Abstract 15: Frequency and Predictors of Inappropriate Aspirin Prescribing for Primary Prevention of Cardiovascular Disease: Insights from the NCDR® PINNACLE Registry.
Background: Aspirin use is recommended in patients with cardiovascular disease (CVD) for secondary prevention. However, among men and women without CVD and low 10 year coronary heart disease (CHD) risk, aspirin use for primary prevention has not been shown to reduce CVD death or all-cause death. In low risk patients, the risks of gastrointestinal bleeding and hemorrhagic strokes associated with aspirin use outweigh any potential atheroprotective benefit. As per the American Heart Association (AHA) guidelines on Primary Prevention of CVD and Stroke in 2002 and U.S. Preventive Services Task Force (USPSTF) recommendations from 2009, use of aspirin is considered appropriate in patients with > 6% 10 year Framingham CHD risk and inappropriate in patients with 10 year risk < 6%. We studied the frequency and predictors of inappropriate aspirin prescribing for primary prevention in a large national registry.
Methods: Within the NCDR Practice Innovation and Clinical Excellence (PINNACLE) Registry, we identified 267,957 patients without CVD (coronary heart disease, peripheral arterial disease or ischemic stroke) or atrial fibrillation receiving aspirin for primary prevention. Of these, Framingham Risk Score (FRS) could be calculated in 68,808 patients. We assessed the frequency of inappropriate aspirin prescribing for primary prevention (aspirin prescribing in those with FRS <6%). Using hierarchical regression models, we also assessed the extent of practice-level variation using the median rate ratio (MRR). MRR is interpreted as the likelihood that 2 random practices would differ in treating identical patients with aspirin inappropriately.
Results: Inappropriate aspirin prescribing rate was 32.8 % (22601/68808) in the overall cohort. Mean FRS in the inappropriate aspirin group was 3.6 versus 16.2 in the appropriate group (p<0.001). Significant variation was noted between practices in the Northeast, Midwest, South and West with inappropriate aspirin prescribing rates ranging from 31.5% to 34.4% (p<0.0001). There was practice-level variation in inappropriate prescribing (range 17.9-52.4%, median rate 33.5%, interquartile range 28.6-37.7%) for practices; adjusted MRR 1.19 [95% CI 1.14 to 1.23]. Results remained consistent after excluding 14,097 patients with diabetes (inappropriate aspirin use rate = 38.2%, median rate 37.6%, interquartile range 32.5-43.8%; adjusted MRR 1.17 [95% CI 1.13- 1.21]).
Conclusion: Inappropriate aspirin prescribing occurs in approximately one third of patients receiving aspirin for primary prevention. There is modest but significant practice-level variation. Our findings identify opportunities to improve evidence-based aspirin prescribing in primary CVD prevention.
Author Disclosures: R.S. Hira: None. K.F. Kennedy: None. V. Nambi: None. H. Jneid: None. M. Alam: None. S.S. Basra: None. M. Ho: None. A. Deswal: None. C.M. Ballantyne: None. L.A. Petersen: None. S.S. Virani: None.
- © 2014 by American Heart Association, Inc.