Risk assessment and aspirin use in Asian and Western populations

Figures & data

Figure 1 Risk factors can be divided into those that are predictive, those that are treatment targets, and those that fall into both categories.²⁴ Copyright © 2007, Elsevier. Reproduced with permission from Gaziano JM, Manson JE, Ridker PM. Primary and secondary prevention of coronary heart disease. In: Libby P, Bonow RO, Mann DL, et al, editors. Libby: Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, PA: Saunders; 2007;1119–1148.

Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; CABG, coronary artery bypass graft; CRP, C-reactive protein; EBT, electron beam tomography; ECHO, echocardiography; ETT, exercise tolerance test; FH, family history; PCI, percutaneous coronary intervention.

Figure 2 Comparison of Framingham model and Chinese prediction model on ischemic CVD and CHD incidence in a Chinese cohort.³⁷ Copyright © 2006. Reproduced with permission from Wu YF, Liu XQ, Li X, et al. Estimation of 10-year risk of fatal and non-fatal ischemic cardiovascular diseases in Chinese adults. Circulation. 2006;114(21):2217–2225.

Abbreviations: CHD, coronary heart disease; ICVD, ischemic cardiovascular disease.

Table 1 Prevalence of major cardiovascular risk factors* in rural and urban China and the US†

	China % (SE)		US % (SE)
	Rural	Urban
≥ 1 risk factor	79.9 (0.5)	83.1 (0.5)	93.1 (1.1)
≥ 2 risk factors	44.0 (0.7)	53.6 (0.7)	73.0 (1.8)
≥ 3 risk factors	15.4 (0.5)	24.5 (0.6)	35.9 (1.8)

* Notes: Risk factors were dyslipidemia, hypertension, diabetes, current smoking, and overweight.

† Adapted from Gu et al.38

Abbreviation: SE, standard error.

Figure 3 Summary of recommendations for low-dose aspirin therapy from the US Preventive Services Task Force.⁴⁶

Abbreviations: CHD, coronary heart disease; CVD, cardiovascular disease; GI, gastrointestinal; MI, myocardial infarction.

Table 2 Summary of recommendations for aspirin use from a selection of recent European and US guidelines

Association	Recommendations for aspirin therapy
European Society of Cardiology^Citation10	Aspirin recommended for all patients with NSTE-ACS without contraindications Aspirin 160–325 mg/day is recommended as the initial loading dose; and aspirin 75–100 mg/day is recommended for long-term therapy
European Society of Cardiology/European Society of Hypertension^Citation9	Aspirin therapy is favorable if 10-year cardiovascular risk is ≥15%–20% Aspirin 75–100 mg/day is recommended for hypertensive patients with previous history of CVD or aged >50 years with a moderate increase in serum creatinine or risk factors
European Society of Cardiology/European Association for the Study of Diabetes^Citation14	Aspirin 75–250 mg/day is recommended for first and recurrent stroke prevention
American College of Cardiology/American Heart Association^Citation11	Aspirin 75–162 mg/day is recommended in all UA/STEMI patients with a 10-year CHD risk ≥10% plus ≥2 risk factors Aspirin 162–325 mg/day should be used for patients with stents
American Heart Association^Citation12	Aspirin 75–325 mg/day is recommended for high-risk women (a 10-year risk of CHD ≥20%) Aspirin 81 mg/day or 100 mg qod is recommended if benefits outweigh risks of hemorrhagic stroke or bleeding in women
American Heart Association/American Diabetes Association^Citation13	Aspirin 75–162 mg/day is recommended for CHD prevention in diabetes patients with increased cardiovascular risk
American Heart Association/American Stroke Association^Citation15	Aspirin is recommended for cardiovascular (including but not specific to stroke) prophylaxis among persons whose risk is sufficiently high for the benefits to outweigh the risks (10-year risk of cardiovascular events of 6–10%)
US Preventive Services Task Force^Citation46	Aspirin therapy is recommended for MI prevention in men aged 45–79 years and stroke prevention in women aged 55–79 years

Abbreviations: CHD, coronary heart disease; CVD, cardiovascular disease; MI, myocardial infarction; NSTE-ACS, non-ST-segment elevation acute coronary syndrome; UA/STEMI, unstable angina/non-ST-elevation myocardial infarction; qod, once daily.

Table 3 An overview of aspirin trials for the prevention of primary events

	PHS^Citation50	BDT^Citation51	HOT^Citation52	WHS^Citation53	PPP^Citation54	TPT^Citation55	JPAD^Citation56
Main country	US	UK	26 countries	US	Italy	UK	Japan
Aspirin dose	325 mg qod	500 mg/day	75 mg/day	100 mg qod	100 mg/day	75 mg/day	81–100 mg/day
Patients (n)	22,071	5139	18,790	39,876	4495	5499	2539
Reduction in CV events (%)	44 (MI)	10 (mortality)	15 (major CV events)	17 (stroke)	23 (composite CV endpoint)	20 (IHD)	20 32 (≥65 years)
Conclusions	Aspirin reduces MI	No significant difference between aspirin or placebo	Aspirin reduces major CV events	Aspirin reduces stroke (no effect on MI or CV death)	Terminated early	Aspirin reduces nonfatal IHD	Aspirin beneficial in older patients

Abbreviations: PHS, Physicians’ Health Study; BDT, British Male Doctors’ Trial; HOT, Hypertension Optimal Trial; WHS, Women’s Health Study; PPP, Primary Prevention Project; TPT, Thrombosis Prevention Trial; JPAD, Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes; CV, cardiovascular; IHD, ischemic heart disease; qod, once daily.

