FOCUS ISSUE: ASPIRIN
Aspirin Use in Older Patients With Heart Failure and Coronary Artery Disease
National Prescription Patterns and Relationship With Outcomes
Frederick A. Masoudi, MD, MSPH, FACC*, , , ,*,
Pam Wolfe, MA, MS,
Edward P. Havranek, MD, FACC*,,,
Saif S. Rathore, MPH||,
JoAnne M. Foody, MD|| and
Harlan M. Krumholz, MD, FACC,||,¶,#
* Division of Cardiology, Department of Medicine, Denver Health Medical Center, Denver, Colorado
Division of Cardiology, Department of Medicine, University of Colorado Health Sciences Center, Denver, Colorado
Division of Geriatric Medicine, Department of Medicine, University of Colorado Health Sciences Center, Denver, Colorado
Colorado Foundation for Medical Care, Aurora, Colorado
|| Section of Cardiovascular Medicine, Department of Internal Medicine, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
¶ Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
# Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.
Manuscript received April 13, 2004;
revised manuscript received July 20, 2004,
accepted July 28, 2004.
* Reprint requests and correspondence: Dr. Frederick A. Masoudi, Division of Cardiology MC 0960, Denver Health Medical Center, 777 Bannock Street, Denver, Colorado 80204. (Email: fred.masoudi{at}uchsc.edu).
Aspirin Use in Older Patients with Heart Failure and Coronary Artery Disease
Frederick A. Masoudi, Pam Wolfe, Edward P. Havranek, Saif S. Rathore, JoAnne M. Foody, Harlan M. Krumholz
Aspirin use in patients with coronary artery disease (CAD) and concomitant heart failure (HF) is controversial. We studied 24,012 hospitalized Medicare beneficiaries  65 years old with the primary diagnosis of HF and documented CAD. Only 52% were treated with aspirin. In multivariable analyses, aspirin was associated with lower risks of death at one year (risk ratio 0.94; 95% confidence interval 0.90 to 0.99) and lower risks of death and all-cause readmission or death and HF readmission. These results suggest that withholding aspirin in patients with CAD and HF may deprive patients of important clinical benefits.
OBJECTIVES: We sought to determine patterns of aspirin use and the relationship between aspirin prescription and outcomes in patients with coronary artery disease (CAD) and heart failure (HF).
BACKGROUND: Because of the potential for exacerbating hypertension or renal insufficiency and possible interactions with angiotensin-converting enzyme (ACE) inhibitors, the use of aspirin for secondary prevention of coronary events is controversial in patients with HF.
METHODS: We studied a national sample of Medicare beneficiaries 65 years old after hospitalization for HF with CAD and without aspirin contraindications between April 1998 and June 2001. We assessed factors associated with aspirin prescription and the relationship between aspirin and outcomes in regression models accounting for differences in patient, physician, and hospital characteristics and for clustering of patients by hospital.
RESULTS: Of the 24,012 patients, 54% received aspirin. Treated patients had lower unadjusted rates of death (31% vs. 39% for those not receiving aspirin, p < 0.001). In multivariable analyses, aspirin remained associated with a lower risk of death (risk ratio [RR] 0.94; 95% confidence interval [CI] 0.90 to 0.99). This association was similar regardless of hypertension, renal insufficiency, or treatment with ACE inhibitors (p for all interactions > 0.2). Aspirin also was associated with lower risks of death or all-cause readmission (RR 0.98; 95% CI 0.97 to 0.99) and of death or readmission for HF (RR 0.98; 95% CI 0.96 to 0.99).
CONCLUSIONS: Almost one-half of patients with CAD hospitalized for HF in the U.S. are not treated with aspirin. This study found no evidence of harm from aspirin in this population and suggests a treatment benefit. Withholding aspirin based upon theoretical concerns about adverse effects appears to be unjustified.
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Abbreviations and Acronyms
| | ACE = angiotensin-converting enzyme | | CAD = coronary artery disease | | CI = confidence interval | | GFR = glomerular filtration rate | | LV = left ventricular | | NHC = National Heart Care | | MI = myocardial infarction | | RR = risk ratio | | SCr = serum creatinine |
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