Inappropriate Aspirin Research Articles

Effect of Low-Dose Aspirin on the Elderly.

Aspirin is a recognized and affordable antiplatelet medicine. Low amounts of aspirin have been used to prevent cardiovascular events, and it is still widely used for primary and secondary stroke prevention. The purpose of this review article is to evaluate the effects of using low doses of aspirin among elderly people. Although taking large dosages of aspirin (500 mg daily) reduces the long-term risk of colorectal cancer, its effectiveness for long-term prevention may be limited by adverse effects. Studies have assessed the relationship between aspirin dosage, incidence, and death in patients withcolorectal cancer. Research has indicated that those with diabetes mellitus have an increased risk of cardiovascular events. Low amounts of aspirin have been used to prevent cardiovascular events. However, there is uncertainty regarding the potential benefits and risks associated with preventing the development ofcardiovascular problems inindividuals with diabetes. The use of aspirin lowers the risk of occlusive vascular events but raises the possibility of bleeding. More attention should be paid to reducing inappropriate aspirin usage in light of its prevalence, particularly among older persons, as the substantial continuous usage of thisdrug increases the chances of bleeding.

Identifying and reducing inappropriate aspirin use in primary care

ObjectiveRecent studies have called into question the safety of aspirin use for the primary prevention of atherosclerotic cardiovascular disease, particularly in older adults. Therefore, the objectives of this study were...

Aspirin deprescribing in primary prevention of cardiovascular disease: a prospective risk-benefit approach.

Current evidence and practice guidelines do not recommend aspirin for primary prevention of cardiovascular disease (CVD). Insufficient all-cause mortality benefits juxtaposed to increased gastrointestinal bleeding rates are well established. Pharmacists are well placed to assess the clinical appropriateness of aspirin in CVD and initiate deprescribing as required with medical colleagues. The aim of this study was to identify medical inpatients taking aspirin for primary prevention of CVD and initiate deprescribing utilising a risk-benefit approach. A single-arm prospective feasibility study of general medicine patients admitted to a major tertiary hospital over 5 weeks (July-August 2020) was conducted. Screened patients were categorised as either taking aspirin for primary or secondary prevention. A 5-year benefit-risk analysis of bleeding and cardiovascular risk was calculated using a validated tool from the Cardiac Society of Australia and New Zealand to guide recommendations. This study screened 277 patients, of which 71 patients were identified as taking aspirin. Ten of these patients (14%) were categorised as taking aspirin for primary prevention and thus were deemed suitable for deprescribing. The analysis showed that aspirin continuance would, on average, increase major bleeding events by 39%, whilst reducing major cardiovascular events by 13.4%. Pharmacists recommended aspirin cessation in seven of the cases identified, and deprescribing was successful in five cases. This study described an impactful pharmacist-led initiative utilising a validated aspirin-specific tool to conduct risk-benefit analysis to reduce potential major bleeding associated with inappropriate aspirin use.

Evaluation of a Pharmacist-Driven Ambulatory Aspirin Deprescribing Protocol.

Recent guidelines indicate that aspirin affords less cardiovascular protection and greater bleeding risks in adults aged > 70 years. Deprescribing potentially inappropriate medications is particularly important in older adults, as this population experiences a high risk of adverse effects and polypharmacy. Limited data are available regarding targeted aspirin deprescribing approaches by pharmacists. The objective of this study was to implement and evaluate the success and feasibility of a pharmacist-led aspirin deprescribing protocol for older adults in a primary care setting. This prospective feasibility study in a US Department of Veterans Affairs ambulatory care pharmacy setting included patients aged ≥ 70 years with documented aspirin use. We reviewed 459 patient records and determined that 110 were eligible for deprescribing. A pharmacistinitiated telephone call was attempted for each eligible patient to discuss the risks and benefits of deprescribing aspirin. The primary outcome was the proportion of patients reached for whom aspirin was discontinued. Secondary outcomes included patient rationale for declining deprescribing and the time to complete the intervention. Of 94 patients reached, 45 (48%) agreed to aspirin deprescribing, 3 (3%) agreed to dose reduction, and 29 (31%) declined the intervention. An additional 17 (18%) had previously stopped aspirin, which led to a medication reconciliation intervention. Pharmacists spent about 2 minutes per record review and 12 minutes on each encounter, including documentation. Implementing a pharmacist-driven aspirin deprescribing protocol in a primary care setting led to the discontinuation of inappropriate aspirin prescribing in nearly half of older adults contacted. The protocol was well accepted by collaborating physicians and feasible for pharmacists to implement, with potential for further dissemination across primary care settings.

