The Role of Aspirin in the primary prevention of cardiovascular disease in patients with diabetes, especially T2DM - current knowledge and recommendations -
Effects of aspirin for primary prevention in persons with Diabetes mellitusShadab Ahmad
The ASCEND(A Study od Cardiovascular Events in Diabetes) randomized trial was performed to assess the efficacy and safety of enteric-coated aspirin at a dose of 100 mg daily, as compared with placebo, in person who had diabetes without manifest cardiovascular disease.
Primary Prevention of Cardiovascular Disease: The Role of Aspirin and StatinsCTSI at UCSF
Presented by Michael Pignone, MD, MPH, at UCSF's symposium "The Role of Risk Stratification and Biomarkers in Prevention of Cardiovascular Disease" in Jan 2012.
Effects of aspirin for primary prevention in persons with Diabetes mellitusShadab Ahmad
The ASCEND(A Study od Cardiovascular Events in Diabetes) randomized trial was performed to assess the efficacy and safety of enteric-coated aspirin at a dose of 100 mg daily, as compared with placebo, in person who had diabetes without manifest cardiovascular disease.
Primary Prevention of Cardiovascular Disease: The Role of Aspirin and StatinsCTSI at UCSF
Presented by Michael Pignone, MD, MPH, at UCSF's symposium "The Role of Risk Stratification and Biomarkers in Prevention of Cardiovascular Disease" in Jan 2012.
Association and prevalence of different comorbidities in hypertension and management with focus guidelines with benefits & choice of different antihypertensives in different comorbidities.
Managing CV risk in Inflammatory Arthritis (Focusing on Gout)Sidney Erwin Manahan
Presentation made during the 1st Inter-Hospital Rheumatology Fellows' Case Discussion on 9 June 2018 at the Speaker Feliciano Belmonte Auditorium, 7/F East Avenue Medical Center. Presentation highlights the needs to recognize gout as one of the rheumatic conditions that put patients at risk for developing CV disease.
Are all ACE inhibitors ace in treatment of essential hypertension?Josep Vidal-Alaball
Abstract: ACE inhibitors (ACEi) are widely recommended and used for treatment of hypertension. There are number of ACEi to choose from. It make sense to use the one that that has been shown to be most effective in prevention of serious hypertension complication such as stroke. If there is more that one choice it make sense to use the one with lower acquisition cost. In this paper we are looking into the evidence for using ACEi as a first line treatment for hypertension and to try and find out which ACEi has been associated with the best clinical outcome. We found no long-term trials comparing ACEi and placebo for treatment of hypertension. We found no head-to-head studies directly comparing the main four ACEi’s, commonly prescribed in England. On the basis of the evidence presented, lisinopril is the only commonly used ACEi that can be considered a first line treatment for hypertension. There is some evidence for ramipril, although this is not as strong. There is no substantial evidence of the effectiveness of enalapril and in the presence of a proven treatment (lisinopril) it makes no sense to use it for the treatment of hypertension. There is no evidence that perindopril improves mortality or stroke rate in patients with hypertension. Perindopril is no better than placebo for treatment of patients with previous TIA or stroke.
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Jeremy Chow
Cardiologist, Electrophysiologist
Asian Heart & Vascular Centre
www.ahvc.com.sg
Goal attainments and their discrepancies for low density lipoprotein choleste...Paul Schoenhagen
Purpose: Low density lipoprotein cholesterol (LDL-C) is primary treatment target for patients with dislipidemia. The apolipoprotein B (apo B), an emerging biomarker for cardiovascular risk prediction, appears to be superior to the LDL-C. However, little is known about goal attainments and their discrepancies for LDL-C and apo B in Chinese patients with known CAD or DM.
Association and prevalence of different comorbidities in hypertension and management with focus guidelines with benefits & choice of different antihypertensives in different comorbidities.
