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
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
Too old to be good?
Too good to be true?
Do we still need Aspirin?
What are the facts?
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)
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
Aspirin use in US secondary prevention
George MG et al, MMWR Morb Mortal Wkly Rep 2012;61 Supp:11-8
Self-reported Aspirin underuse among US patients with established indication
Rivera et al, J Womens Health (Larchmt) 2012;21:379-87
Aspirin compliance in Europe-Latin America
Zaninelli et al, Postgrad Med 2009;121:44-53
Aspirin compliance in Asia-Pacific
Zaninelli et al, Postgrad Med 2010;122:108-17
Focus on post-ACS in China: the BRIG study
Niu et al, Am Heart J 2009;157:709-15.e1
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)
Aspirin for primary prevention in women
Ridker et al, for the Women Health Study Investigators, New Engl J Med 2005;352:1293-304
Aspirin for primary prevention in men
Physicians’ Health Study Investigators, New Engl J Med 1989;321:129-35
Impact on fatal/non-fatal colorectal cancer
Rothwell et al, Lancet 2010;376:1741-50
Benefits vs harms
Patrono et al, Eur Heart J 2013
Some remain skeptical
Cleland et al, Eur Heart J 2013;34:3412-8
Differences between US and Europe
Wolff et al, Ann Intern Med 2009
Differences between US and Europe
Perk et al, Eur Heart J 2012
Underuse in US ambulatory care
Stafford et al, PLoS Med 2005;2:e353
Causes of underuse
Pignone et al, Am J Prev Med 2007;32:403-7
Non-compliance vs discontinuation
Herlitz et al, Am J Cardiovasc Drugs 2010;10:125-41
Perceptions on Aspirin in Europe-Latin America
Zaninelli et al, Postgrad Med 2009;121:44-53
Perceptions on Aspirin in Asia-Pacific
Zaninelli et al, Postgrad Med 2010;122:108-17
Means to improve compliance
Zaninelli et al, Postgrad Med 2009;121:44-53
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)
Ominous impact of aspirin discontinuation
Biondi-Zoccai et al, Eur Heart J 2006;27:2667-74
Discontinuation after stenting
Rossini et al, Am J Cardiol 2011;107:186-94
Impact DAPT discontinuation after stenting
Mehran et al, Lancet 2013;382:1714-22
MYOCARDIAL INFARCTION
CARDIAC DEATH
Discontinuation in UK primary care
Rodriguez et al, BMJ 2011;343:d4094
Discontinuation: thrombotic vs bleeding events
Cea Soriano et al, Thromb Haemost 2013;110:1298-304
Avoiding discontinuation is also cheaper
Cea Soriano et al, Thromb Haemost 2013;110:1298-304
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
Many thanks for your attentionFor any query:
[email protected]@gmail.com
For these and other slides:http://www.metcardio.org/slides.html
Reserve slides
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
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
Aspirin discontinuation: a hot topic
Biondi-Zoccai et al, BMJ 2011;343:d3942
Focus on terminology
Mehran et al, Lancet 2013;382:1714-22
Delayed anti-cancer effects
Burn et al, Lancet 2011;378:2081-7
Aspirin as key component of polypills
Wald et al, BMJ 2003;326:1419
Compliance according to indication
VanWormer et al, J Fam Pract 2012;61:525-32
*with 102 (18%) reporting aspirin use
*
Some remain skeptical
Sutcliffe et al, PLoS ONE 2013;8:e81970
Aspirin use in US primary prevention
George MG et al, MMWR Morb Mortal Wkly Rep 2012;61 Supp:11-8
Self-reported Aspirin underuse
Rivera et al, J Womens Health (Larchmt) 2012;21:379-87
Underuse in US ambulatory care
Stafford et al, PLoS Med 2005;2:e353
Self-reported Aspirin underuse
Rivera et al, J Womens Health (Larchmt) 2012;21:379-87
Focus on post-MI in China: the BRIG study
Niu et al, Am Heart J 2009;157:709-15.e1
Aspirin compliance in Europe-Latin America
Zaninelli et al, Postgrad Med 2009;121:44-53
Aspirin compliance in Asia-Pacific
Zaninelli et al, Postgrad Med 2010;122:108-17
Aspirin resistance: fact or fiction?
Biondi-Zoccai et al, BMJ 2008;336:166-7
Aspirin for primary prevention in men
Physicians’ Health Study Investigators, New Engl J Med 1989;321:129-35
Focus on post-ACS in China: the BRIG study
Niu et al, Am Heart J 2009;157:709-15.e1
Resistance or non-compliance?
Schwartz et al, Am J Cardiol 2005;95:973-5
Cumulative incidence after stenting
Mehran et al, Lancet 2013;382:1714-22
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
Discontinuation after stenting
Rossini et al, Am J Cardiol 2011;107:186-94
Discontinuation after stenting
Rossini et al, Am J Cardiol 2011;107:186-94
Discontinuation after stenting
Rossini et al, Am J Cardiol 2011;107:186-94
Discontinuation after stenting
Rossini et al, Am J Cardiol 2011;107:186-94
Avoiding discontinuation is also cheaper
Cea Soriano et al, Thromb Haemost 2013;110:1298-304