Impact of pharmacist intervention to deprescribe inappropriate aspirin therapy in an outpatient anticoagulation clinic at a community hospital

Study objectiveThis study describes a pharmacist-led process to identify and discontinue inappropriate aspirin in patients receiving concomitant anticoagulant therapy and to evaluate the effectiveness of the intervention. SettingThe study took place in an outpatient anticoagulation clinic within a small community hospital. ParticipantsPatients ≥40 years old on indefinite anticoagulation therapy for atrial fibrillation and/or venous thromboembolism were included. DesignThis is a quality improvement initiative. InterventionsUtilizing the electronic medical record and patient interview, use and indication for daily aspirin therapy was confirmed. Prospectively collected patient demographics and past medical history were used to determine appropriateness of aspirin therapy. For patients identified as receiving inappropriate aspirin therapy, a fax was sent to the referring provider recommending aspirin discontinuation. Main outcome measuresTo assess the effectiveness of the intervention, outcomes were retrospectively measured. The primary outcome was the percentage of “accepted” recommendations. Secondary outcomes included the prevalence, dosing, and indications for aspirin therapy. ResultsEighty (33 %) of 242 patients were on aspirin. Fifty-two patients with atrial fibrillation and/or venous thromboembolism were assessed and aspirin was deemed inappropriate in 22 patients. The provider agreed with deprescribing aspirin therapy in 45 %. The most common dose and indication of aspirin therapy was 81 mg (98 %) and primary prevention (40 %) respectively. ConclusionsIn our small practice, pharmacist-led interventions were an effective means to recommend aspirin discontinuation in our identified patients. Further studies are needed to optimize a pharmacist's role and address the long-term effects of deprescription.

Low-dose aspirin for primary and secondary prevention of cardiovascular events in Denmark 1998\u20132018

Randomised controlled trials have shown a neutral or even unfavourable risk–benefit balance of aspirin for primary prevention of cardiovascular events. Using Danish nationwide registries, we investigated aspirin use and associated risks during the past two decades (1998–2018). We linked individual patient data on repeated aspirin redemptions with registered hospital ICD-10 diagnoses of atherosclerotic cardiovascular disease and bleedings. The prevalence of aspirin use among 1.1 million Danish adults fluctuated over the 20-year study period peaking in 2008 with 8.5% (5.4% primary prevention) and dropping to 5.1% (3.1% primary prevention) in 2018. Aspirin use showed strong age dependency, and 21% of individuals > 80 years were treated with aspirin for primary prevention in 2018. Medication adding to bleeding risk was used concurrently by 21% of all aspirin users in 2018. The incidence of major bleedings were similar with primary and secondary prevention aspirin use and highest in elderly (2 per 100 patient years among individuals > 80 years in 2018). In conclusion, low-dose aspirin use for primary prevention of cardiovascular events remains prevalent. The widespread use of aspirin, especially among older adults, and substantial concomitant use of medications adding to bleeding risk warrant increased focus on discontinuation of inappropriate aspirin use.

