DIABETES CAD AND ASPIRIN

1. Aspirin in Primary Prevention in
CAD in T2DM---really needed?
Dr. Pijush Kanti Mandal
Assistant Professor
Department of Medicine
Malda Medical College ,Malda

2. Introduction
• 382 million people worldwide have diabetes mellitus, and is
expected to reach 592 million by the year 2035.
•Atherosclerotic Cardiovascular Disease (ASCVD) remains the
principal cause of death and disability among patients with
Diabetes Mellitus (DM).
Guariguata L et al. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract. 2014;103:137–149

3. • ASCVD in DM manifests as –
 Coronary heart disease
 Ischemic stroke
 Peripheral artery disease
 Heart failure

4. Age-standardized rates of selected vascular diseases in
individuals with or without diabetes mellitus in the years 1990,
2000, and 2010 – 20 years surveillance data
Rates of vascular diseases are decreasing in persons with diabetes
mellitus but are still higher than in persons without diabetes mellitus
Low Wang CC et al. Circulation. 2016 Jun 14;133(24):2459-502.

5. Development & Progression of atherosclerosis in DM
Adapted from Low Wang CC et al. Circulation. 2016 Jun 14;133(24):2459-502.

6. CVD in DM
• Individuals with diabetes have a 2–4 fold increased
risk for serious cardiovascular events as a result of
 Increased coronary thrombus formation,
 Increased platelet reactivity, and
 Worsened endothelial dysfunction
• Controversies regarding the use of low dose aspirin
in DM is a hot topic of debate
Pignone M et al. Circulation. 2010 Jun 22; 121(24):2694-701

7. Aspirin in DM
• Guidelines from early 2000s recommended the use
of low-dose aspirin for primary prevention in
patients with diabetes mellitus over a certain age
or in the presence of concomitant cardiovascular
risk factors
 Recommendation was based largely on results from
randomized clinical trials that showed a positive effect
of low-dose aspirin in healthy volunteers
 In patients with hypertension
 for secondary prevention in patients after myocardial
infarction
Saito Y et al. Circulation. 2017;135:659–670

8. ADA position statement
• Aspirin therapy (75–162 mg/day)
 May be considered as a primary prevention strategy in
those with type 1 or type 2 diabetes who are at
increased cardiovascular risk
 This includes most men and women with diabetes aged
≥50 years who have at least one additional major risk
factor (family history of premature atherosclerotic
cardiovascular disease, hypertension, dyslipidemia,
smoking, or albuminuria) and are not at increased risk of
bleeding.
Saito Y et al. Circulation. 2017;135:659–670

9. Pros & Cons
Adapted from Pignone M et al. Nat Rev Endocrinol. 2010 November ; 6(11): 619–628

10. What does recent
evidences suggest ?

11. Design Patients Inclusion criteria Dosage Primary
outcome
Open label,
RCT
2539 T2DM without pre-
existing CVD
Aspirin group (81-
100 mg)
Vs
No Aspirin group
CV events
including
sudden deaths,
fatal & non
fatal CADs,
stroke, PVDs
Saito Y et al. Circulation. 2017;135:659–670
JPAD (Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes) Trial

12. Results
• Median FU: 10.3 years; 1621 patients (64%)
• Low-dose aspirin did not reduce cardiovascular
events in the per-protocol cohort (hazard ratio,
1.14; 95% confidence interval, 0.91–1.42).
• Incidence of hemorrhagic stroke was not different
between groups.
• GI bleeding risk 2% (Aspirin gp) vs. 0.9% (non
Aspirin gp)
Concluding Remark: Low-dose aspirin did not affect the risk for cardiovascular
events but increased risk for gastrointestinal bleeding in patients with type 2
diabetes mellitus in a primary prevention setting

13. Design Patients Inclusion criteria Dosage Primary outcome
RCT 15480 T2DM without
evidence of CVD
Aspirin group
(100 mg)
Vs
Placebo
First serious vascular event
(i.e., myocardial infarction,
stroke or transient ischemic
attack, or death from any
vascular cause, excluding
any confirmed intracranial
hemorrhage)
The ASCEND Study Collaborative Group. N Engl J Med 2018;379:1529-39.
ASCEND (A Study of Cardiovascular Events in Diabetes)