Managing CV risk in Inflammatory Arthritis (Focusing on Gout)Sidney Erwin Manahan
Presentation made during the 1st Inter-Hospital Rheumatology Fellows' Case Discussion on 9 June 2018 at the Speaker Feliciano Belmonte Auditorium, 7/F East Avenue Medical Center. Presentation highlights the needs to recognize gout as one of the rheumatic conditions that put patients at risk for developing CV disease.
Are all ACE inhibitors ace in treatment of essential hypertension?Josep Vidal-Alaball
Abstract: ACE inhibitors (ACEi) are widely recommended and used for treatment of hypertension. There are number of ACEi to choose from. It make sense to use the one that that has been shown to be most effective in prevention of serious hypertension complication such as stroke. If there is more that one choice it make sense to use the one with lower acquisition cost. In this paper we are looking into the evidence for using ACEi as a first line treatment for hypertension and to try and find out which ACEi has been associated with the best clinical outcome. We found no long-term trials comparing ACEi and placebo for treatment of hypertension. We found no head-to-head studies directly comparing the main four ACEi’s, commonly prescribed in England. On the basis of the evidence presented, lisinopril is the only commonly used ACEi that can be considered a first line treatment for hypertension. There is some evidence for ramipril, although this is not as strong. There is no substantial evidence of the effectiveness of enalapril and in the presence of a proven treatment (lisinopril) it makes no sense to use it for the treatment of hypertension. There is no evidence that perindopril improves mortality or stroke rate in patients with hypertension. Perindopril is no better than placebo for treatment of patients with previous TIA or stroke.
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Jeremy Chow
Cardiologist, Electrophysiologist
Asian Heart & Vascular Centre
www.ahvc.com.sg
Goal attainments and their discrepancies for low density lipoprotein choleste...Paul Schoenhagen
Purpose: Low density lipoprotein cholesterol (LDL-C) is primary treatment target for patients with dislipidemia. The apolipoprotein B (apo B), an emerging biomarker for cardiovascular risk prediction, appears to be superior to the LDL-C. However, little is known about goal attainments and their discrepancies for LDL-C and apo B in Chinese patients with known CAD or DM.
CHRONIC ASPIRIN AND STATIN THERAPYIN PATIENTS WITH IMPAIRED RENAL FUNCTIONA...Vishwanath Hesarur
Chronic use of aspirin and statin may reduce the risk of subsequent MI and improve outcome in patients with documented IHD or in patients at high risk of a first cardiovascular event.
Moreover, previous aspirin & statin therapy may interfere with the clinical presentation of acute MI, with a higher incidence of NSTEMI as compared to STEMI.
Dyslipidemia management an evidence based approachDr Vivek Baliga
In this presentation by Dr Vivek Baliga, he discusses the different available statins and how you can choose the right one in different clinical situations. See articles from Dr Baliga on http://drvivekbaliga.net
Assessment Outcomes Dyslipidaemia in Dialysis PatientAI Publications
Background: Chronic kidney disease is defined as the presence, for more than three months, of changes in the structure or function of the kidneys, secondary to a progressive decline in the number of nephrons, with a consequent deterioration in health resulting from the inability of the kidneys to perform their excretory functions, softener, and metabolism. Chronic kidney disease (CKD) is a clinical condition caused by the progressive and progressive loss of kidney function. Chronic kidney disease is not only implicated by the gradual deterioration of quality of life and life expectancy when it progresses to more advanced stages but also by the increase in cardiovascular morbidity and mortality, which is the leading cause of death in these patients. Aim: This paper aims to assess the outcomes of dyslipidemia in a dialysis patient. Patients and method: In this study, a descriptive cross-sectional study was applied to study the Assessment Outcomes of Dyslipidemia in Dialysis Patients in Iraq from 4th January 2021 to 7th August 