylic acid and other non-steroidal anti-inflammatory drugs are mediated via cyclooxygenase COX-dependent mechanisms, as well as other tumorigenic pathways. Current systematic review addresses potential role of ASA and other NSAIDs in reduction of cancer risk for the following localizations: head and neck, lungs, gastrointestinal tract, breast, ovaries, prostate, and skin. The role of ASA in primary prevention of colorectal cancer in specific populations is presented in 2016 U. S. Preventive Services Task Force guidelines. Studies indicate heterogeneous protective potential of ASA against different cancer types, depending on studied population, duration of intake and dose. Influence of non-aspirin NSAIDs on cancer morbidity and mortality is more controversial.

Impact of pre-treatment with acetylsalicylic acid on the severity of a first myocardial infarction in diabetic patients

Abstract Introduction Diabetes Mellitus (DM) is one of the main risk factors for cardiovascular disease (CVD). Guidelines on the use of acetylsalicylic acid (ASA) for primary prevention of CVD in this population are conflicting. A potential reduction in the severity of a first episode of Acute Myocardial Infarction (AMI) could be seen has an additional argument for the use of ASA in primary prevention. Aim: To evaluate the impact of prior intake of ASA on the presentation, severity and short-term prognosis of AMI in diabetic patients without history of CVD. Methods Retrospective analysis of diabetic patients without previous evidence of CVD diagnosed with type 1 AMI between January 2002 and December 2018, inserted in a multicentric registry of acute coronary syndromes. Patients were dichotomized according to whether or not they were taking ASA prior to the index event. Groups were compared according to clinical, analytical and imaging endpoints. Results A total of 2596 patients were included, predominantly men (66.4%), with a mean age of 68±12 years old. Patients on ASA (19.7%) were significantly older (71±10 vs. 67±12, p<0.001) and had a higher prevalence of hypertension (89.2% vs 77.9%, p<0.001), dyslipidaemia (69.8% vs. 61.1%, p<0.001) and chronic kidney disease (10.6% vs. 4.9%, p<0.001). Overall, there was a lower prevalence of AMI with ST-segment elevation (36.5% vs. 50.8%, p<0.001) in patients on ASA. However, the same group of patients had a significantly higher probability of evolution in Killip class > I (25.4% vs. 17.0%, p<0.001), a higher median BNP elevation (315 [126–623] vs. 166 [64–431], p<0.001); and a lower average ejection fraction upon discharge (49.0±12 vs. 51±12, p=0.011). Patients on prior regular intake of ASA also had a higher prevalence of multivessel disease (38.4% vs. 28.9%, p<0.001) and multiple significant stenosis (70.2% vs. 61.7%, p<0.001). There was no significant difference regarding the percentage of electrical complications (2.3% vs. 1.2%, p=0.06), use of intra-aortic balloon pump (1.0 vs. 0.9%, p=0.74) and in-hospital death (3.0% vs. 2.4%, p=0.46). In a logistic regression model adjusted for age, sex, comorbidities and previous medication as variates, prior ASA intake was an independent predictor of a lower rate of AMI with ST-segment elevation (ExpB −0.34; 95% CI: 0.57–0.89; p=0.003). On the contrary, when adjusted to these variables, prior ASA intake was not an independent predictor of higher BNP (p=0.13) or higher probability of multivessel disease (p=0.22) or presence of ≥1 significant stenosis (p=0.31). Conclusions In this population of diabetic patients with a first episode of ACS, prior use of ASA in the context of primary prevention was associated with a significant lower rate of ST-segment elevation myocardial infarction. Funding Acknowledgement Type of funding source: None

Primary prevention of chronic non-communicable diseases and acetylsalicylic acid: ambiguity of opinions

Chronic noninfectious diseases (cardiovascular, bronchopulmonary, oncological diseases and diabetes mellitus) are presently the most common cause of death worldwide, with cardiovascular diseases (CVD) being predominant. For this reason, the key goal of a physician is not only to treat but also to prevent diseases. Acetylsalicylic acid (ASA) is considered one of the most effective drugs for secondary prevention of CVD. However, the use of ASA for primary prevention is still debated. Results of many studies of ASA are inconsistent. Some studies have suggested that using ASA in patients aged 40-70 with a high 10-year risk of CVD and a low risk of bleeding may reduce the incidence of CVD. Administration of ASA to patients with a high or medium risk of CVD is also considered.