14. Results
• Mean FU – 7.4 years
• Serious vascular events occurred in a significantly
lower percentage of participants in the aspirin
group
 8.5% (Aspirin gp) vs. 9. 6% (Placebo) [P=0.01]
• Major bleeding events occurred in the aspirin
group
 4.1% (Aspirin gp) vs. 3.2% (Placebo) [P=0.003]
Are benefits outweighing the risks?

15. Design Patients Inclusion criteria Primary outcome
Meta-
analysis
11 trials
with
1,57,248
subjects
were
included
Subjects without
established
atherosclerotic
disease
All cause mortality
Mahmoud AN et al. Eur Heart J. 2019 Feb 14;40(7):607-617.
ASPREE (Aspirin in Reducing Events in the Elderly)

16. Results
• Mean FU – 6.6 years
• Aspirin was not associated with a lower incidence
of all-cause mortality
 [risk ratio (RR) 0.98, 95% confidence interval (CI) 0.93–
1.02; P = 0.30]
• Aspirin was associated with an increased incidence
of major bleeding
 [RR 1.47, 95% CI 1.31–1.65; P < 0.0001]
• Aspirin was associated with an increased incidence
of intracranial hemorrhage
 [RR 1.33, 95% CI 1.13–1.58; P = 0.001]

17. Design Patients Inclusion criteria Dosage Primary outcome
DB,
PC,
Multic
entred
RCT
12546
enrolled
Men ≥ 55 years &
Women ≥ 60
years
Aspirin 100
mg
Vs
Placebo
Composite outcome of time to
first occurrence of
cardiovascular death,
myocardial infarction,
unstable angina, stroke, or
transient ischaemic attack
Gaziano MJ et al. Lancet. 2018 Sep 22;392(10152):1036-1046.
ARRIVE (Aspirin to reduce risk of initial vascular events)

18. Results
• Mean FU – 60 months
• Primary endpoint occurred in 4·29% patients in the
aspirin group versus 4·48% patients in the placebo
group (P=0·6038)
• GI bleeding events 0.97% in Aspirin group vs. 0.46%
in the placebo group (P=0.0007)

19. Design Patients Inclusion criteria Dosage Primary outcome
RCT 19114 ≥70 years without
CVD
Aspirin 100
mg
Vs
Placebo
Mortality comparison
between the groups
ASPREE (Aspirin in Reducing Events in the Elderly)
McNeil JJ et al. N Engl J Med. 2018 Oct 18;379(16):1519-1528

20. Results
• FU – 4.7 years
• Total deaths occurred – 1052
• Risk of deaths from any cause
 12.7 (aspirin groups) vs. 11.1 (placebo group) events
every 1000 person-years
• Cancer was the major contributor to the deaths in
Aspirin group
Higher all-cause mortality was observed among
apparently healthy older adults who received daily
aspirin than among those who received placebo

21. In conclusion
 The use of low-dose aspirin led to a lower risk of
serious vascular events than placebo among
persons with diabetes who did not have evident
cardiovascular disease at trial entry.
 However, the absolute lower rates of serious
vascular events were of similar magnitude to the
absolute higher rates of major bleeding, even
among participants who had a high vascular risk.

22. RECOMMENDATIONS
<50 Years of Age aspirin is not recommended for those
at low risk of ASCVD (such as men and women aged ,50
years with diabetes with no other major ASCVD risk
factors) as the low benefit is likely to be outweighed by
the risks of bleeding.
 Clinical judgment should be used for those at
intermediate risk (younger patients with one or more
risk factors or older patients with no risk factors) until
further research is available.
Patients’ willingness to undergo long-term aspirin
therapy should also be considered.
 Aspirin use in patients aged ,21 years is generally
contraindicated due to the associated risk of Reye
syndrome.

23. THANKS…..