2022. Data were collected for 150 patients in different hospitals in Iraq, where the patients were divided into two groups, the first group of patients, which included DIALYSIS PATIENTS, which included 80, and the second group, the control group, which included patients, which include 70 patients. Results and discussions: collected 150 cases distributed according to dialysis patients (80) and controls (70); the most frequent ages in this study ranged from 40-49 years old 34 (42.5%) patients group, 33 (47.14%) control group with a statistical difference of 0.0831. In this study was evaluated the Outcomes of dyslipidemia in a dialysis patient. Imbalances were found in levels of dyslipidemia which LDL 5.12±3.4 of the patients' group, as for the control group 2.1±3.3-HDL 2.43±2.4 of the patients' group, 1.4±1.5 for the control group, TRIGLYCERIDE 1.75±1.8 of patients group, 0.55±0.43 for the control group with A statistically significant relationship were found between dyslipidemia levels and outcomes in the group of patients at P value < 0.05.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Best Ayurvedic medicine for Gas and IndigestionSwastikAyurveda
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Aspirin as Prevention Therapy for Cardiovascular Events in patients with Diabetes
1. Aspirin as Prevention Therapy for Cardiovascular Events
Stefania Dumitrescu
in patients with Diabetes
2. Prevalence of CHD rises from 2% to 4% in the general population to as
high as 55% among adult diabetic patients (Berry et al. 2007)
Diabetes mellitus is an independent risk factor for CVD (acute MI, stroke,
heart failure, PAD, arrhythmias) in both men and women.
About one-quarter of patients with an acute MI have DM (Grundy et al., 2002)
Excess risk for CVD can be found in patients with type 1 and type 2 DM,
prediabetes, obesity or metabolic syndrome (Lteif et al., 2003)
Overall mortality from CHD is twice as great in men and 4 to 5 times
higher in women with than without DM (Hammoud et al., 2000)
Berry et al. 2007 Coronary Heart Disease in Patients with Diabetes Am Coll Cardiol. 2007;49(6):631-642.
Grundy et al., 2002 Prevention Conference VI: Diabetes and Cardiovascular Disease: Executive Summary Conference
Proceeding for Healthcare Professionals From a Special Writing Group of the American Heart Association. Circulation.
2002;105:2231-2239.
Lteif et al.,.; Diabetes and heart disease an evidence-driven guide to risk factors management in diabetes. Cardiol Rev. 11
2003:262-274.
Hammoud et al., 2000; Management of coronary artery disease: therapeutic options in patients with diabetes. J Am Coll
Cardiol. 36 2000:355-365.
3. Compared with non-diabetics, diabetic subjects
• have more severe coronary disease,
• more extensive coronary/ vessels calcifications,
• higher prevalence of left main stem disease,
• reduced coronary collateral artery recruitment (Natali et al., 2000; Cariou et
al., 2000; Werner et al.,2003) .
Diabetes mellitus is considered a CHD risk factor equivalent, especially in
patients with coexisting cardiovascular risk factors (Grundy SM 2006)
CHD risk equivalent defines the risk of developing a major acute coronary
event (MACE) over 10 years of more than 20% (Grundy SM 2006).
Natali et al.,2000 Coronary atherosclerosis in Type II diabetes: angiographic findings and clinical outcome. Diabetologia. 43 2000:632-641.
Cariou et al., 2000 Angiographic characteristics of coronary artery disease in diabetic patients compared with matched non-diabetic
subjects. Diabetes Nutr Metab. 13 2000:134-141.
Werner et al., 2003 Impaired acute collateral recruitment as a possible mechanism for increased cardiac adverse events in patients with
diabetes mellitus. Eur Heart J. 24 2003:1134-1142.
Grundy SM 2006 Diabetes and coronary risk equivalency, Diabetes care, 2006; 29(2): 457-460
4. Reasons for increased vascular risk in DM
• Accelerated/ premature atherosclerosis due to increased prevalence of risk factors:
long term diabetes (especially T2DM) favoring long term hyperinsulinemia and hyperglycemia,
autonomic dysfunction, blood hypertension, dyslipidemia, obesity, smoking, chronic kidney disease
(albuminuria, hyperhomocysteinemia), autoimmune diseases (Grundy et al., 2007)( Anavekar et al.,2004) (Berry
et al., 2007) .
