Correspondence

Aspirin and Coronary Disease

N Engl J Med 1996; 335:1161-1162October 10, 1996

Article

To the Editor:

In his editorial on platelets and coronary artery disease (April 25 issue),1 Handin states, “Aspirin has now become an essential cardiovascular drug, and it is unusual to find patients with established coronary artery disease who do not take it.” Sadly, despite overwhelming evidence of the clinical benefit of aspirin in patients with coronary heart disease, many if not most patients with established disease do not take aspirin. Only 37 percent of patients received aspirin in the Scandinavian Simvastatin Survival Study.2 Reviewing the treatment of Medicare patients with acute myocardial infarction, the Cooperative Cardiovascular Project found that only 50 percent of patients received aspirin within 48 hours after the diagnosis of infarction.3 Moreover, the mortality rate at six months among patients not receiving aspirin was twice the rate among those receiving it.4 Studying community practice, Shahar et al. found a low level of aspirin use among patients with symptomatic coronary heart disease: 58 percent among white men, 35 percent among black men, 34 percent among white women, and 13 percent among black women.5 Physicians' misperceptions of the available data are a substantial problem. Ayanian et al. found that only 55 percent of internists believe that aspirin definitely improves the long-term prognosis after myocardial infarction.6

Documentation of similar deficiencies in care abounds in medicine. The reasons for not prescribing effective therapies are complex and may involve cost considerations. In the case of aspirin, high cost is not a factor.

Robert A. Vogel, M.D.
University of Maryland School of Medicine, Baltimore, MD 21201-1595

6 References

1. 1

   Handin RI. Platelets and coronary artery disease. N Engl J Med 1996;334:1126-1128
   Full Text | Web of Science | Medline

2. 2

   Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994;344:1383-1389
   Web of Science | Medline

3. 3

   Ellerbeck EF, Jencks SF, Radford MJ, et al. Quality of care for Medicare patients with acute myocardial infarction: a four-state pilot study from the Cooperative Cardiovascular Project. JAMA 1995;273:1509-1514
   CrossRef | Web of Science | Medline

4. 4

   Krumholz HM, Radford MJ, Ellerbeck EF, et al. Aspirin for secondary prevention after acute myocardial infarction in the elderly: prescribed use and outcomes. Arch Intern Med 1996;124:292-298
   Web of Science

5. 5

   Shahar E, Folsom AR, Romm FJ, et al. Patterns of aspirin use in middle-aged adults: the Atherosclerosis Risk in Communities (ARIC) Study. Am Heart J 1996;131:915-922
   CrossRef | Web of Science | Medline

6. 6

   Ayanian JZ, Hauptman PJ, Guadagnoli E, Antman EM, Pashos CL, McNeil BJ. Knowledge and practices of generalist and specialist physicians regarding drug therapy for acute myocardial infarction. N Engl J Med 1994;331:1136-1142
   Full Text | Web of Science | Medline

Author/Editor Response

Dr. Handin replies:

To the Editor: I agree completely with Dr. Vogel's comments about the failure of physicians to recognize the important role of aspirin as prophylaxis against thrombotic events in patients with coronary artery disease. His analysis is both sobering and disconcerting. We have all grown so accustomed to using aspirin for the treatment of fever, musculoskeletal discomfort, and headache that it is difficult to accept its new role. Perhaps practitioners are incredulous that an agent as inexpensive, innocuous, and ubiquitous as aspirin is also an effective antithrombotic agent.

Although I claim no expertise in outcomes research and cost-effectiveness analysis, fairly simple calculations show that aspirin is a remarkably cost-effective antithrombotic agent. On the basis of published data from multiple sources, I make the following assumptions: daily ingestion of aspirin reduces fatal initial coronary events by 20 percent; there are approximately 600,000 new acute coronary events each year, 50 percent of which are fatal; there are approximately 80 million people in the United States over the age of 45 years who could be considered at risk; and a year's supply of generic aspirin costs $4.50. Each of these assumptions can be challenged, but they are a fair approximation of the facts. Using these assumptions, I have calculated that the use of aspirin by the at-risk population would save approximately 60,000 lives each year, at a cost of $6,000 per life saved. These numbers do not take into account patients with apparently fatal coronary events that are converted to nonfatal events or those who escape hospitalization completely. I have also made no attempt to determine the length of time that aspirin will be protective. Nevertheless, the results compare quite favorably with estimates of the cost effectiveness of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors or antihypertensive agents.1,2

As Dr. Vogel rightly points out, despite the compelling clinical data, sometimes the obvious is not so obvious.

Robert I. Handin, M.D.
Brigham and Women's Hospital, Boston, MA 02115

2 References

1. 1

   Goldman L, Weinstein MC, Goldman PA, Williams LW. Cost-effectiveness of HMG-CoA reductase inhibition for primary and secondary prevention of coronary heart disease. JAMA 1991;265:1145-1151
   CrossRef | Web of Science | Medline

2. 2

   Edelson JT, Weinstein MC, Tosteson AN, Williams L, Lee TH, Goldman L. Long-term cost-effectiveness of various initial monotherapies for mild to moderate hypertension. JAMA 1990;263:407-413
   CrossRef | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Lofty L. Basta. (2003) Routine Implantation of Cardioverter/Defibrillator Devices in Patients Aged 75 Years and Older With Prior Myocardial Infarction and Left Ventricular Ejection Fraction <30: Antagonist Viewpoint. The American Journal of Geriatric Cardiology 12:6, 363-365
   CrossRef