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Bringing Science to Practice: Therapy Underutilization and Compliance in CV disease - The Aspirin Perspective
Aspirin underuse, poor compliance and cessation
Giuseppe Biondi-Zoccai, MDSapienza University of Rome, Latina, Italy
Melbourne, May 6, 2014 – 16:00 to 19:00 - Room M14, Crown Promenade
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Goals of the Roundtable
• Prevalence of non-adherence to Aspirin• Consequences of
non-compliance/discontinuation to Aspirin• Issues surrounding non-compliance to Aspirin• Tools and programs to improve compliance to
Aspirin
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Too old to be good?
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Too good to be true?
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Do we still need Aspirin?
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What are the facts?
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Goals of the Presentation
• Underutilisation and poor adherence in secondary prevention of CVD
• Physician and patient perceptions about Aspirin
• Impact of Aspirin discontinuation (including inconsistent use and temporary discontinuation)
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Updated terminology• Cessation: any ceasing or discontinuance• Compliance: accuracy with which a patient follows an
agreed treatment plan• Discontinuation: physician-supervised withdrawal as
perceived as no longer needed• Disruption: cessation due to non-compliance or bleeding
(brief: 1-5 days; temporary: 6-30 days; permanent: >30 days)
• Interruption: physician-supervised temporary discontinuation for surgery lasting <15 days
• Underuse: act of using (or prescribing) less than expected
Mehran et al, Lancet 2013;382:1714-22
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Aspirin use in US secondary prevention
George MG et al, MMWR Morb Mortal Wkly Rep 2012;61 Supp:11-8
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Self-reported Aspirin underuse among US patients with established indication
Rivera et al, J Womens Health (Larchmt) 2012;21:379-87
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Aspirin compliance in Europe-Latin America
Zaninelli et al, Postgrad Med 2009;121:44-53
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Aspirin compliance in Asia-Pacific
Zaninelli et al, Postgrad Med 2010;122:108-17
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Focus on post-ACS in China: the BRIG study
Niu et al, Am Heart J 2009;157:709-15.e1
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Goals of the Presentation
• Underutilisation and poor adherence in secondary prevention of CVD
• Physician and patient perceptions about Aspirin
• Impact of Aspirin discontinuation (including inconsistent use and temporary discontinuation)
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Aspirin for primary prevention in women
Ridker et al, for the Women Health Study Investigators, New Engl J Med 2005;352:1293-304
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Aspirin for primary prevention in men
Physicians’ Health Study Investigators, New Engl J Med 1989;321:129-35
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Impact on fatal/non-fatal colorectal cancer
Rothwell et al, Lancet 2010;376:1741-50
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Benefits vs harms
Patrono et al, Eur Heart J 2013
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Some remain skeptical
Cleland et al, Eur Heart J 2013;34:3412-8
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Differences between US and Europe
Wolff et al, Ann Intern Med 2009
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Differences between US and Europe
Perk et al, Eur Heart J 2012
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Underuse in US ambulatory care
Stafford et al, PLoS Med 2005;2:e353
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Causes of underuse
Pignone et al, Am J Prev Med 2007;32:403-7
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Non-compliance vs discontinuation
Herlitz et al, Am J Cardiovasc Drugs 2010;10:125-41
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Perceptions on Aspirin in Europe-Latin America
Zaninelli et al, Postgrad Med 2009;121:44-53
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Perceptions on Aspirin in Asia-Pacific
Zaninelli et al, Postgrad Med 2010;122:108-17
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Means to improve compliance
Zaninelli et al, Postgrad Med 2009;121:44-53
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Goals of the Presentation
• Underutilisation and poor adherence in secondary prevention of CVD
• Physician and patient perceptions about Aspirin
• Impact of Aspirin discontinuation (including inconsistent use and temporary discontinuation)
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Ominous impact of aspirin discontinuation
Biondi-Zoccai et al, Eur Heart J 2006;27:2667-74
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Discontinuation after stenting
Rossini et al, Am J Cardiol 2011;107:186-94
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Impact DAPT discontinuation after stenting
Mehran et al, Lancet 2013;382:1714-22
MYOCARDIAL INFARCTION
CARDIAC DEATH
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Discontinuation in UK primary care
Rodriguez et al, BMJ 2011;343:d4094
