Men and women with diabetes are 2 to 4 times more likelythan other persons to die of complications of cardiovasculardisease (CVD). Solid evidence from primary andsecondary prevention trials has prompted the AmericanDiabetes Association to recommend low-dose aspirin therapyfor patients with diabetes who either have or are athigh risk for CVD (Table).
Men and women with diabetes are 2 to 4 times more likelythan other persons to die of complications of cardiovasculardisease (CVD). Solid evidence from primary andsecondary prevention trials has prompted the AmericanDiabetes Association to recommend low-dose aspirin therapyfor patients with diabetes who either have or are athigh risk for CVD (Table).1THE EVIDENCE BEHIND ASPIRINPrimary prevention. Low-dose aspirin therapy(325 mg every other day) reduced the risk of cardiovascularevents in men by 44% in the US Physicians' HealthStudy. A subgroup of patients with diabetes experienced a6% decrease in the incidence of myocardial infarction.1Secondary prevention. In the Anti-Platelet Trialists'(APT) meta-analysis, secondary vascular events were reducedby 25% among patients with diabetes who receivedlow-dose aspirin therapy. The Early Treatment DiabeticRetinopathy Study (ETDRS) demonstrated that aspirin significantlylowered the relative risk of myocardial infarctionto 0.72 (CI, 0.55 to 0.95) in patients with either type 1 ortype 2 diabetes. Myocardial infarction and other cardiovascularevents were reduced by 36% and 15%, respectively, inpatients with hypertension in the Hypertension OptimalTreatment (HOT) Trial; this study includedpersons with diabetes.2SAFETY OF ASPIRINThe major risks of aspirin therapyare gastric mucosal injury and GIhemorrhage. However, these adverseeffects are dose-related. When lowdoses (75 to 325 mg/d) of entericcoatedaspirin are used, the incidenceof these risks is comparable to thatassociated with placebo. Low-doseaspirin may predispose patients tominor bleeding events, such as epistaxisor bruising.The ETDRS showed that aspirintherapy did not increase the risk ofretinal or vitreous hemorrhage; moreover,it had no effect on the progressionof diabetic retinopathy andmaculopathy. Low-dose aspirin doesnot significantly impair renal functionor blood pressure control in patientswith hypertension.
Aspirin reduces the effectiveness of angiotensin-convertingenzyme inhibitors in patients with establishedCVD.3 Consider an alternative antiplatelet agent for thesepatients.RECOMMENDATIONS FOR PRACTICE
REFERENCES:1. Colwell JA. Aspirin therapy in diabetes. Diabetes Care. 2003;26(suppl 1):S87-S88.
2. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive bloodpressurelowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomized trial. Lancet.1998;351:1755-1762.
3. Peterson JG, Topol EJ, Sapp SK, et al. Evaluation of the effects of aspirin combinedwith angiotensin-converting enzyme inhibitors in patients with coronary artery disease. Am J Med. 2000;109:371-377.
4. CAPRIE Steering Committee. A randomised, blinded trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet. 1996;348:1329-1339.