Lo mejor del Congreso 2019 del American College of Cardiology

As every year, on this occasion the 68th Congress of the American College of Cardiology was held from March 16 to 18 in New Orleans, Louisiana. Set in the city of Mardi Gras and jazz, it once again called on global cardiology to promote knowledge through the presentation of multiple scientific activities. It counted with the presence of more than 16.000 attendees and 2.300 articles were received, many of which will undoubtedly modify the current clinical practice. It is also worth mentioning the presentation of the Primary Prevention of Cardiovascular Disease Guideline, which highlights the almost total discontinuation of acetylsalicylic acid in primary prevention due to the lack of net benefit.We will make a brief summary of some of the main scientific papers presented: Antithrombotic Therapy after Acute Coronary Syndrome or PCI in Atrial Fibrillation – The AUGUSTUS Trial TranscatheterAortic-ValveReplacement with aBalloon-ExpandableValve in Low-Risk Patients –ThePARTNER3 trial The Safety and Efficacy of Femoral Access in STEMI: The SAFARI-STEMI Trial One-Month Dual Antiplatelet Therapy Followed by Clopidogrel Monotherapy versus Standard 12-Month Dual Antiplatelet Therapy With Clopidogrel After Drug-Eluting Stent Implantation. STOP-DAPT 2 Trial Results of a Large-scale, App-based Study to Identify Atrial Fibrillation Using a Smartwatch: The Apple Heart Study

Acetylsalicylic Acid for Primary Prevention of Cardiovascular Disease

Introducao: A doenca cardiovascular (DCV) constitui uma das principais causas de morbimortalidade mundial. O risco cardiovascular SCORE (Systematic Coronary Risk Evaluation) estima o risco a 10 anos de um evento aterosclerotico fatal. O uso do acido acetilsalicilico (AAS) em doentes com DCV previa associa-se a diminuicao da mortalidade e a novos eventos cardiovasculares, estando comprovado o seu beneficio. Contudo, em prevencao primaria (PP), atendendo a menor incidencia de eventos cardiovasculares, o balanco risco-beneficio e menos claro.Objetivos: Avaliar a prevalencia da prescricao do AAS na prevencao primaria de eventos cardiovasculares nos doentes de muito alto risco (SCORE ≥ 10%) e verificar se existe maior taxa de prescricao naqueles que apresentam varios fatores de risco. Como objetivos secundarios pretende-se avaliar a prevalencia desses fatores de risco e caraterizar a populacao, definindo o perfil do doente elegivel para AAS.Metodos: A populacao do estudo foram doentes com Diabetes Mellitus (DM) com idades entre os 50 e os 70 anos, de muito alto risco cardiovascular, sem doenca cardiovascular aterosclerotica documentada, da Unidade de Saude Familiar S. Felix/Perosinho. Foram selecionados todos os doentes diabeticos que apresentassem concomitantemente um ou mais fatores de risco cardiovasculares.Resultados: Obteve-se uma amostra final de 234 doentes (72,2%), com uma media de idades de 62 anos e com uma distribuicao homogenea entre os sexos. Desta amostra, 24,8% dos doentes encontravam-se sob terapeutica com AAS em PP. Nenhum doente apresentava diagnostico de DM isolada, e que quanto maior o numero de fatores de risco cardiovasculares, maior a percentagem de prescricao de AAS.Discussao: A taxa de prescricao de AAS como PP encontrada neste estudo reflete a variabilidade nas indicacoes para prescricao. O doente elegivel nao se encontra sob AAS como PP (75,2%). Assim, a definicao do perfil do doente elegivel e crucial atendendo que permitira realizar estudos mais dirigidos a este grupo.

Impact of acetylsalicylic acid on primary prevention of cardiovascular diseases: A meta-analysis of randomized trials.

