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Aspirin for primary prevention of ST segment elevation myocardial infarction in persons with diabetes and multiple
Raffaele Bugiardini1, Saša Pavasović1,2, Jinsung Yoon3
1Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Policlinico Sant'Orsola Malpighi, Padiglione 11, Via Massarenti 9, 40138 Bologna, Italy.
Insights
Low-dose aspirin use effectively reduces the risk of ST-segment elevation myocardial infarction (STEMI) as an initial cardiovascular event. However, diabetic patients only benefit when other risk factors are also present.
Area of Science:
- Cardiology
- Preventive Medicine
- Clinical Research
Background:
- The efficacy of low-dose aspirin for primary prevention of cardiovascular events remains debated.
- This study aimed to re-evaluate aspirin's benefits, hypothesizing they are underestimated.
Purpose of the Study:
- To investigate the effectiveness of low-dose aspirin in reducing the risk of ST-segment elevation myocardial infarction (STEMI) as a first manifestation of cardiovascular disease.
- To explore the association between STEMI and 30-day mortality.
- To identify patient subgroups that benefit most from aspirin therapy.
Main Methods:
- A multicenter registry (ISACS-TC) including 12,123 Caucasian patients with acute coronary syndromes as their first cardiovascular manifestation (2010-2019).
- Inverse probability of treatment weighting models were used to quantify STEMI risk and its association with 30-day mortality, controlling for concomitant medications.
- Tests of interaction were employed to compare estimates across different patient characteristics.
Main Results:
- Aspirin use was associated with a significantly lower risk of STEMI (absolute reduction: 6.8%; OR: 0.73).
- Benefits were observed regardless of sex or age, and in patients with hypertension, hypercholesterolemia, and smokers.
- Diabetic patients showed no significant risk reduction in STEMI (OR: 1.10), with a significant interaction (p < 0.0001) compared to controls (OR: 0.64).
- Aspirin provided benefits in diabetic patients only when hypertension and hypercholesterolemia were also present (OR: 0.87).
- STEMI was strongly linked to 30-day mortality (OR: 1.93).
Conclusions:
- Low-dose aspirin effectively reduces STEMI risk as an initial cardiovascular event and may improve mortality.
- Diabetic patients require a tailored approach, deriving substantial benefit from aspirin only when multiple risk factors coexist.
- Precision medicine strategies are necessary for optimizing aspirin therapy in cardiovascular disease prevention.
Background:
Controversy exists as to whether low-dose aspirin use may give benefit in primary prevention of cardiovascular (CV) events. We hypothesized that the benefits of aspirin are underevaluated.
Methods:
We investigated 12,123 Caucasian patients presenting to hospital with acute coronary syndromes as first manifestation of CV disease from 2010 to 2019 in the ISACS-TC multicenter registry (ClinicalTrials.gov, NCT01218776). Individual risk of ST segment elevation myocardial infarction (STEMI) and its association with 30-day mortality was quantified using inverse probability of treatment weighting models matching for concomitant medications. Estimates were compared by test of interaction on the log scale.
Findings:
The risk of STEMI was lower in the aspirin users (absolute reduction: 6·8%; OR: 0·73; 95%CI: 0·65-0·82) regardless of sex (p for interaction=0·1962) or age (p for interaction=0·1209). Benefits of aspirin were seen in patients with hypertension, hypercholesterolemia, and in smokers. In contrast, aspirin failed to demonstrate a significant risk reduction in STEMI among diabetic patients (OR:1·10;95%CI:0·89-1·35) with a significant interaction (p: <0·0001) when compared with controls (OR:0·64,95%CI:0·56-0·73). Stratification of diabetes in risk categories revealed benefits (p interaction=0·0864) only in patients with concomitant hypertension and hypercholesterolemia (OR:0·87, 95% CI:0·65-1·15), but not in smokers. STEMI was strongly related to 30-day mortality (OR:1·93; 95%CI:1·59-2·35).
Interpretation:
Low-dose aspirin reduces the risk of STEMI as initial manifestation of CV disease with potential benefit in mortality. Patients with diabetes derive substantial benefit from aspirin only in the presence of multiple risk factors. In the era of precision medicine, a more tailored strategy is required.
Funding:
None.
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