This JAMA Clinical Guidelines Synopsis summarizes the American College of Cardiology and American Heart Association’s 2024 guidelines on management of lower extremity peripheral artery disease.
This JAMA Clinical Guidelines Synopsis summarizes the American College of Cardiology and American Heart Association’s 2024 guidelines on management of lower extremity peripheral artery disease.
EVIDENCE-BASED ANSWER:
NOT VERY WELL. IN ASYMPTOMATIC PATIENTS, CAROTID ARTERY CALCIFICATION SEEN ON RADIOGRAPH HAS A POSITIVE PREDICTIVE VALUE OF 70% AND A NEGATIVE PREDICTIVE VALUE OF 75% FOR CAROTID ARTERY STENOSIS (STRENGTH OF RECOMMENDATION [SOR]: B, SYSTEMATIC REVIEW OF OBSERVATIONAL STUDIES WITH HETEROGENEOUS RESULTS AND A RETROSPECTIVE COHORT STUDY). CAROTID CALCIFICATIONS ON RADIOGRAPHS MAY BE MORE PREDICTIVE OF CAROTID STENOSIS IN PEOPLE WITH ATHEROSCLEROTIC RISK FACTORS (SOR: C, CROSS-SECTIONAL STUDY). HARMS OUTWEIGH BENEFITS IN SCREENING FOR CAROTID ARTERY STENOSIS IN ASYMPTOMATIC ADULTS (SOR: B, MULTIPLE COHORT STUDIES); THEREFORE, INCIDENTAL RADIOGRAPHIC CAROTID ARTERY CALCIFICATIONS IN ASYMPTOMATIC PATIENTS SHOULD NOT PROMPT FURTHER TESTING.
Background
Aspirin is often prescribed for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) however, recent randomized trials (RCTs) have challenged this practice. Despite this, aspirin is commonly recommended for high risk primary prevention. We tested the hypothesis that aspirin is more efficacious for the primary prevention of ASCVD, as the baseline risk increases.
Methods
RCTs that compared aspirin to control for primary prevention and evaluated ASCVD (composite of myocardial infarction and ischemic stroke) and major bleeding were included. Rate ratios (RR) and 95% confidence intervals (CI) were calculated. A regression analysis was performed using the ASCVD event rate in the control arm of each RCT as the moderator.
Results
Twelve RCTs were identified with 963,829 patient years of follow-up. Aspirin was associated with a reduction in ASCVD (4.7 versus 5.3 events per 1,000 patient years; RR 0.86; 95% CI 0.79-0.92). There was increased major bleeding among aspirin users (2.5 versus 1.8 events per 1000 patient years, RR 1.41 95% CI, 1.29-1.54). Regression analysis found no relationship between the log rate ratio of ASCVD or major bleeding and incidence of ASCVD in the control arm of each RCT.
Conclusion
Aspirin is associated with a reduction in ASCVD when used for primary prevention; however, it is unlikely to be clinically significant given the increase in bleeding. More importantly, aspirin's treatment effect does not increase as ASCVD risk increases as many hypothesize. There is no suggestion from this data that use of aspirin for higher risk primary prevention patients is beneficial.
OBJECTIVE:
To evaluate and compare the efficacy of long-term use of low-dose aspirin for the prevention of dementia in men and women.
RESEARCH DESIGN AND METHODS:
This study is a follow-up cohort study of the Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes (JPAD) trial, which was a randomized, open-label, standard care-controlled trial examining the effects of low-dose aspirin on cardiovascular events. We followed up 2,536 Japanese patients with type 2 diabetes (T2D) enrolled in the JPAD trial from 2002 to 2017. The primary outcome of this post hoc analysis was the incidence of dementia, which was defined by the prescription of antidementia drugs or admission due to dementia.
RESULTS:
Among the originally enrolled patients, 2,121 (84%) retained their original allocation. During a median follow-up of 11.4 years, 128 patients developed dementia. The overall effect of low-dose aspirin on the prevention of dementia adjusted for age, sex, and other established risk factors was not significant (hazard ratio [HR] 0.82, 95% CI 0.58-1.16). However, a significant reduction was seen in the risk of dementia in women (HR 0.58, 95% CI 0.36-0.95), but not in men (HR 1.27, 95% CI 0.75-2.13) (P interaction = 0.03).
CONCLUSIONS:
Long-term use of low-dose aspirin may reduce the risk for dementia in women with T2D.
Description:
In November 2018, the American Heart Association and American College of Cardiology (AHA/ACC) released a new clinical practice guideline on cholesterol management. It was accompanied by a risk assessment report on primary prevention of atherosclerotic cardiovascular disease (ASCVD).
Methods:
A panel of experts free of recent and relevant industry-related conflicts was chosen to carry out systematic reviews and meta-analyses of randomized controlled trials (RCTs) that examined cardiovascular outcomes. High-quality observational studies were used for estimation of ASCVD risk. An independent panel systematically reviewed RCT evidence about the benefits and risks of adding nonstatin medications to statin therapy compared with receiving statin therapy alone in persons who have or are at high risk for ASCVD.
Recommendation:
The guideline endorses a heart-healthy lifestyle beginning in childhood to reduce lifetime risk for ASCVD. It contains several new features compared with the 2013 guideline. For secondary prevention, patients at very high risk may be candidates for adding nonstatin medications (ezetimibe or proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors) to statin therapy. In primary prevention, a clinician–patient risk discussion is still strongly recommended before a decision is made about statin treatment. The AHA/ACC risk calculator first triages patients into 4 risk categories. Those at intermediate risk deserve a focused clinician–patient discussion before initiation of statin therapy. Among intermediate-risk patients, identification of risk-enhancing factors and coronary artery calcium testing can assist in the decision to use a statin. Compared with the 2013 guideline, the new guideline gives more attention to percentage reduction in low-density lipoprotein cholesterol as a treatment goal and to long-term monitoring of therapeutic efficacy. To simplify monitoring, nonfasting lipid measurements are allowed.