Numerous studies have investigated use of acetylsalicylic acid (ASA) for prevention of cardiovascular deaths. The vast majority of the work in this area has focused on secondary prevention. However, underuse of ASA still remains a major issue. Fewer studies have investigated the impact of ASA on primary prevention of cardiovascular death. A meta-analysis of individual participant data from six randomized studies, published in 2009, showed decrease in serious vascular events but at the cost of causing increased bleeding and hemorrhagic stroke. Recent studies have raised a number of key questions regarding the benefits and risks of using ASA for primary prevention.

DOCTOR’S ADHERENCE TO RECOMMENDATIONS GOVERNING THE ANTIPLATELET AGENTS USE IN THE CARDIOVASCULAR DISEASES PREVENTION AND TREATMENT

Aim. To study the doctors' opinions on the main aspects of antiplatelet agents use, and to test their knowledge of the basic provisions of the current recommendations on antiplatelet therapy. Material and methods. As a material for the study the results of an anonymous questionnaire in randomly selected doctors were used. The questionnaire contained 11 questions concerning the use of antiplatelet agents for primary and secondary prevention of cardiovascular diseases. 276 questionnaires filled out by 185 therapists, 84 cardiologists and 7 physicians of other therapeutic specialties were analyzed. Results. The results of the study reflect the doctor’s tendency to use acetylsalicylic acid for the primary prevention of cardiovascular diseases, including the patients who do not have indications for its prescribing. 11.6% of respondents never recommend acetylsalicylic acid for primary prevention of cardiovascular diseases. 22.8% of doctors don’t consider it necessary to stop acetylsalicylic acid in patients who do not have indications for such treatment. Therapists demonstrate very low adherence to recommendations which underline the need for a weighted approach to the acetylsalicylic acid prescription. Cardiologists less often than therapists recommend acetylsalicylic acid for the primary prevention of cardiovascular disease in patients with low cardiovascular risk. Less than 30% of therapists and cardiologists tend to prescribe gastroprotectors to patients with aspirin-induced gastropathy. Only 19.6% of the respondents correctly indicated the P2Y12 receptor inhibitor dose to be used in combination with acetylsalicylic acid on the 1st day of acute coronary syndrome depending on planed treatment strategy. 88.4% of doctors consider the use of antiplatelet agents, if the patient with atrial fibrillation and a high risk of thromboembolism refused to take oral anticoagulants. 51.8% of respondents recommend a combination of acetylsalicylic acid and clopidogrel for such patients. Cardiologists are better informed about the recommendations regarding the use of dual antiplatelet therapy and a combination of antiplatelet agents with oral anticoagulants. However, in general, doctors' knowledge of combined antithrombotic therapy is inadequate. Conclusion. The results of the study show that it is necessary to discuss current recommendations on the use of antiplatelet agents for the primary and secondary prevention of cardiovascular diseases in the context of continuous medical education more actively.

OP-619 - The Effect of Inappropriate Use of Acetylsalicylic Acid to Non-Fatal Bleeding

Objective: Acetylsalicylic acid has benefical and hazardous effect. It is not clear that inappropriate usage of acetylsalicylic acid in primary prevention has increased risk of bleeding events. This study aims to assess non-fatal major and minor bleeding event in patients with inappropriate, appropriate primary and secondary prevention group.

PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE AND ANTIPLATELET THERAPY. CLINICAL LECTURE

Today, treatment with low doses of acetylsalicylic acid (ASA) (alone or in combination with other antiplatelet drugs) is the key element in the secondary prevention of coronary artery disease. Long-term therapy with low-dose ASA is recommended to patients with stable coronary artery disease, patients after acute coronary syndrome with or without ST segment elevation, and after revascularization. [1–3] The need for antithrombotic therapy in the primary prevention of cardiovascular events raises many questions. The currently available guidelines are contradictory – from complete denial of the need for antiplatelet therapy to designation of the specific groups of patients for whom ASA treatment is recommended. [4, 5] Findings of clinical trials underlie those contradictory opinions. ASA is the only antiplatelet agent the administration of which is debated for primary prevention. Administration of ASA in primary prevention usually results in a reduced risk of cardiovascular complications, but the positive effect is largely offset by an increased risk of bleeding, particularly gastrointestinal. Therefore, the challenge is in the selection of patients for whom the benefit from antithrombotic therapy could outweigh the risks associated with bleeding. Risk scores are commonly used to assess the risk of complications.

PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE AND ANTIPLATELET THERAPY. CLINICAL LECTURE

Today, treatment with low doses of acetylsalicylic acid (ASA) (alone or in combination with other antiplatelet drugs) is the key element in the secondary prevention of coronary artery disease. Long-term therapy with low-dose ASA is recommended to patients with stable coronary artery disease, patients after acute coronary syndrome with or without ST segment elevation, and after revascularization. [1–3] The need for antithrombotic therapy in the primary prevention of cardiovascular events raises many questions. The currently available guidelines are contradictory – from complete denial of the need for antiplatelet therapy to designation of the specific groups of patients for whom ASA treatment is recommended. [4, 5] Findings of clinical trials underlie those contradictory opinions. ASA is the only antiplatelet agent the administration of which is debated for primary prevention. Administration of ASA in primary prevention usually results in a reduced risk of cardiovascular complications, but the positive effect is largely offset by an increased risk of bleeding, particularly gastrointestinal. Therefore, the challenge is in the selection of patients for whom the benefit from antithrombotic therapy could outweigh the risks associated with bleeding. Risk scores are commonly used to assess the risk of complications.

Standardised tomato extract as an alternative to acetylsalicylic acid in patients with primary hypertension and high cardiovascular risk - a randomised, controlled trial.

IntroductionCardiovascular (CV) diseases remain a leading global cause of death. It has been proven that the use of acetylsalicylic acid (ASA) in secondary prevention reduces the CV risk, while the benefits of ASA in primary prevention have recently been debated. The aim of the study was to compare the antiplatelet effect of standardised tomato extract (STE) and ASA in hypertensive patients with high CV risk.Material and methodsThe study involved high-risk patients with arterial hypertension (AH) randomly assigned to one of two groups: group 1 included 33 patients receiving ASA and group 2 included 32 patients receiving STE. The platelet aggregation was determined using the VerifyNow analyser.ResultsAfter 4 weeks of ASA treatment in group 1, a statistically significant reduction in aspirin reaction units (ARU) was observed (p < 0.001). However, the obese subgroup using ASA (n = 18) did not reveal a significant decrease in ARU (p > 0.05). After 4 weeks of STE treatment in the obese subgroup (n = 14), significant declines in ARU by 8.6% (95% CI: –19.5 to –1.7%; p < 0.05) and in P2Y12 reaction units (PRU) by 7.5% (95% CI: –17.6 to 1.8%; p < 0.05) were observed.ConclusionsThe antiplatelet effect of STE in hypertensive patients may be weight dependent. The group with AH and obesity might have potentially benefitted from STE treatment.

Acetylsalicylic acid use in primary prevention in Canada: Insight from the Primary Care Audit of Global Risk Management (PARADIGM) study

Background: Acetylsalicylic acid (ASA) is of proven benefit in reducing cardiovascular (CV) events in both acute and chronic CV conditions. However, the role of ASA for the primary prevention of CV disease remains controversial, compounded by the risk of major hemorrhage with ASA therapy. Despite this, ASA remains frequently used in primary prevention. Methods: The PARADIGM study is an observational registry of 3015 healthy, middle-age Canadians, free of CV disease or diabetes, who underwent CV risk stratification. The present analysis assessed the use of ASA in this primary prevention cohort. Results: A total of 406 subjects (13.5%) were prescribed ASA by their primary care physician. Those prescribed ASA, compared with those who were not, were more likely to be older, of male sex, white Caucasian, past/current smokers, hypertensive and to have a family history of premature CV disease. Blood pressure, renal function, high-sensitivity C-reactive protein, waist circumference and body mass index were all discriminators of ASA use. The mean modified Framingham risk score was significantly higher for those prescribed ASA compared with those who were not. Importantly, only 44% of those prescribed ASA were at high risk according to Framingham risk score. Conclusions: The contemporary use of ASA in primary prevention remains high. Several clinical and laboratory factors influence the decision to prescribe ASA. However, the majority of ASA use was noted in individuals at low and intermediate risk (versus those at high risk).