Table 4 An overview of key aspirin combination trials

	CHARISMA^Citation64	MATCH^Citation65	COMMIT^Citation66	CARESS^Citation67	CURE^Citation68	CREDO^Citation69	PRoFESS^Citation70	ESPS-2^Citation71	TPT^Citation35
Main country	US	Germany	UK	UK	Canada	US	35 countries	Europe	UK
Patients (n)	15,603	7599	45,852	107	12,562	2116	20,332	6602	5499
Aspirin dose	75–162 mg/day	75 mg/day	162 mg/day	75–162 mg/day	75–325 mg/day	325 mg/day	50 mg/day	50 mg/day	75 mg/day
Combination drug and dose	Clopidogrel 75 mg/day	Clopidogrel 75 mg/day	Clopidogrel 75 mg/day	Clopidogrel 300 mg/day then 75 mg/day	Clopidogrel 300 mg/day then 75 mg/day	Clopidogrel 300 mg/day then 75 mg/day	ERDP 400 mg/day	ERDP 400 mg/day	Warfarin INR: 1.47
Reduction in CV events (%)
Aspirin	7.3*	–	–	72.7	–	–	–	13	20
Combination	6.8*	15.7*	9	43.8	11.4 (P < 0.001)	26.9 (P = 0.02)	9**	24	34
Conclusions	Favors aspirin (efficacy)	Favors antiplatelet monotherapy (safety)	Favors combination (efficacy and safety)	Favors combination (efficacy)	Favors combination over clopidogrel (efficacy)	Combination effective (no direct comparison with aspirin)	Aspirin plus ERDP as effective as clopidogrel or telmisartan	Favors combination (efficacy)	Favors combination (efficacy)

* Notes: Rate of events;

** rate of recurrent stroke in all groups (aspirin plus ERDP), clopidogrel, telmisartan. –comparator group was clopidogrel.

Abbreviations: CVD, cardiovascular disease; CHARISMA, Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management and Avoidance; MI, myocardial infarction; MATCH, Management of Atherothrombosis with Clopidogrel in High-risk patients; COMMIT; ClOpidogrel and Metoprolol in Myocardial Infarction Trial; CARESS, Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic carotid Stenosis; CURE, Clopidogrel in Unstable angina to prevent Recurrent Events; CREDO, Clopidogrel for the Reduction of Events During Observation; PRoFESS, Prevention Regimen for Effectively Avoiding Second Strokes; ESPS-2, European Stroke Prevention Study 2; ERDP, extended-release dipyridamole

Table 5 Ongoing studies with aspirin

Trial name	Country	Cardiovascular risk factors in patients	Intervention
Diabetic Atherosclerosis Prevention by Cilostazol (DAPC) study	Japan, China, Philippines, and Korea	Diabetic atherosclerosis	Cilostazol and aspirin
Japanese Primary Prevention Project with Aspirin (JPPP)	Japan	At least one of: hypertension, hyperlipidemia, diabetes	Enteric-coated aspirin 100 mg
Low Dose Aspirin and Statins for Primary Prevention of Atherosclerosis and Arterial Thromboembolism in Systemic Lupus Erythematosus (SLE)	Hong Kong	Atherosclerosis, thromboembolism, SLE	Aspirin 80 mg, rosuvastatin 10 mg
Aspirin Dose and Atherosclerosis in Patients with Metabolic Syndrome (PAD)	US	Metabolic syndrome	Aspirin 81, 162, 325, 650, or 1300 mg
A Study to Assess the Efficacy and Safety of 100 mg Acetylsalicylic Acid in Patients at Moderate Risk of Cardiovascular Disease (ARRIVE)	US, Italy, Puerto Rico	At least two of: hypertension, hypercholesterolemia, diabetes, smoker, family history of early coronary heart disease	Enteric-coated aspirin 100 mg
ASCEND: A Study of Cardiovascular Events in Diabetes	UK	Diabetes mellitus	Aspirin, omega-3-acid supplements

Table 6 Recommendations and concerns regarding aspirin use in Asian and Western populations

Aspirin is underutilized in high-risk patients in both Asian and Western countries, which indicates a need for educational initiatives and improved physician-patient communication across all countries Risk estimation scores are useful guides for determining the threshold at which aspirin should be used; however, greater validation is needed in countries such as Japan, India and in South Asia. Until validated scores are available, physicians should be aware of the limitations and should monitor risk factors that are relevant to their patient but are not covered in all scores (eg, triglyceride levels in Japanese patients or high density lipoprotein cholesterol in South Asians) Large-scale trials addressing the benefits of aspirin in preventing recurrent events in Asian populations are needed; the prevention of recurrent myocardial infarction may be higher in Chinese patients Underutilization of aspirin in Asian countries may be linked to an overestimation of bleeding risks. It is possible that a higher prevalence of Helicobacter pylori infection and genetic differences may make Asian populations more susceptible to gastrointestinal bleeding. Until further trials are available, very low aspirin doses and even the wide use of gastroprotective agents may be the optimal approach to high-risk patients in Asian countries

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