Dashboards to reduce inappropriate prescribing of metformin and aspirin: A quality assurance programme in a primary care sentinel network

AimsTo pilot two dashboards to monitor prescribing of metformin and aspirin according to the National Institute for Health and Care Excellence (NICE) ‘Do-Not-Do’ recommendations. MethodsThis quality assurance programme was conducted in twelve general practices of the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network. We developed dashboards to flag inappropriate prescribing of metformin and aspirin to people with type 2 diabetes mellitus (T2DM). In Phase 1, six practices (Group A) received a dashboard flagging suboptimal metformin prescriptions in people with reduced renal function. The other six practices (Group B) were controls. In Phase 2, Group B were provided a dashboard to flag inappropriate aspirin prescribing and Group A were controls. We used logistic regression to explore associations between dashboard exposure and inappropriate prescribing. ResultsThe cohort comprised 5644 individuals (Group A, n = 2656; Group B, n = 2988). Half (51.6%, n = 2991) were prescribed metformin of which 15 (0.5%) were inappropriate (Group A, n = 10; Group B, n = 5). A fifth (17.6%, n = 986) were prescribed aspirin of which 828 (84.0%) were inappropriate. During Phase 1, metformin was stopped in 50% (n = 5) of people in Group A, compared with 20% (n = 1) in the control group (Group B); in Phase 2, the odds ratio of inappropriate aspirin prescribing was significantly lower in practices that received the dashboard versus control (0.44, 95%CI 0.27−0.72). ConclusionsIt was feasible to use a dashboard to flag inappropriate prescribing. Whilst underpowered to report a change in metformin, we demonstrated a reduction in inappropriate aspirin prescribing.

A Multi-Center Quality Improvement Intervention to Reduce the Inappropriate Use of Aspirin Among Patients Anticoagulated with Warfarin for Atrial Fibrillation or Venous Thromboembolism

