Correspondence
Aspirin for the Primary Prevention of Coronary Events
N Engl J Med 2002; 347:948September 19, 2002
- Article
To the Editor:
In his Clinical Practice article on aspirin for the primary prevention of coronary events (May 9 issue),1 Dr. Lauer notes that diabetes is associated with a significant risk of fatal and nonfatal coronary heart disease. He reviews data on the use of aspirin in the primary prevention of cardiac events in patients with diabetes.2,3 However, he does not take the presence of diabetes into account in calculating the risk of coronary events. A recent meta-analysis by the Antithrombotic Trialists' Collaboration4 provides support for the prophylactic use of aspirin in patients with diabetes. There is no evidence to suggest that the prophylactic use of aspirin results in any risk for patients with diabetes.
The guidelines of the Adult Treatment Panel III of the National Institutes of Health have included the presence of diabetes as a factor associated with a risk of coronary events equivalent to that associated with established coronary heart disease.5 Accordingly, it appears that diabetes should be included as a major risk factor in determining whether aspirin therapy is warranted to reduce the risk of coronary events. In addition, the presence of proteinuria should be assigned a higher score in the calculation of the 10-year risk of coronary events in adults.
5 ReferencesJ.L. Mehta, M.D., Ph.D.
University of Arkansas for Medical Sciences, Little Rock, AR 72205-7199
mehtajl@uams.edu 1
Lauer MS . Aspirin for primary prevention of coronary events. N Engl J Med 2002;346:1468-1474
Full Text | Web of Science | Medline2
Steering Committee of the Physicians' Health Study Research Group
Full Text | Web of Science | Medline3
Aspirin effects on mortality and morbidity in patients with diabetes mellitus: Early Treatment Diabetic Retinopathy Study report 14. JAMA 1992;268:1292-1300
CrossRef | Web of Science4
Antithrombotic Trialists' Collaboration
CrossRef | Web of Science5
Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497
CrossRef | Web of Science
To the Editor:
Decisions about aspirin therapy should take into account the overall risk of coronary heart disease. Several risk-assessment methods based on the Framingham risk score1 are widely used, but this scoring system underestimates the risk of coronary heart disease in persons with a family history of premature coronary heart disease.2 Such a family history should be considered as an adjunctive risk factor by physicians making recommendations on the use of aspirin to reduce the risk of myocardial infarction.
2 ReferencesLuca Mascitelli, M.D.
Case di Cura Città di Udine, 33100 Udine, Italy
lumasci@libero.it Francesca Pezzetta, M.D.
Ospedale San Michele, 33013 Gemona del Friuli, Italy1
Wilson PW ,D'Agostino RB ,Levy D ,Belanger AM ,Silbershatz H ,Kannel WB . Prediction of coronary heart disease using risk factor categories. Circulation 1998;97:1837-1847
Web of Science | Medline2
Wallis EJ ,Ramsay LE ,Haq IU , et al. Coronary and cardiovascular risk estimation for primary prevention: validation of a new Sheffield table in the 1995 Scottish health survey population. BMJ 2000;320:671-676[Erratum, BMJ 2000;320:1034.]
CrossRef | Web of Science | Medline
Author/Editor Response
Dr. Lauer replies:
To the Editor: Dr. Mehta correctly points out that the Framingham score that accompanied the latest guidelines of the Adult Treatment Panel leaves out diabetes because it is now considered a coronary-disease equivalent.1 Although subgroup analyses have suggested beneficial effects in patients with diabetes,2,3 in my article I considered the use of aspirin for primary prevention in such patients to be an area of uncertainty because no randomized trial has specifically been designed and executed to answer this question.
Drs. Mascitelli and Pezzetta wonder why family history is not considered in determining the risk of coronary heart disease. Although researchers involved in the Framingham Heart Study have noted that a family history of premature coronary disease is independently associated with a 30 percent increase in risk, they deliberately left it out of risk equations because information on family history is often not available or not reliable.4
The URL listed in the article for calculating the Framingham risk score was not correct. The correct address is http://hin.nhlbi.nih.gov/atpiii/calculator.asp?usertype-prof.
4 ReferencesMichael S. Lauer, M.D.
Cleveland Clinic Foundation, Cleveland, OH 44195
lauerm@ccf.org 1
Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001;285:2486-2497
CrossRef | Web of Science2
Steering Committee of the Physicians' Health Study Research Group
Full Text | Web of Science | Medline3
Antithrombotic Trialists' Collaboration
CrossRef | Web of Science4
Wilson PW ,D'Agostino RB ,Levy D ,Belanger AM ,Silbershatz H ,Kannel WB . Prediction of coronary heart disease using risk factor categories. Circulation 1998;97:1837-1847
Web of Science | Medline