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Discontinuation: thrombotic vs bleeding events
Cea Soriano et al, Thromb Haemost 2013;110:1298-304
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Avoiding discontinuation is also cheaper
Cea Soriano et al, Thromb Haemost 2013;110:1298-304
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Take home messages• Differentiating between type, reason, setting and
timing of underuse and discontinuation of Aspirin is crucial
• Inadequate physician-patient communication and lack of awareness of underlying cardiovascular risk and benefits are the key reasons for Aspirin underuse and discontinuation
• Underuse and discontinuation are clearly detrimental for patients, especially early after an acute cardiovascular event or procedure, but even later on
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Many thanks for your attentionFor any query:
[email protected]@gmail.com
For these and other slides:http://www.metcardio.org/slides.html
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Reserve slides
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ASPREE
• ASPREE is a randomised, double-blind placebo trial of 5-year low-dose (100mg) aspirin for 5 years
• It involves both males and females, 70 years and older • The study is recruiting 19,000 healthy participants through
regional centres (both in urban and rural locations throughout Australia and the United States)
• The trial has a number of sub-studies, which investigate the effect of aspirin on specific diseases: Biobank, ENVIS-ion, ALSOP, SNORE-ASA, ASPREE-AMD, ASPREE-Knee, and ASPREE-NEURO
• Results are expected for 2018
http://www.aspree.org/AUS/aspree-content/aspree-study-details/about-aspree.aspx
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Aspirin: a measure of quality of care?
Quality of health care according to the US Institute of Medicine:
degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with professional knowledge
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Aspirin discontinuation: a hot topic
Biondi-Zoccai et al, BMJ 2011;343:d3942
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Focus on terminology
Mehran et al, Lancet 2013;382:1714-22
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Delayed anti-cancer effects
Burn et al, Lancet 2011;378:2081-7
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Aspirin as key component of polypills
Wald et al, BMJ 2003;326:1419
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Compliance according to indication
VanWormer et al, J Fam Pract 2012;61:525-32
*with 102 (18%) reporting aspirin use
*
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Some remain skeptical
Sutcliffe et al, PLoS ONE 2013;8:e81970
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Aspirin use in US primary prevention
George MG et al, MMWR Morb Mortal Wkly Rep 2012;61 Supp:11-8
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Self-reported Aspirin underuse
Rivera et al, J Womens Health (Larchmt) 2012;21:379-87
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Underuse in US ambulatory care
Stafford et al, PLoS Med 2005;2:e353
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Self-reported Aspirin underuse
Rivera et al, J Womens Health (Larchmt) 2012;21:379-87
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Focus on post-MI in China: the BRIG study
Niu et al, Am Heart J 2009;157:709-15.e1
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Aspirin compliance in Europe-Latin America
Zaninelli et al, Postgrad Med 2009;121:44-53
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Aspirin compliance in Asia-Pacific
Zaninelli et al, Postgrad Med 2010;122:108-17
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Aspirin resistance: fact or fiction?
Biondi-Zoccai et al, BMJ 2008;336:166-7
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Aspirin for primary prevention in men
Physicians’ Health Study Investigators, New Engl J Med 1989;321:129-35
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Focus on post-ACS in China: the BRIG study
Niu et al, Am Heart J 2009;157:709-15.e1
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Resistance or non-compliance?
Schwartz et al, Am J Cardiol 2005;95:973-5
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Cumulative incidence after stenting
Mehran et al, Lancet 2013;382:1714-22
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Means to improve compliance in Asia-Pacific
• Perceived as effective by most physicians:1. Material demonstrating the lifelong benefits of
Aspirin2. Material demonstrating the immediate effects of
Aspirin3. Shared patient-physician decision-making4. Suitable patient information
Zaninelli et al, Postgrad Med 2010;122:108-17
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Discontinuation after stenting
Rossini et al, Am J Cardiol 2011;107:186-94
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Discontinuation after stenting
Rossini et al, Am J Cardiol 2011;107:186-94
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Discontinuation after stenting
Rossini et al, Am J Cardiol 2011;107:186-94
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Discontinuation after stenting
Rossini et al, Am J Cardiol 2011;107:186-94
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Avoiding discontinuation is also cheaper
Cea Soriano et al, Thromb Haemost 2013;110:1298-304