Introduction: For warfarin-treated patients with atrial fibrillation (AF) or venous thromboembolism (VTE), concomitant use of aspirin and warfarin increases the risk of major bleeding 1.5-1.8 fold without an apparent reduction in thrombotic events when there is no clear indication for combination therapy. As a result, each of six anticoagulation clinics in the Michigan Anticoagulation Quality Improvement Initiative (MAQI2) consortium implemented a common intervention between late 2017 and mid 2018 aiming to reduce inappropriate aspirin use. The intervention consisted of a screening process to identify possible inappropriate aspirin use and then contacting the patient's provider to discuss the need for ongoing aspirin therapy. Site-level implementation variation included the personnel carrying out the intervention, the use of technology, and the means of provider communication. Treatment decisions were deferred to the treating provider but facilitated by the anticoagulation clinic staff. We sought to assess the impact of this intervention on the rate of inappropriate aspirin use over time and compare patient characteristics based on aspirin use post intervention. Methods: First, we compared the overall rate of inappropriate aspirin use among the six center MAQI2 anticoagulation clinic cohort immediately before and after the intervention. All patients in MAQI2 were treated with warfarin. Then, we identified a sub-cohort of warfarin-treated patients with AF and/or VTE enrolled between January 2010 to June 2019. Within that sub-cohort, we assessed aspirin use pre and post the site-specific date of implementation of the intervention. Patients with a potential indication for aspirin use were excluded (e.g., any history of coronary artery disease, myocardial infarction, percutaneous coronary intervention, mechanical heart valve replacement, left ventricular assist device placement, peripheral arterial disease, or coronary artery bypass grafting). Each site was able to further restrict who was targeted for intervention (for example, excluding patients with a history of antiphospholipid syndrome or stroke). Using site specific definitions for inappropriate aspirin use we identified four groups at the end of the study period: 1) patients not on aspirin, 2) aspirin-using patients without an apparent indication who stopped aspirin following implementation, 3) aspirin-using patients without an apparent indication who remained on aspirin following implementation, and 4) aspirin-using patients who developed an indication for aspirin during the study period. To assess inappropriate aspirin use in our cohort, the characteristics of the first three groups were compared. Results: Between August 2017 and May 2019, a total of 3,766 warfarin-treated patients enrolled in MAQI2. Following implementation, inappropriate aspirin use was reduced by 34% (from 27.9% [401/1437] to 18.5% [251/1356]). A sub-cohort of 1,007 patients who met the inclusion criteria had clinical follow-up pre and post intervention and were followed for an average of 40.1 months from enrollment to their first follow-up post-intervention. Of this sub-cohort, 226 (22.4%) were inappropriately on aspirin, with 50 (22.1%) stopping aspirin. A small number of patients 37 (3.7%) developed an indication for aspirin (e.g., myocardial infarction) during the study period and were removed from this analysis. As compared to patients not taking aspirin, patients on inappropriate aspirin were more often taking warfarin for AF, had congestive heart failure, chronic kidney disease, diabetes mellitus, hypertension, and had a higher Charlson Comorbidity index; they were less likely to have VTE or a history of VTE. As compared to patients continuing on aspirin following implementation, patients stopping inappropriate aspirin were more likely to have chronic kidney disease (p=0.02) or a history of falls (p=0.03). Conclusion: Among warfarin-treated patients with AF or VTE, inappropriate aspirin usage can be identified and significantly reduced using a simple intervention in the anticoagulation clinic. Patients at higher risk of bleeding may be more likely to have their aspirin discontinued. Further studies are needed to see if reducing inappropriate aspirin usage translates to improved clinical outcomes and to determine the reasons for patient persistence on inappropriate aspirin. Disclosures Kaatz: Janssen: Honoraria, Research Funding; Pfizer: Honoraria; Bristol Myers Squibb: Honoraria; Portola: Honoraria. Kline-Rogers:AC Forum: Membership on an entity's Board of Directors or advisory committees; Janssen: Honoraria; QUANTUM-AF: Membership on an entity's Board of Directors or advisory committees. Sood:Bayer: Research Funding. Froehlich:Blue Cross Blue Shield of Michigan: Research Funding; Novartis: Honoraria; Boehringer-Ingelheim: Honoraria; Fibromuscular Dysplasia Society: Research Funding; Merck: Honoraria; Pfizer: Honoraria; Janssen: Honoraria. Barnes:Portola: Honoraria; Pfizer/Bristol Myers Squib: Research Funding; Pfizer: Honoraria; AMAG Pharmaceuticals: Honoraria; Bristol Myers Squib: Honoraria; Blue Cross Blue Shield of Michigan: Research Funding; Janssen: Honoraria.

The present status of aspirin use for primary prevention among hypertensive outpatients in China

To evaluate the current status of aspirin for primary prevention in hypertensive outpatients in China, and the gap between aspirin use and guidelines. This was a multi-center cross-sectional study and carried out in hypertensive patients from 46 hospitals of twenty two cities in China from June to December in 2009. At least 100 essential hypertensive outpatients were consecutively recruited from each participant hospitals according to the consistent inclusion criteria. The patients underwent physical examinations and biochemical analyses, and answered questionnaires. Based on the relevant guidelines, the risk assessment of cardiovascular disease (CVD) is a prerequisite for the proper use of aspirin in primary prevention. A total of 5 206 hypertensive outpatients were included. Among them, 1 324 (25.4%) were with a history of CVD. Among those with no history of CVD, 2 705 patients (69.7%) were at high risk of CVD, and the aspirin utilization rate for primary prevention was 29.2%, with 32.2% patients at high risk and 22.4% patients at low-medium risk of CVD, respectively. In the application of aspirin for CVD primary prevention, the inappropriate aspirin use rate in patients at low-medium risk was 23.3%. The proportion of subjects at high risk for CVD is high in hypertensive outpatients suggesting a wide range of application space for aspirin.There exists underutilization for high risk and overutilization for low-medium risk patients in current aspirin primary prevention application.