• Altered cardiac metabolism
• Undiagnosed DM
• Underutilized evidence based therapies
• Increased restenosis post-PCI
Grundy et al., 2002 Prevention Conference VI: Diabetes and Cardiovascular Disease: Executive Summary Conference Proceeding for
Healthcare Professionals From a Special Writing Group of the American Heart Association. Circulation. 2002;105:2231-2239.
Anavekar et al., 2004 Predictors of cardiovascular events in patients with type 2 diabetic nephropathy and hypertension: a case for
albuminuria. Kidney Internat. 2004;66:S50-S55.
Berry et al. 2007 Coronary Heart Disease in Patients with Diabetes Am Coll Cardiol. 2007;49(6):631-642.
5. Pathophysiologic mechanisms of accelerated
atherosclerosis and thrombosis in DM (Berry et al. 2007):
• systemic inflammation,
• oxidative stress systemic
• endothelial dysfunction
• increased coagulation factors synthesis and activation
• platelet function abnormalities
• impaired fibrinolysis
• Increased glycation and oxidation of coagulation factors
Berry et al. 2007 Coronary Heart Disease in Patients with Diabetes Am Coll Cardiol. 2007;49(6):631-642.
6. 1997- American Diabetes Association (ADA) has
recommended aspirin (ASA) therapy for the primary and
secondary prevention of cardiovascular events
7. Gurbel, P (2009). Aspirin – scope and limitations. The British Journal of Cardiology, 17 (Suppl 1), pp.S8–S9.
8. Major Clinical Trials Using Routine Aspirin to Prevent Major Cardiovascular Events in patients with or
without diabetes (Nguyen et al. 2005)
Nguyen, K.X., Marinac, J.S. & Sun, C., (2005). Aspirin for primary prevention in patients with diabetes mellitus. Family medicine, 37(2),
pp.112–7.
9.
10. Aspirin is recommended in secondary prevention in any patient with
established CVD, being the most cost effective intervention for
reducing the risk of MACE in patients with or without diabetes (Buse et al.
2007).
Platelet inhibition with low-dose aspirin (75–250 mg/day) is indicated
in all patients with T2DM and overt CVD who do not have a
contraindication (Ryden et al. 2007).
Buse JB et al., (2007). Primary Prevention of Cardiovascular Disease in people with Diabetes Mellitus: A Scientific
Statement From the American Heart Association and the American Diabetes Association. Circulation.2007; 115: 114-126
Ryden, L. et al., (2007). Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: full text: The Task Force on
Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for
the Study of Diabetes (EASD). European Heart Journal Supplements, 9(Suppl C), pp.C3–C74.
11. Aspirin efficacy and safety in primary prevention of MACE in patients with
diabetes is controversial
The optimal dosage of aspirin for prevention of CHD events is also controversial
(Butalia et al. 2011)
• risk reduction achieved with low dosages (75 to 162 mg per day) similar
to that obtained with higher dosages
• ASPECT study found a stronger dose-dependency of platelet function
among patients with diabetes, suggesting the need for need higher
doses of aspirin (Gurbel et al., 2007).
• Aspirin resistance (1%-27%)(Schrör K. 2010)
• Platelet hyperreactivity (“residual platelet activity”) (i.e. diabetes, atherosclerosis)
• Platelet stimulation by aspirin-insensitive mechanisms (ADP, shear stress)
• COX-2-dependent (platelet-mediated) thromboxane formation (i.e. ,
atherosclerosis)
• Platelet sensitisation by isoprostanes (i.e. diabetes)
• COX-1 gene polymorphisms (A842G / C50T)
• Impaired sensitivity of platelet COX-1 (CABG)
• Insufficient bioavailability (low-dose enteric- coated preparations)
• Prevention of access to binding sites inside the COX-1 channel by NSAIDs
Butalia et al., (2011). Aspirin effect on the incidence of major adverse cardiovascular events in patients with diabetes mellitus: a
systematic review and meta-analysis. Cardiovascular diabetology, 10(1), p.25.
