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1.
Regarding the use of aspirin for CVD primary prevention, randomized clinical trials suggest the risks of bleeding outweigh the health benefits. [339, 340, 341, 342, 343, 344, 345, 346, 93] The benefits of aspirin for primary prevention in patients with diabetes mellitus may be counterbalanced by bleeding hazard. [347, 348] Aspirin may be beneficial in primary prevention for select patients at high risk for CVD and who are at low risk for bleeding, but only after a patient-centered evaluation and discussion. [349, 191, 350] Coronary artery calcium (CAC) assessment can help inform the clinical use of aspirin in primary prevention, with those having a CAC score of ≥ 100 Agatston Units (AU) having a favorable risk/benefit estimation from the use of aspirin, while those with zero CAC are estimated to have net harm from aspirin. [351, 352, 353]
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2.
The standard of care for managing thrombotic risk in secondary prevention (i.e., preventing recurrent ischemic events after an acute coronary syndrome and to prevent stent thrombosis after percutaneous coronary intervention) includes DAPT. DAPT is typically defined as aspirin plus the use of a P2Y12 receptor inhibitor (e.g., clopidogrel, ticagrelor, or prasugrel). [354]
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3.
Aspirin is the first antithrombotic drug of choice in secondary prevention after a myocardial infarction and should be continued indefinitely unless contraindicated or adverse experiences occur. [355] Aspirin coated preparations may reduce gastrointestinal bleeding. The coated aspirin dose of 100 mg per day may help reduce CVD, death (and cancer), with lower doses being better tolerated (i.e., less bleeding) and higher doses having greater CVD risk reduction. [356] Aspirin doses of 75 – 100 mg per day may offer the optimal benefit/risk ratio in chronic prevention of recurrent atherothrombosis in patients with an acute coronary syndrome [355] (i.e., 81 mg “baby aspirin”). [331]
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4.
Acutely, aspirin is beneficial in patients with unstable coronary artery disease, acute myocardial infarction, and unstable angina.[357, 358, 359] Aspirin platelet inhibition is fastest with chewable aspirin, which has a more rapid onset of action than soluble aspirin, which has a more rapid onset of action than whole solid aspirin, which has a more rapid onset of action than enteric-coated aspirin. [360] After calling 9-1-1 for emergency phone help, patients undergoing an acute myocardial infarction are often advised to chew one 325 mg aspirin slowly, preferably within 30 minutes of the onset of symptoms. [361] Chronic administration of aspirin is recommended to prevent recurrent ischemic stroke. Administration of aspirin is NOT recommended for acute stroke, due to the potential of worsening of a hemorrhagic stroke. [361, 362]
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5.
In patients experiencing an acute coronary syndrome, unless side effects occur or contraindications exist, DAPT should be continued for at least 12 months after the CVD event, regardless of stent implantation. After a patient-centered discussion, DAPT for longer than 12 months may be considered if the net potential benefit if thought to outweigh the potential risk (i.e., bleeding). [363] Conversely, shorter duration DAPT may be reasonable for patients at high bleeding risk. [364, 365]
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6.
The “5 A's” framework (as adapted for other CVD risk factor management, such as counseling for obesity [366]) can help engage patients in a discussion about smoking cessation. The 5 A's include: (a) Ask patients about tobacco use; (b) Advise smokers to quit tobacco; (c) Assess a smoker's readiness to quit; (d) Assist smokers to quit; (e) Arrange follow-up. [366, 367, 368]
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7.
To reduce the risk of thrombosis, CVD, cancer, and other ill effects of tobacco cigarette smoking, [93] patients who smoke cigarettes may benefit from a Ask, Advise, and Refer (AAR) approach to a behavioral support program. Referral program utilization is enhanced with patient agreement to be contacted (Ask, Advise, and Contact or AAC) for a behavior support appointment, as opposed to simply being referred. [369] If upon initial patient-centered discussions, the patient declines referral for behavior support, then this offer should be repeated on subsequent clinician encounters, as the willingness of the patient to quit smoking may change over time.
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8.
Antismoking pharmacotherapy can act synergistically with behavior therapy and enhance the chances the patient will stop cigarette smoking. FDA approved anti-smoking medications include nicotine patch, lozenge, gum, inhaler, nasal spray, varenicline, and bupropion. Many of these medications can be used in combination. Clinicians should be aware of the dosing, precautions, and inform the patient of potential side effects of these therapies. [370, 371]
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9.
The aerosol from e-cigarettes typically does not contain all the contaminants in tobacco smoke. Short-term use of e-cigarettes in healthy individuals may not adversely affect vascular function. [372, 330] However, most e-cigarettes contain nicotine, which is highly addictive and likely increases the long-term risk of CVD. Also, some analyses suggest use of e-cigarettes may not be effective regarding success in stopping smoking or to prevent relapse of smoking. [373]
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10.
While potentially safer than traditional tobacco cigarettes, the Centers for Disease Control (CDC) and Food and Drug Administration recommend that tetrahydrocannabinol (THC)-containing and/or nicotine-containing e-cigarettes should not be used by youths and young adults, females who are pregnant, or adults who do not currently use tobacco products. [335] Those choosing to use e-cigarettes as an alternative to cigarettes should completely switch from cigarettes to e-cigarettes, and not use both products concomitantly. [335] While reasonable to use e-cigarettes as a part of a bridging smoking cessation strategy in certain populations, the data on such an approach remain unclear. [374] The FDA has not approved e-cigarettes as a smoking cessation aid, and more research is needed to better understand the long term health effects of e-cigarettes and their role in helping smokers to stop tobacco smoking. [375, 330]
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