January 30, 2013
A Push for Wider Prescribing of Low-Dose Aspirin to Prevent Cardiovascular Events

Atlanta—“It’s good medicine to take a daily low-dose aspirin,” according to public health officials, but not enough patients are prescribed the therapy for the secondary prevention of cardiovascular events.

A perspective article in The New England Journal of Medicine said recent data from the CDC's National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey was “sobering”; in 2007 to 2008, antiplatelet medications were prescribed at only 46.9% of visits for patients with ischemic vascular disease, a rate virtually unchanged from the 2005 to 2006 period. It also notes that general medicine or primary care physicians prescribed antiplatelet medications for this population only 34.8% of the time, a decrease from 37.9% in 2005 to 2006.

“The results of these surveys and the strong evidence of the benefit of aspirin in terms of cardiovascular outcomes underscore the substantial opportunity before clinicians and patients,” write the authors from the CDC, the U.S. Department of Health and Human Services, and the Center for Medicare and Medicaid Innovation. “Though some patients may not be receiving antiplatelet medications because of valid contraindications, the vast majority of these patients would be candidates.”

They maintain the low rate of prescription is despite strong evidence for the effectiveness of aspirin in helping control cardiovascular disease, which causes one of every three deaths in the United States and costs this country about $450 billion annually, as well as the strong evidence of the effectiveness of aspirin in preventing it.

“The role of aspirin in the secondary prevention of myocardial infarction, stroke, and death from vascular causes is well established,” the authors write. “Results from a meta-analysis of randomized trials of the Antithrombotic Trialists' Collaboration have shown that aspirin can reduce the risk of recurrent major coronary events and stroke by 20% and 19%, respectively. In addition, a more recent Australian study shows that aspirin use for secondary prevention not only provides a health outcomes benefit, but may also result in cost savings: the number needed to treat to prevent any type of event (nonfatal myocardial infarction, stroke, or death from any cause) was 48, and on average, the use of aspirin resulted in savings of $69 per person.”

The authors make several arguments as to why aspirin therapy should be increased:

• It is an inexpensive, OTC drug that need be taken only once a day;
• Clinical management is relatively uncomplicated;
• The generally accepted dose is 81 mg and does not require adjustment;
• No screening tests or follow-up laboratory tests are required;
• Aspirin use does not require substantial behavior change or modification.

So why isn’t aspirin prescribing almost universal among patients at risk for cardiovascular disease?

The authors suggest that “the shifting guidance in the past regarding dosage and target population has contributed to less-than-optimal prescribing patterns.” They also recommend more education as well as embedding aspirin reminders within electronic health record systems.

Financial incentives may also play a role, they note. Starting in 2013, the Physician Quality Reporting System will allow eligible professionals to earn a 0.5% incentive payment—based on all the services they provide that are covered by Medicare Part B—if they satisfactorily report on a set of quality measures, including aspirin use. Also, measures of daily aspirin use for patients with diabetes and ischemic vascular disease and use of aspirin or another antithrombotic agent for patients with ischemic vascular disease are among the quality measures for accountable care organizations participating in the Medicare Shared Savings Program created by the Affordable Care Act.

“There is an important and urgent opportunity to engage all health care providers, particularly primary care providers, in a singular, simple intervention with the potential to prevent heart attacks and strokes and save lives,” according the article. “Provision of aspirin to patients with coronary artery disease, atherosclerotic peripheral artery disease, or a history of cerebrovascular disease (transient ischemic attack or stroke) should be the norm; everyone without a contraindication should receive it.”

U.S. Pharmacist Social Connect