Gurbel et al., (2007) Evaluation of dose-related effects of aspirin on platelet function: results from the Aspirin-Induced Platelet Effect
(ASPECT) study. Circulation 2007;115:3156–64.
Schrör K. (2010). What is aspirin resistance? The British Journal of Cardiology, 17 (Suppl 1), pp.S8–S9.
12. Evidence from trials conducted in patients with diabetes without CVD suggests that
aspirin therapy in primary prevention is associated at most with a non-significant
decrease in the risk of CHD events and stroke
• Japanese Primary Prevention of Atherosclerosis With Aspirin for Diabetes study (JPAD 2008)(Ogawa et al.
2008)(diabetes patients only)
• Prevention of Progression of Arterial Disease and Diabetes trial (POPADAD 2008) (Belch et al. 2008)
(diabetes patients only)
• Early Treatment of Diabetic Retinopathy Study (ETDRS 1992) (Butalia et al. 2011)
• Aspirin for Asymptomatic Atherosclerosis (AAA)
• Primary Prevention Project (PPP 2003) (diabetes subgroup) (Sacco et al., 2003)
• Physician Health Study (PHS 1989) (diabetes subgroup) (***, 1989)
• Womens’ Health Study (WHS 2005) (diabetes subgroup )(Ridker et al., 2005)
Ogawa, H. et al., (2008). Low-dose aspirin for primary prevention of atherosclerotic events in patients with type 2 diabetes: a randomized controlled
trial. JAMA : the journal of the American Medical Association, 300(18), pp.2134–41
Belch, J. et al., (2008). The prevention of progression of arterial disease and diabetes (POPADAD) trial: factorial randomised placebo controlled trial of
aspirin and antioxidants in patients with diabetes and asymptomatic peripheral arterial disease. BMJ (Clinical research ed.), 337(oct16_2), p.a1840.
Butalia, S. et al., (2011). Aspirin effect on the incidence of major adverse cardiovascular events in patients with diabetes mellitus: a systematic review
and meta-analysis. Cardiovascular diabetology, 10(1), p.25.
Sacco et al.,( 2003) A Primary prevention of cardiovascular events with low-dose aspirin and vitamin E in type 2 diabetic patients: results of the
Primary Prevention Project (PPP) trial. Diabetes Care 2003;26:3264-72
***,( 1989) Final report on the aspirin component of the ongoing Physicians’ Health Study. Steering Committee of the Physicians’ Health Study Research
Group. N Engl J Med 1989;321:129-35
Ridker et al., (2005) NEJM 2005;352:1293-304
13.
14. Belch J et al.,2008; for Prevention of Progression of Arterial Disease and Diabetes Study Group. BMJ.337;
15. 2 major ongoing trials collectively enrolling over 15,000 participants are evaluating the role of aspirin (100mg daily)
in patients with diabetes without cardiovascular disease:
• Aspirin and Simvastatin Combination for Cardiovascular Events Prevention Trial in Diabetes
(ACCEPT-D) (De Berardis et al.2007 )
• A Study of Cardiovascular Events in Diabetes (ASCEND)
De Berardis G, Sacco M, Evangelista V, the ACCEPT-D Study Group, et al: Aspirin and simvastatin combination for cardiovascular
events prevention trial in diabetes (ACCEPT-D): design of a randomized study of the efficacy of low-dose aspirin in the prevention of
cardiovascular events in subject with diabetes mellitus treated with statins. Trials 2007, 8:21-29.