Inappropriate use of aspirin for primary prevention

Finer points Current guidelines vary slightly in their exact recommendations for aspirin use in the primary prevention setting. However, most consider aspirin appropriate for primary prevention when the 10-year CV risk is 6% or more. To determine the frequency of inappropriate use of aspirin in the primary prevention setting, researchers examined a cohort of patients receiving aspirin for primary prevention who were enrolled in the American College of Cardiology’s National Cardiovascular Disease Registry’s Practice Innovation and Clinical Excellence (PINNACLE) registry. Inappropriate aspirin use was characterized as use in patients with a 10-year CV risk of less than 6% by the Framingham CV risk assessment tool. A total of 68,808 patients were identi ed from 119 medical practices across the United States from January 2008 to June 2013. Of the 68,808 patients reviewed, 7,972 (11.6%) were classi ed as inappropriately receiving aspirin therapy for primary prevention. The mean 10-year CV risk in the inappropriate-use group was 4% compared with 24.5% in the appropriate-use group (P < 0.001). An assessment of individual practices revealed substantial variation for inappropriate aspirin use across practices, ranging from 0% to 71.8% (median 10.1%). However, only modest regional variations were observed in the northeast, midwest, south, and west.

Frequency and Practice-Level Variation in Inappropriate Aspirin Use for the Primary Prevention of Cardiovascular Disease: Insights From the National Cardiovascular Disease Registry’s Practice Innovation and Clinical Excellence Registry

BackgroundAmong patients without cardiovascular disease (CVD) and low 10-year CVD risk, the risks of gastrointestinal bleeding and hemorrhagic strokes associated with aspirin use outweigh any potential atheroprotective benefit. According to the guidelines on primary prevention of CVD, aspirin use is considered appropriate only in patients with 10-year CVD risk ≥6% and inappropriate in patients with 10-year CVD risk <6%. ObjectivesThe goal of this study was to examine the frequency and practice-level variation in inappropriate aspirin use for primary prevention in a large U.S. nationwide registry. MethodsWithin the National Cardiovascular Disease Registry’s Practice Innovation and Clinical Excellence registry, we assessed 68,808 unique patients receiving aspirin for primary prevention from 119 U.S. practices. The frequency of inappropriate aspirin use was determined for primary prevention (aspirin use in those with 10-year CVD risk <6%). Using hierarchical regression models, the extent of practice-level variation using the median rate ratio (MRR) was assessed. ResultsInappropriate aspirin use frequency was 11.6% (7,972 of 68,808) in the overall cohort. There was significant practice-level variation in inappropriate use (range 0% to 71.8%; median 10.1%; interquartile range 6.4%) for practices; adjusted MRR was 1.63 (95% confidence interval [CI]: 1.47 to 1.77). Results remained consistent after excluding 21,052 women age ≥65 years (inappropriate aspirin use 15.2%; median practice-level inappropriate aspirin use 13.8%; interquartile range 8.2%; adjusted MRR 1.61 [95% CI: 1.46 to 1.75]) and after excluding patients with diabetes (inappropriate aspirin use 13.9%; median practice-level inappropriate aspirin use 12.4%; interquartile range 7.6%; adjusted MRR 1.55 [95% CI: 1.41 to 1.67]). ConclusionsMore than 1 in 10 patients in this national registry were receiving inappropriate aspirin therapy for primary prevention, with significant practice-level variations. Our findings suggest that there are important opportunities to improve evidence-based aspirin use for the primary prevention of CVD.

Inappropriate aspirin use for primary prevention of CVD

Inappropriate aspirin use for primary prevention of CVD

Inappropriate aspirin use for primary prevention of CVD

Inappropriate aspirin use for primary prevention of CVD

Aspirin overutilization for the primary prevention of cardiovascular disease.

