This site is intended for healthcare professionals only

DiabetesontheNet Logo
×


Diabetes Digest

Issue:

Share this article
Share on facebook
Share on twitter
Share on email
Share on print

Aspirin for primary prevention of CVD: The controversy remains in diabetes

The role of aspirin for the primary prevention of cardiovascular disease (CVD) in people with diabetes remains a contentious issue. The current consensus is that aspirin should only be offered as primary prevention in people with an elevated risk (>10%) of CVD (Handelsman et al, 2011). Numerous meta-analyses have been conducted to evaluate the safety and efficacy of aspirin for CVD prevention in people with diabetes (Calvin et al, 2009; De Berardis et al, 2009; Younis et al, 2010; Zhang et al, 2010; Butalia et al, 2011). These analyses found no increase in the risk of bleeding with aspirin doses ranging from 100 mg every other day to 650 mg per day. However, no benefit in terms of preventing CVD endpoints, including all-cause mortality, CVD mortality, myocardial infarction and stroke, was identified either.

The role of aspirin for the primary prevention of cardiovascular disease (CVD) in people with diabetes remains a contentious issue. The current consensus is that aspirin should only be offered as primary prevention in people with an elevated risk (>10%) of CVD (Handelsman et al, 2011). Numerous meta-analyses have been conducted to evaluate the safety and efficacy of aspirin for CVD prevention in people with diabetes (Calvin et al, 2009; De Berardis et al, 2009; Younis et al, 2010; Zhang et al, 2010; Butalia et al, 2011). These analyses found no increase in the risk of bleeding with aspirin doses ranging from 100 mg every other day to 650 mg per day. However, no benefit in terms of preventing CVD endpoints, including all-cause mortality, CVD mortality, myocardial infarction and stroke, was identified either.

It would thus appear that aspirin has no benefit in terms of primary CVD prevention; however, these meta-analyses did not include other atherosclerotic endpoints, such as angina, transient ischaemic attack (TIA), peripheral artery disease (PAD) or revascularisation. Consequently, the meta-analysis by Kokoska and colleagues (summarised alongside) sought to evaluate aspirin’s safety and efficacy in the primary prevention of CVD, including a full array of atherosclerotic events, in people with diabetes.

Following an extensive literature search, six studies with a total of 10117 participants were identified as being pertinent to the issues under investigation, with median follow-up ranging from 3.6 to 10.1 years. There was no difference between aspirin and placebo with respect to the risk of all-cause mortality (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.81–1.06) or individual atherosclerotic events. In addition, there was no significant difference in the rates of bleeding (OR, 2.53; 95% CI, 0.77–8.34), gastrointestinal bleeding (OR, 2.14; 95% CI, 0.63–7.33) or haemorrhagic stroke rates (OR, 0.90; 95% CI, 0.34–2.33) between the treatments.

There are some limitations worth noting in this analysis. Firstly, a wide range of aspirin doses was evaluated in the studies, ranging from 100 mg to 625 mg daily. Secondly, not all of the trials assessed or reported all the efficacy and safety endpoints; that is, TIA, PAD and angina were only included in half of the trials, and the safety endpoints of bleeding, gastrointestinal bleeding and intracranial haemorrhage were only included in three trials each. As the number of participants for these endpoints is smaller than for the CVD endpoints, it is difficult to draw conclusions in terms of risk–benefit analysis from such data. A final confounding issue with respect to the safety profile of aspirin is the fact that the intervals between routine assessments in the studies varied from 2 weeks to 2 years, which may have led to under-reporting of adverse events in some studies.

Nevertheless, this meta-analysis helps provide further insight into the role of aspirin in CVD risk management in people with diabetes. The data suggest that aspirin may not be beneficial for the prevention of angina, TIA, PAD or revascularisation, while no evidence of harm due to excess bleeding could be identified.

It remains unclear whether aspirin may be beneficial for primary CVD prevention in certain subsets of people with diabetes; however, the results of studies such as ACCEPT-D (Aspirin and Simvastatin Combination for Cardiovascular Events Prevention Trial in Diabetes; De Berardis et al, 2007) and ASCEND (A Study of Cardiovascular Events iN Diabetes; ClinicalTrials.gov identifier: NCT00135226) may finally provide definitive answers to this question.

To read the article summaries, please download the PDF

Butalia S, Leung AA, Ghali WA, Rabi DM (2011) Aspirin effect on the incidence of major adverse cardiovascular events in patients with diabetes mellitus: a systematic review and meta-analysis. Cardiovasc Diabetol 10: 25
Calvin AD, Aggarwal NR, Murad MH et al (2009) Aspirin for the primary prevention of cardiovascular events: a systematic review and meta-analysis comparing patients with and without diabetes. Diabetes Care 32: 2300–6
De Berardis G, Sacco M, Evangelista V et al (2007) Aspirin and Simvastatin Combination for Cardiovascular Events Prevention Trial in Diabetes (ACCEPT-D): design of a randomized study of the efficacy of low-dose aspirin in the prevention of cardiovascular events in subjects with diabetes mellitus treated with statins. Trials 8: 21
De Berardis G, Sacco M, Strippoli GF et al (2009) Aspirin for primary prevention of cardiovascular events in people with diabetes: meta-analysis of randomised controlled trials. BMJ 339: b4531
Handelsman Y, Mechanick JI, Blonde L et al (2011) American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care plan. Endocr Pract 17(Suppl 2): 1–53
Younis N, Williams S, Ammori B, Soran H (2010) Role of aspirin in the primary prevention of cardiovascular disease in diabetes mellitus: a meta-analysis. Expert Opin Pharmacother 11: 1459–66
Zhang C, Sun A, Zhang P et al (2010) Aspirin for primary prevention of cardiovascular events in patients with diabetes: a meta-analysis. Diabetes Res Clin Pract 87: 211–8

Share this article
Share on facebook
Share on twitter
Share on linkedin
Share on email
Share on whatsapp
Related content
For the latest news and articles

Sign up to all DiabetesontheNet journals

© Copyright Omniamed Communications. All Rights Reserved​
108 Cannon Street, London, EC4N 6EU. Registered in the United Kingdom​
Omniamed logo white
DiabetesontheNet Logo
For the latest news and articles

Sign up to all DiabetesontheNet journals

 

By clicking ‘Subscribe’, you are agreeing that DiabetesontheNet.com are able to email you periodic newsletters. You may unsubscribe from these at any time. Your info is safe with us and we will never sell or trade your details. For information please review our Privacy Policy.

DiabetesontheNet Logo

This website is for healthcare professionals only. To continue, please confirm that you are a healthcare professional below.