16. Current recommendations regarding aspirin therapy in primary
prevention of CVD in patients with diabetes:
The International Diabetes Federation (IDF) 2012 recommends the use of
low dose aspirin along with lifestyle modification only in diabetes patients who
have had a previous CVD event (IDF 2012). No recommendations for primary
prevention.
The European Society of Cardiology (ESC) and the European Association
for the Study of Diabetes (EASD) do not recommend primary prevention with
aspirin in patients with diabetes, considering the evidence supporting the safety,
efficacy and net benefits of aspirin inconclusive (Rydén et al. 2013).
NICE type 2 diabetes guidelines recommend primary prevention with
75 mg/day aspirin in patients aged 50 years or older if their blood pressure is
below 145/90 mm/Hg and in patients younger than 50 who have another
significant cardiovascular risk factor (NICE-CG87 2009).
17. The JBS2 guidelines recommend daily 75 mg aspirin in selected people with
diabetes (> 50 years, or who are younger but have had the disease for more than 10
years, or who are already receiving treatment for hypertension), once the blood
pressure has been controlled to at least the audit standard of <150mm Hg systolic
and <90 mm Hg diastolic (JBS 2 2005).
The American Diabetes Association (ADA) 2014 guidelines for the management of
diabetes recommend the use of a statin in combination with aspirin in diabetes
patients with overt CVD to reduce the risk of a CV event (ADA 2014). No
recommendations for primary prevention.
The Standards of Medical Care in diabetes (2014) recommend aspirin therapy
(75–162 mg/ day) as primary prevention strategy in diabetes patients at increased
cardiovascular risk (10-year risk >10%). This includes most men aged >50 years or
women aged >60 years who have at least one additional major risk factor (family
history of CVD, hypertension, smoking, dyslipidemia, or albuminuria) (American Diabetes
Association 2014)
18. The American Heart Association (AHA), American Stroke Association (ASA) and an
expert consensus document of the American College of Cardiology Foundation
recommend
1. Low-dose (75–162 mg/day) aspirin for primary prevention in adults with diabetes
and no previous history of vascular disease who are at high CVD risk (10 year risk of
CVD events over 10%) and who are not at increased risk for bleeding. This include
most men over age 50 years and women over age 60 years who have one or more of
the following additional major risk factors: smoking, hypertension, dyslipidemia,
family history of premature CVD, and albuminuria.
2. Aspirin should not be recommended for CVD prevention for adults with diabetes at
low CVD risk (men under age 50 years and women under 60 years with no major
additional CVD risk factors; 10-year CVD risk under 5%).
3. Low-dose (75–162 mg/day) aspirin use for prevention might be considered for
those with diabetes at intermediate CVD risk (younger patients with one or more risk
factors, or older patients with no risk factors, or patients with 10-year CVD risk of 5–
10%) until further research is available (Pignone et al. 2010) (Goldstein et al. 2011) .
19. Conclusions
Cardiovascular disease is a major cause of morbidity and mortality in individuals with
diabetes
Periodic assessment of cardiovascular risk is a key step in the clinical judgment process
for recommending aspirin therapy
The benefits of aspirin in the secondary prevention of MACE in patients with diabetes
are well established
Aspirin use in primary prevention of MACE in patients with diabetes is still controversial
but ongoing trial results are awaited
In selected individuals with diabetes and high risk for CV events assessed by
cardiovascular risk calculators low dose aspirin can be effective in preventing CV
events, especially nonfatal ones. Because the potential benefits of aspirin therapy are
offset by clinically relevant bleeding events, routine use of aspirin for primary prevention
is not warranted and treatment decisions should be considered on an individual case
Future longer-term studies should aim to assess the impact of low- dose, alternate-day
aspirin treatment on both vascular and nonvascular outcomes, especially in specific sub-groups
of individuals and within diverse populations
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Editor's Notes
The Japanese Primary Prevention of Atherosclerosis With Aspirin for Diabetes (JPAD) trial sought to examine the efficacy of low-dose aspirin for the primary prevention of cardiovascular (CV) events among subjects with type 2 diabetes.