BackgroundAspirin is commonly used for the primary prevention of cardiovascular disease (CVD) in the US. Previous research has observed significant levels of inappropriate aspirin use for primary CVD prevention in some European populations, but the degree to which aspirin is overutilized in the US remains unknown. This study examined the association between regular aspirin use and demographic/clinical factors in a population-based sample of adults without a clinical indication for aspirin for primary prevention.MethodsA cross-sectional analysis was performed using 2010–2012 data from individuals aged 30–79 years in the Marshfield Epidemiologic Study Area (WI, USA). Regular aspirin users included those who took aspirin at least every other day.ResultsThere were 16,922 individuals who were not clinically indicated for aspirin therapy for primary CVD prevention. Of these, 19% were regular aspirin users. In the final adjusted model, participants who were older, male, lived in northern Wisconsin, had more frequent medical visits, and had greater body mass index had significantly higher odds of regular aspirin use (P<0.001 for all). Race/ethnicity, health insurance, smoking, blood pressure, and lipid levels had negligible influence on aspirin use. A sensitivity analysis found a significant interaction between age and number of medical visits, indicating progressively more aspirin use in older age groups who visited their provider frequently.ConclusionThere was evidence of aspirin overutilization in this US population without CVD. Older age and more frequent provider visits were the strongest predictors of inappropriate aspirin use. Obesity was the only significant clinical factor, suggesting misalignment between perceived aspirin benefits and cardiovascular risks in this subgroup of patients. Prospective studies that examine cardiac and bleeding events associated with regular aspirin use among obese samples (without CVD) are needed to refine clinical guidelines in this area.

Abstract 15: Frequency and Predictors of Inappropriate Aspirin Prescribing for Primary Prevention of Cardiovascular Disease: Insights from the NCDR® PINNACLE Registry.

Background: Aspirin use is recommended in patients with cardiovascular disease (CVD) for secondary prevention. However, among men and women without CVD and low 10 year coronary heart disease (CHD) risk, aspirin use for primary prevention has not been shown to reduce CVD death or all-cause death. In low risk patients, the risks of gastrointestinal bleeding and hemorrhagic strokes associated with aspirin use outweigh any potential atheroprotective benefit. As per the American Heart Association (AHA) guidelines on Primary Prevention of CVD and Stroke in 2002 and U.S. Preventive Services Task Force (USPSTF) recommendations from 2009, use of aspirin is considered appropriate in patients with &gt; 6% 10 year Framingham CHD risk and inappropriate in patients with 10 year risk &lt; 6%. We studied the frequency and predictors of inappropriate aspirin prescribing for primary prevention in a large national registry. Methods: Within the NCDR Practice Innovation and Clinical Excellence (PINNACLE) Registry, we identified 267,957 patients without CVD (coronary heart disease, peripheral arterial disease or ischemic stroke) or atrial fibrillation receiving aspirin for primary prevention. Of these, Framingham Risk Score (FRS) could be calculated in 68,808 patients. We assessed the frequency of inappropriate aspirin prescribing for primary prevention (aspirin prescribing in those with FRS &lt;6%). Using hierarchical regression models, we also assessed the extent of practice-level variation using the median rate ratio (MRR). MRR is interpreted as the likelihood that 2 random practices would differ in treating identical patients with aspirin inappropriately. Results: Inappropriate aspirin prescribing rate was 32.8 % (22601/68808) in the overall cohort. Mean FRS in the inappropriate aspirin group was 3.6 versus 16.2 in the appropriate group (p&lt;0.001). Significant variation was noted between practices in the Northeast, Midwest, South and West with inappropriate aspirin prescribing rates ranging from 31.5% to 34.4% (p&lt;0.0001). There was practice-level variation in inappropriate prescribing (range 17.9-52.4%, median rate 33.5%, interquartile range 28.6-37.7%) for practices; adjusted MRR 1.19 [95% CI 1.14 to 1.23]. Results remained consistent after excluding 14,097 patients with diabetes (inappropriate aspirin use rate = 38.2%, median rate 37.6%, interquartile range 32.5-43.8%; adjusted MRR 1.17 [95% CI 1.13- 1.21]). Conclusion: Inappropriate aspirin prescribing occurs in approximately one third of patients receiving aspirin for primary prevention. There is modest but significant practice-level variation. Our findings identify opportunities to improve evidence-based aspirin prescribing in primary CVD prevention.