A study about the relevance of adding acetylsalicylic acid in primary prevention in subjects with type 2 diabetes mellitus: effects on some new emerging biomarkers of cardiovascular risk.

AimTo evaluate the relevance of adding acetylsalicylic acid (ASA) in primary prevention in subjects with type 2 diabetes mellitus.Methods213 patients with type 2 diabetes mellitus and hypertension were randomized to amlodipine 5 mg, or amlodipine 5 mg + ASA 100 mg for 3 months (Phase A); then, if adequate blood pressure control was reached patients terminated the study; otherwise, amlodipine was up-titrated to 10 mg/day for further 3 months and compared to amlodipine 10 mg + ASA 100 mg (Phase B). We assessed at baseline, at the end of Phase A, and at the end of Phase B the levels of some new emerging biomarkers of cardiovascular risk including: high sensitivity C-reactive protein (Hs-CRP), adiponectin (ADN), tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), myeloperoxidase (MPO), soluble CD40 ligand (sCDL40).ResultsCompared to baseline, at the end of Phase A, patients treated with amlodipine 5 mg + ASA 100 mg showed a statistically significant reduction of Hs-CRP (−15.0%), TNF-α (−21.7%), MPO (−9.7%), and sCDL40 (−15.7%), and a statistically significant increase of ADN (+15.0%). These values were significantly better than the ones obtained with amlodipine alone. Similarly, at the end of Phase B, amlodipine 10 mg + ASA significantly lowered Hs-CRP (−18.8%), TNF-α (−15.0%), MPO (−9.2%), and sCDL40 (−20.0%) and increased ADN (+11.8%), with a better effect compared to amlodipine alone.ConclusionAll biomarkers considered were significantly improved by ASA addition. These data suggest that the use of ASA in primary prevention could be useful in patients with type 2 diabetes mellitus and hypertension.Trial registration: ClinicalTrials.gov: NCT02064218

Acetylsalicylic acid in primary prevention among patients with arterial hypertension

Arterial hypertension (AH) remains one of the most prevalent cardiovascular diseases (CVD) and is an important risk factor of severe, often fatal complications. CVD prevention in AH patients is a complex task, including not only blood pressure reduction, but also targeting additional risk factors. The HOT study was the first attempt to assess the effects of acetylsalicylic acid (ASA) on CVD risk in AH patients. It was shown that ASA reduced the risk of major cardiovascular events (non-fatal acute myocardial infarction (MI), non-fatal stroke, and cardiac death) by 15% (p=0,03). The risk of MI was reduced by 36% (p=0,02). In order to implement the HOT study results in the clinical practice, additional data analyses were performed, which demonstrated that ASA benefits were the most pronounced in patients with creatinine levels &gt;150 mmol/l. The evidence from the HOT study, including the subgroup analysis results, has been included in the latest guidelines on AH management.

Acetylsalicylic acid for primary prevention of cardiovascular diseases in older patients with diabetes: do the benefits overcome the risks?

Cardiovascular diseases (CVDs) represent a huge health burden for older patients with diabetes. Acetylsalicylic acid (ASA) has long been used as a cardioprotective agent in primary and secondary prevention of CVD. However, there are important issues regarding the benefits and risks of ASA therapy in primary prevention of CVDs, for the older group in general and for individuals of all ages with diabetes. In this review, we summarize the benefits and risks related to ASA therapy by outlining the evidence for older patients and for patients with diabetes. There appear to be significant gaps in knowledge. The balance of benefits and risks is not well defined but ASA treatment seems to be unfavorable in many older patients.

