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. 2020 Sep 20:27:100548.
doi: 10.1016/j.eclinm.2020.100548. eCollection 2020 Oct.

Aspirin for primary prevention of ST segment elevation myocardial infarction in persons with diabetes and multiple risk factors

Raffaele Bugiardini  1 , Saša Pavasović  1   2 , Jinsung Yoon  3 , Mihaela van der Schaar  4 , Sasko Kedev  5 , Marija Vavlukis  5 , Zorana Vasiljevic  6 , Maria Bergami  1 , Davor Miličić  2 , Olivia Manfrini  1 , Edina Cenko  1 , Lina Badimon  7
Affiliations

Aspirin for primary prevention of ST segment elevation myocardial infarction in persons with diabetes and multiple risk factors

Raffaele Bugiardini et al. EClinicalMedicine. .

Abstract

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.

Keywords: Aspirin; Primary prevention; ST segment elevation myocardial infarction.

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Conflict of interest statement

Professor Badimon reports other from Bayer, personal fees and other from International Aspirin Foundation, UK, during the conduct of the study; other from SANOFI, personal fees from LILLY, grants from ASTRAZENECA, personal fees from ASTRAZENECA, other from Glycardial, personal fees from BMS/Pfizer, personal fees from PACE, personal fees and other from FICYE (FORUM TO STUDY BEER & LIFESTYLE), outside the submitted work; In addition, Professor Badimon has a patent APOj-Gly licensed, a patent IV_STATIN pending, and a patent DJ1-F pending. All other authors have nothing to report.

Figures

Fig. 1
Fig. 1
Estimated effects of aspirin on STEMI: distribution by CV risk factors. Association between use of aspirin before index event and incidence of ST elevation myocardial infarction sorted by the presence of one traditional risk factor. Abbreviations: OR, Odds Ratio; CI, Confidence Interval; CV, cardiovascular; STEMI, ST elevation myocardial infarction.
Fig. 2
Fig. 2
Estimated effects of aspirin on STEMI in patients with diabetes: distribution by one more CV risk factor. Association between use of aspirin before index event and incidence of ST elevation myocardial infarction in patients with diabetes sorted by its combination with one more traditional risk factor. Abbreviations: OR, Odds Ratio; CI, Confidence Interval; CV, cardiovascular; STEMI, ST elevation myocardial infarction.
Fig. 3
Fig. 3
Estimated effects of aspirin on STEMI in patients with diabetes: distribution by two or more CV risk factors. Association between use of aspirin before index event and incidence of ST elevation myocardial infarction in patients with diabetes sorted its combination with two or more traditional risk factors. Abbreviations: OR, Odds Ratio; CI, Confidence Interval; CV, cardiovascular; STEMI, ST elevation myocardial infarction.
Fig. 4
Fig. 4
Aspirin and prevention of STEMI in diabetes. Abbreviations: STEMI, ST elevation myocardial infarction.
See this image and copyright information in PMC

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