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

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.

Aspirin overprescription in primary cardiovascular prevention

Introduction Aspirin overprescription is of some concern, especially in still-healthy individuals, and estimates of the magnitude of this problem are lacking. We evaluated the inappropriateness of aspirin prescription by primary care physicians in primary cardiovascular prevention. Materials and methods Out of 20,599 patients screened by 16 primary care physicians in the Abruzzi region, central Italy, 400 patients were on treatment with aspirin for primary prevention. For each such patient, the absolute cardiovascular and coronary risks were assessed according to the Italian Cardiovascular Risk Chart for Primary Prevention and the European Society of Cardiology Coronary Risk Chart, respectively. Patients with a cardiovascular and/or coronary risk < 1.0 event/100 patients/year were considered as treated inappropriately (aspirin overprescription), on the basis of previous literature. Results Overall, as many as 12% and 18% of patients had a cardiovascular and/or coronary risk < 1.0 event/100 patients/year according to the European and the Italian charts, respectively, and therefore were defined as treated inappropriately. Patients with and without inappropriate treatment were similar with respect to smoking habits, family history and body max index. However, inappropriately treated patients had significantly lower levels of blood pressure and total cholesterol, and were more likely to be female, younger and non-diabetic than patients appropriately treated. Conclusions A non-negligible proportion–up to 18%–of subjects in primary prevention is currently more likely to derive harm than benefit from inappropriate aspirin use. A wider use of Cardiovascular Risk Charts should guide primary care physicians in prescribing aspirin for primary prevention.

P02 Adenosine-induced bronchoconstriction in the allergic rabbit: Evidence for A,-adenosine receptor

Among patients without cardiovascular disease (CVD) and low 10-year CVD risk, the risks of gastrointestinal bleeding and hemorrhagic strokes associated with aspirin use outweigh any potential atheroprotective benefit. According to the guidelines on primary prevention of CVD, aspirin use is considered appropriate only in patients with 10-year CVD risk ≥6% and inappropriate in patients with 10-year CVD risk <6%.The goal of this study was to examine the frequency and practice-level variation in inappropriate aspirin use for primary prevention in a large U.S. nationwide registry.Within the National Cardiovascular Disease Registry’s Practice Innovation and Clinical Excellence registry, we assessed 68,808 unique patients receiving aspirin for primary prevention from 119 U.S. practices. The frequency of inappropriate aspirin use was determined for primary prevention (aspirin use in those with 10-year CVD risk <6%). Using hierarchical regression models, the extent of practice-level variation using the median rate ratio (MRR) was assessed.Inappropriate aspirin use frequency was 11.6% (7,972 of 68,808) in the overall cohort. There was significant practice-level variation in inappropriate use (range 0% to 71.8%; median 10.1%; interquartile range 6.4%) for practices; adjusted MRR was 1.63 (95% confidence interval [CI]: 1.47 to 1.77). Results remained consistent after excluding 21,052 women age ≥65 years (inappropriate aspirin use 15.2%; median practice-level inappropriate aspirin use 13.8%; interquartile range 8.2%; adjusted MRR 1.61 [95% CI: 1.46 to 1.75]) and after excluding patients with diabetes (inappropriate aspirin use 13.9%; median practice-level inappropriate aspirin use 12.4%; interquartile range 7.6%; adjusted MRR 1.55 [95% CI: 1.41 to 1.67]).More than 1 in 10 patients in this national registry were receiving inappropriate aspirin therapy for primary prevention, with significant practice-level variations. Our findings suggest that there are important opportunities to improve evidence-based aspirin use for the primary prevention of CVD.