Lack of Aspirin Before Angioplasty Linked to
Significantly Higher Death Rate
Failure to follow basic aspirin protocol raises
questions about medical staff adherence to other guidelines
7, 2013 - Despite recommendations from leading medical groups, a
surprising number of patients are not given aspirin before
artery-clearing coronary angioplasty and stenting, and those patients
have a significantly higher in-hospital death rate, according to
research from a Michigan network being presented at the American College
of Cardiology's 62nd Annual Scientific Session.
Aspirin use before angioplasty is a Class I
recommendation of the American College of Cardiology and American Heart
Association, the highest level of evidence for ACC/AHA guidelines.
Aspirin has well-documented anti-platelet activity in reducing the risk
of cardiac events.
Researchers evaluated registry data for 65,175
patients who had angioplasty and stenting, a percutaneous coronary
intervention or PCI, at one of 42 hospitals enrolled in the Blue Cross
Blue Shield of Michigan Cardiovascular Consortium PCI Quality
Improvement Initiative from January 2010 through December 2011.
Of these, 4,640 patients, or 7.1 percent, did not
receive aspirin as recommended within 24 hours before PCI. Roughly 90
percent of the non-aspirin patients had no documented barriers to
aspirin. Records did show that aspirin was withheld from some patients
who had a history of gastrointestinal bleeding, even though such a
history usually does not preclude pre-PCI aspirin.
"Our study is not designed to confirm a direct
causal effect of aspirin use on PCI outcomes, but [rather] to examine
any association with worse outcomes," said Mohamad Kenaan, MD, a
cardiovascular medicine fellow with University of Michigan Health
Systems, Ann Arbor, Mich., and the study's lead investigator.
it highlights an unexpectedly significant number of patients undergoing
PCI without receiving aspirin, despite the lack of a documented
contraindication in the majority of caseseven in institutions that are
active participants in an ongoing quality improvement initiative."
The in-hospital mortality rate of 3.9 percent for
the non-aspirin group was considerably higher than the aspirin group's
1.2 percent, and the disadvantage remained after adjustment for
confounding bias: death, 3.9 vs. 2.8 percent and stroke, 0.5 vs. 0.1
Those findings held across subgroups, including
gender, age, type of coronary artery disease presentation and diabetes.
The exception was cardiogenic shocka state that presents challenges for
use of oral medicines like aspirin. There was no difference between the
groups in bleeding, need for transfusions or kidney damage caused by
imaging contrast agent.
Additional data analysis will address other
subgroups, hospital length of stay and bleeding. The registry does not
contain post-discharge data for longer-term follow-up.
"The strong association our study demonstrated
between aspirin non-use before PCI and worse outcomes, including
in-hospital death, across all types of ischemic heart disease should be
used as a platform for more studies to confirm our findings and motivate
quality efforts focused on optimizing aspirin use before PCI," Dr.
"Our findings also may indicate lack of adherence to other
guidelines, thus leading to worse outcomes."
This research was funded by the Blue Cross Blue
Shield of Michigan Cardiovascular Consortium Percutaneous Coronary
Intervention Quality Improvement Initiative.
The ACC's Annual Scientific Session brings together
cardiologists and cardiovascular specialists from around the world each
year to share the newest discoveries in treatment and prevention. Follow
@ACCMediaCenter and #ACC13 for the latest news from the meeting.
The American College of Cardiology is a nonprofit
medical society comprised of 43,000 physicians, surgeons, nurses,
physician assistants, pharmacists and practice managers. The College is
dedicated to transforming cardiovascular care, improving heart health
and advancing quality improvement, patient-centered care, payment
innovation and professionalism. The ACC also leads the formulation of
important cardiovascular health policy, standards and guidelines. It
bestows credentials upon cardiovascular specialists, provides
professional education, supports and disseminates cardiovascular
research, and operates national registries to measure and promote
quality care. For more information, visit
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