Aspirin for the Masses

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91JACC Vol. 54, No. 1, 2009 CorrespondenceJune 30, 2009:90–2

ptimize the management of patients with non–ST-segment acuteoronary syndromes who require coronary artery bypass grafting.

effrey S. Berger, MD, MSarla B. Frye, PharmDing Harshaw, MD, PhD

red H. Edwards, MDteven R. Steinhubl, MD

Richard C. Becker, MD

Duke University Medical Center400 Pratt Streeturham, North Carolina 27705-mail: richard.becker@duke.edu

doi:10.1016/j.jacc.2009.03.041

EFERENCES

. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction: a report of the American College ofCardiology/American Heart Association Task Force on PracticeGuidelines (Writing Committee to Revise the 2002 Guidelines for theManagement of Patients With Unstable Angina/Non–ST-ElevationMyocardial Infarction). J Am Coll Cardiol 2007;50:e1–157.

. Fox KAA, Mehta SR, Peters R, et al. Benefits and risks of thecombination of clopidogrel and aspirin in patients undergoing surgicalrevascularization for non–ST-elevation acute coronary syndrome: theClopidogrel in Unstable angina to prevent Recurrent ischemic Events(CURE) trial. Circulation 2004;110:1202–8.

. Berger JS, Frye CB, Harshaw Q, et al. Impact of clopidogrel in patientswith acute coronary syndromes requiring coronary artery bypass surgery:a multicenter analysis. J Am Coll Cardiol 2008;52:1693–701.

. Mehta RH, Chen AY, Pollack JCV, et al. Challenges in predicting theneed for coronary artery bypass grafting at presentation in patients withnon–ST-segment elevation acute coronary syndromes. Am J Cardiol2006;98:624–7.

. Chew DP, Mahaffey KW, White HD, et al. Coronary artery bypasssurgery in patients with acute coronary syndromes is difficult to predict.Am Heart J 2008;155:841–7.

. Kim JH, Newby LK, Clare RM, et al. Clopidogrel use and bleedingafter coronary artery bypass graft surgery. Am Heart J 2008;156:886 –92.

. Welsby IJ, Podgoreanu MV, Phillips-Bute B, et al. Genetic factorscontribute to bleeding after cardiac surgery. J Thromb Haemost2005;3:1206–12.

spirin for the Masseshe recent article by Joshi et al. (1) stressed the need for aonphysician workforce in cardiovascular disease (CVD) manage-ent in low- and middle-income countries. We believe that there

s a need to go one step further, considering the exigency of theituation. The use of aspirin for primary prevention is wellstablished and must be added to this approach at a communityevel. The combination of nonphysician health care workersNPHWs) equipped with aspirin can potentially be a very effectivetrategy. Aspirin is a drug of common social acceptance ineveloping countries, is often readily available over the counter,nd is easily affordable because most payments are out of pocket.tatins and diuretics unfortunately do not share these attributes, at

east at present.A program should be developed to teach the NPHWs the

dministration of aspirin along with lifestyle modification after the b

dentification of high-risk patients. This will not be easy, and a riskssessment tool would need to incorporate the risk of bleeding withspirin. Routine availability of cholesterol and glucose evaluation athe community level will remain elusive for years to come, andlinical criteria and clinical risk prediction models will have to beelied upon. The use of a national cholesterol average as aubstitute is a decent suggestion in these calculations (2). The

orld Health Organization CVD risk management package haseen successfully practiced by NPHWs (3) and can be useful inhis regard.

Compliance, however, will still be the fundamental problem.here is evidence to suggest that although interventions result in

mproved knowledge, they do not necessarily translate into practice4). There is anecdotal evidence to suggest that people in theseettings do not comply with medicines for which they see no overtenefits. This necessitates that vessels of established trust be used,here available, to spread prevention and proven interventionand-in-hand to the current epidemic of CVD in developingountries.

There are many examples of effective health care delivery byPHWs in developing world settings, such as the success of the

ntegrated Management of Childhood Illness program on annternational scale and the Lady Health Visitor program for femaleealth care in Pakistan (4). The latter can also serve to address theender inequity of health care access more effectively because of itsarge network, penetration, and reputation.

Fawad Aslam, MDbdul Waheed, MD

Baylor College of Medicineouston, Texas 77030-mail: fawadaslam2@gmail.com

doi:10.1016/j.jacc.2008.12.081

EFERENCES

. Joshi R, Jan S, Wu Y, MacMahon S. Global inequalities in cardiovas-cular health care. J Am Coll Cardiol 2008;52:1817–25.

. Mendis S. Cardiovascular risk assessment and management in devel-oping countries. Vasc Health Risk Manag 2005;1:15–8.

. Abegunde DO, Shengelia B, Luyten A, et al. Can non-physicianhealth-care worker assess and manage cardiovascular risk in primarycare? Bull World Health Organ 2007;85:532–40.

. Nishtar S, Badar A, Kamal MU, et al. The Heartfile Lodhran CVDprevention project—end of project evaluation. Promot Educ 2007;15:17–27.

eply

e thank Drs. Aslam and Waheed for their comments on ourecent paper (1). They raise an important issue regarding the rolef nonphysician health care workers in the identification ofndividuals at high risk of cardiovascular disease, such as those with

history of myocardial infarction or ischemic stroke, and theiranagement in the community with low-cost drugs such as

spirin. We agree that nonphysician health care workersNPHWs) should be able to prescribe aspirin for secondaryrevention, but we also believe that they should be able to prescribether low-cost, low-risk, high-benefit treatments both for second-ry prevention (e.g., blood pressure- and lipid-lowering drugs) andor cardiovascular symptom management (e.g., nitrates, beta-