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Using Aspirin f..

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Aspirin is an anti-inflammatory agent which also inhibits platelet aggregation through irreversibly inactivating cyclooxygenase and preventing the production of thromboxane A2.1 Because of its antiplatelet property, aspirin is commonly used in patients with heart disease to prevent cardiovascular events. Aspirin’s efficacy in the secondary prevention of cardiovascular disease (CVD) has been well-established. However, the evidence for primary prevention of CVD has been mixed with differing efficacy based on gender and baseline CVD risk.1,2 Additionally, recent data has shown that daily aspirin use can significantly reduce cancer mortality.3 To clarify the role for aspirin in primary prevention, Seshasi and colleagues performed a meta-analysis to evaluate aspirin’s efficacy and safety on vascular and nonvascular outcomes when used for in patients without CVD.2

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The authors of the meta-analysis searched PubMed and Cochrane Library to find primary prevention articles about aspirin on vascular and non-vascular outcomes. The inclusion criteria for trials selected included randomized placebo-controlled with at least 1,000 participants (without previous CVD), at least 1 year of follow-up, main endpoints of coronary heart disease (CHD) and/or CVD, and bleeding event reports. Nine articles were selected. The primary endpoints for the meta-analysis included total CHD and total cancer mortality and the secondary endpoints were subtypes of vascular disease, total CVD events, cause specific death, and all cause mortality. Data for cancer and non-vascular events were collected from subsequent trial reports, a recent meta-analysis of aspirin in mixed populations, and from investigators for individual studies since the data was unavailable in the primary trial reports. Due to the variation in classification of major bleeding among the studies, the endpoint, clinically nontrivial bleeding, was used and was the composite safety endpoint of fatal bleeding, cerebrovascular or retinal bleeding, bleeding from hollow viscus, bleeding requiring hospitalization and/or transfusion, or study-defined major bleeding. Heterogeneity and publication bias was also evaluated in this meta-analysis.2

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There were 102,621 patients included in the meta-analysis with a mean follow-up of 6.0±2.1 years (~700,000 person-years). The average age was 57±4 years with 46% of persons being male. Total CVD events were reduced 10% by aspirin (OR, 0.90; 95% CI, 0.85-0.96; NNT, 120). The difference was driven by a 20% reduction in nonfatal myocardial infarctions (MI) (OR, 0.8; 95% CI, 0.67-0.96; NNT, 162). No difference was seen in fatal MI, stroke, or CVD death and non-significant reductions were observed with total CHD, total non-vascular mortality, and all cause mortality. No benefit was observed with cancer mortality (OR, 0.93; 95% CI, 0.84-1.03).  Aspirin was associated with significantly more total bleeds (OR, 1.7; 95% CI, 1.17-2.46) and 30% more nontrivial bleeding events compared to placebo (OR, 1.31; 95% CI, 1.14-1.50; NNH, 73). No significant difference in total CVD events was found between genders or based on aspirin dose; no subgroups were identified that would benefit more from aspirin. Heterogeneity was observed for the efficacy and safety endpoints (except for cancer), which was unable to be explained by reported patient characteristics.  Publication bias was ...

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