Subjects (n=2,359) were randomized to low-dose aspirin (81 or 100 mg qd) or nonaspirin. Median follow-up time was 4.37 years.
There was no significant difference in incidence of the primary endpoint (cardiovascular disease composite) in the aspirin vs nonaspirin groups (68 events, 5.4% vs 86 events, 6.7%, respectively; hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.58–1.10; log-rank test, P=0.16).
The only significant between-group difference in CV events was in the combined endpoint of fatal coronary events and fatal cerebrovascular events (1 subject in the aspirin group vs 10 subjects in the nonaspirin group, HR, 0.10; 95% CI, 0.01–0.79; P=0.0037).
Aspirin was well tolerated, with very few adverse effects (4 GI bleeding episodes requiring transfusion, no hemorrhagic death, no increase in hemorrhagic stroke).
The authors noted that interpretation of the results is challenging, due to the overall low event rates observed among study subjects. They also stated that the findings should be interpreted in context with the low incidence of atherosclerotic disease seen among Japanese subjects.
Ogawa H, Nakayama M, Morimoto T, et al; Japanese Primary Prevention of Atherosclerosis With Aspirin for Diabetes (JPAD) Trial Investigators. Low-dose aspirin for primary prevention of atherosclerotic events in patients with type 2 diabetes: a randomized controlled trial. JAMA. 2008;300(18):2134-2141.
Evidence has established that the use of antiplatelet agents is known to reduce secondary cardiovascular events in patients with both diabetes and cardiovascular disease—and in patients with peripheral arterial disease (PAD). However, little data are available on the primary prevention effect of aspirin in patients with diabetes. The Prevention Of Progression of Arterial Disease And Diabetes (POPADAD) trial, whose setting was 16 hospitals in Scotland, examined the efficacy and safety of aspirin plus antioxidant compared with aspirin alone, antioxidant alone, and placebo in patients with type 1 or type 2 diabetes and asymptomatic PAD.
The 1,276 participants were adults =40 years of age whose PAD was based on a lower than normal (=0.99) ankle brachial index (ABI); they had no symptomatic cardiovascular disease.
These interventions were utilized daily in this multicenter, randomized, double-blind, placebo-controlled trial: aspirin (100 mg) plus antioxidant capsule (n=320), aspirin plus placebo (n=318), placebo plus antioxidant capsule (n=320), placebo plus placebo (n=318). There were two hierarchical composite primary endpoints: death from coronary heart disease (CHD) or stroke, non-fatal myocardial infarction or stroke, or above-ankle amputation for critical limb ischemia; and death from CHD or stroke.
Shown in this figure are the cumulative percentages of patients in the aspirin groups over time who experienced each primary endpoint. The differences between these two groups were not statistically significant for either of the endpoints:
A total of the 116 of 638 composite events occurred in the aspirin groups, compared with 117 of 640 in the no-aspirin groups (18.2% vs 18.3%; HR, hazard ratio 0.98; 95% CI, 0.76-1.26; P=0.86).
Forty-three deaths from CHD or stroke occurred in the aspirin groups, compared with 35 in the no-aspirin groups (6.7% vs 5.5%; HR, 1.23; 95% CI, 0.79-1.93; P=0.36).
Researchers concluded that these trial results do not provide evidence to support the use of aspirin in the primary prevention of cardiovascular events and mortality in patients with diabetes. They caution, however, that aspirin should still be given for secondary prevention of cardiovascular disease in this population, as supported in the evidence.
Belch J et al; for Prevention of Progression of Arterial Disease and Diabetes Study Group. BMJ. 2008;337;
This meta-analysis of seven randomized clinical trials, combining data from 11,618 participants, indicates that aspirin therapy in patients with diabetes leads to a 9% relative reduction in the risk of major adverse cardiovascular events (MACE),