Antiplatelet agents and anticoagulants for hypertension

Elevated systemic blood pressure results in high intravascular pressure but the main complications, coronary heart disease (CHD), ischaemic strokes and peripheral vascular disease (PVD), are related to thrombosis rather than haemorrhage. Some complications related to elevated blood pressure, heart failure or atrial fibrillation, are themselves associated with stroke and thromboembolism. Therefore it is important to investigate if antithrombotic therapy may be useful in preventing thrombosis-related complications in patients with elevated blood pressure. To conduct a systematic review of the role of antiplatelet therapy and anticoagulation in patients with high blood pressure, including those with elevations in both systolic and diastolic blood pressure, isolated elevations of either systolic or diastolic blood pressure, to address the following hypotheses: (i) antiplatelet agents reduce total deaths and/or major thrombotic events when compared to placebo or other active treatment; and (ii) oral anticoagulants reduce total deaths and/or major thromboembolic events when compared to placebo or other active treatment. Electronic databases (MEDLINE, EMBASE, DARE, CENTRAL, Hypertension Group specialised register) were searched up to January 2011. The reference lists of papers resulting from the electronic searches and abstracts from national and international cardiovascular meetings were hand-searched to identify missed or unpublished studies. Relevant authors of studies were contacted to obtain further data. Randomised controlled trials (RCTs) in patients with elevated blood pressure were included if they were of at least 3 months in duration and compared antithrombotic therapy with control or other active treatment. Data were independently collected and verified by two reviewers. Data from different trials were pooled where appropriate. Four trials with a combined total of 44,012 patients met the inclusion criteria and are included in this review. Acetylsalicylic acid (ASA) did not reduce stroke or 'all cardiovascular events' compared to placebo in primary prevention patients with elevated blood pressure and no prior cardiovascular disease. In one large trial ASA taken for 5 years reduced myocardial infarction (ARR 0.5%, NNT 200), increased major haemorrhage (ARI 0.7%, NNT 154), and did not reduce all cause mortality or cardiovascular mortality. In one trial there was no significant difference between ASA and clopidogrel for the composite endpoint of stroke, myocardial infarction or vascular death. In two small trials warfarin alone or in combination with ASA did not reduce stroke or coronary events. The ATC meta-analysis of antiplatelet therapy for secondary prevention in patients with elevated blood pressure reported an absolute reduction in vascular events of 4.1% as compared to placebo. Data on the 10,600 patients with elevated blood pressure from the 29 individual trials included in the ATC meta-analysis was requested but could not be obtained. Antiplatelet therapy with ASA for primary prevention in patients with elevated blood pressure provides a benefit, reduction in myocardial infarction, which is negated by a harm of similar magnitude, increase in major haemorrhage.The benefit of antiplatelet therapy for secondary prevention in patients with elevated blood pressure is many times greater than the harm.Benefit has not been demonstrated for warfarin therapy alone or in combination with aspirin in patients with elevated blood pressure. Ticlopidine, clopidogrel and newer antiplatelet agents such as prasugrel and ticagrelor have not been sufficiently evaluated in patients with high blood pressure. Newer antithrombotic oral drugs such as dabigatran, rivaroxaban, apixaban and endosaban are yet to be tested in patients with high blood pressure.Further trials of antithrombotic therapy including with newer agents and complete documentation of all benefits and harms are required in patients with elevated blood pressure.

Hypertension in diabetes: A call to action

The Canadian Hypertension Education Program, Blood Pressure Canada, Canadian Hypertension Society, Heart and Stroke Foundation of Canada, Canadian Diabetes Association, College of Family Physicians of Canada, Canadian Pharmacists Association and the Canadian Council of Cardiovascular Nurses call on Canadian health care professionals to redouble efforts to help patients achieve treatment targets (blood pressure less than 130 mmHg systolic and less than 80 mmHg diastolic) in people with diabetes. Treatment of high blood pressure in people with diabetes results in large reductions in death and disability within a short period of time and needs to be a therapeutic priority. Achieving blood pressure targets requires sustained lifestyle modification, and three or more drugs including a diuretic are often required. Antihypertensive treatment in people with diabetes is one of the few medical treatments estimated to reduce overall health costs. The cost of treatment is less than the cost of complications prevented. Blood pressure needs to be assessed at all visits and home blood pressure assessment is encouraged. Management strategies need to include assessment and management of cardiovascular risks including smoking, unhealthy eating, physical inactivity, abdominal obesity, dyslipidemia as well as dysglycemia. The risks and benefits of acetylsalicylic acid in primary prevention of cardiovascular disease are uncertain in people with hypertension and diabetes. Intensive individualized lifestyle modification is recommended to prevent and treat hypertension, dyslipidemia, dysglycemia and other vascular risks in people with diabetes.