Aspirin underused in secondary CVD prevention, especially in lower-income countries
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Key takeaways:
- Aspirin has long been recommended for secondary prevention of heart events, but is underused for that purpose worldwide.
- The greatest underuse is in the lowest-income countries.
Aspirin is underused for secondary CVD prevention worldwide, particularly in lower-income countries, researchers reported in JAMA.
“In the prevention of atherosclerotic CVD, aspirin is an effective and low-cost option for reducing CVD events and improving mortality among individuals with established CVD,” Sang Gune K. Yoo, MD, a fellow in the cardiovascular division of the John T. Milliken department of internal medicine at Washington University School of Medicine in St. Louis, and colleagues wrote. “The current study aims to provide updated evidence on worldwide aspirin use among individuals with a history of CVD. Using nationally representative health surveys, we estimate aspirin use for secondary prevention of CVD and report its association with individual-level characteristics.”
Yoo and colleagues conducted a cross-sectional analysis of pooled, individual participant data from nationally representative health surveys conducted from 2013 to 2020 in 51 countries. The population included 124,505 nonpregnant adults aged 40 to 69 years (median age, 52 years; 50.5% women), of whom 8.1% (95% CI, 7.6-8.6), or 10,589, had a self-reported history of CVD.
In the overall cohort of those with a self-reported history of CVD, 40.3% (95% CI, 37.6-43) were using aspirin, Yoo and colleagues wrote.
The rate of aspirin use for secondary CVD prevention was lowest in lower-income countries and highest in higher-income countries, according to the researchers.
In low-income countries, the rate was 16.6% (95% CI, 12.4-21.9), whereas it was 24.5% (95% CI, 20.8-28.6) in lower-middle-income countries, 51.1% (95% CI, 48.2-54) in upper-middle-income countries and 65% (95% CI, 59.1-70.4) in high-income countries, the researchers wrote.
“Worldwide, aspirin is underused in secondary prevention, particularly in low-income countries,” Yoo and colleagues wrote. “To meet the goal of reducing premature mortality from [noncommunicable diseases], including CVD, national health policies and health systems must develop, implement and evaluate strategies to promote evidence-based use of aspirin.”
Perspective
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I think the results are concerning. Unfortunately, they are not surprising. We live in a time where we have incredible, well-established therapies that are effective at reducing the risk for CV events, and despite the plethora of evidence supporting its use, we suboptimally use many lifesaving medicines. And this is just one example.
I think that there is so much attention paid to “what is the newest drug?” Or “what is the nth medicine that somebody should be on to reduce the risk for a CV event?” It’s really important to spend more time on the basics to make sure that people are on the therapies that are known to lower the risk for heart attack, stroke or death. This is another great example where, despite overwhelming and compelling data, there is significant underuse of a lifesaving therapy. What is really concerning about this article is the apparent disparity by socioeconomic status. This reinforces that not only do we need to get people on the right medicines, but we really need to spend some of our time and resources on those that are at greatest need and those that are of the lowest socioeconomic strata.
Aspirin has been around for more than a century. It has been shown to be effective at lowering the risk for a CV event for close to 40 years. I think people forget about the overwhelming data supporting its use. Unfortunately, there is sometimes a misunderstanding of patients and health care providers. There is a lot of uncertainty over who should be on aspirin for the prevention of a first heart attack or stroke. But I think the data for its use in secondary prevention, for example, in those with established CVD, is much more established. Now, I will say there are some important nuances. In certain cases, there is some data that clopidogrel monotherapy may be effective. Maybe that’s why there are some people who are on that, which is a very good option, but I don’t think that is the reason for this dramatic underuse.
Unfortunately, we live in an era where people at the lowest socioeconomic status are just pervasively undertreated. I think that we need to look at the system and look at all the different points where we can do a better job. That includes health care education and provider education, but also very importantly, patient education. There are some data that going to the community barber — places where communities congregate and meet up — is a good strategy. I think we need to figure out why there is such a great disparity. There are many studies that demonstrate this lack of parity among socioeconomic risk. We really need to do a better job as a community.
I think this also gets into education. Because of the unimpressive data in primary prevention, there may be some misunderstanding or there may be some uncertainty about how good the data in fact really are. We need to reeducate the health care providers. We also need to educate patients that aspirin is a lifesaving medicine in somebody who has established CVD. We really need to do a better job at educating the patient and changing the system so that patients at higher risk are not overlooked.
We have a lot of studies that show a disparity by socioeconomic strata. I think we need to do a better job not just at identifying the disparities, but really target them. Hopefully studies like this will spur new directions for improving these well-established problems that we have in the health care system, but also society in general.
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