1
optimize the management of patients with non–ST-segment acute coronary syndromes who require coronary artery bypass grafting. Jeffrey S. Berger, MD, MS Carla B. Frye, PharmD Qing Harshaw, MD, PhD Fred H. Edwards, MD Steven R. Steinhubl, MD *Richard C. Becker, MD *Duke University Medical Center 2400 Pratt Street Durham, North Carolina 27705 E-mail: [email protected] doi:10.1016/j.jacc.2009.03.041 REFERENCES 1. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non– ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction). J Am Coll Cardiol 2007;50:e1–157. 2. Fox KAA, Mehta SR, Peters R, et al. Benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularization for non–ST-elevation acute coronary syndrome: the Clopidogrel in Unstable angina to prevent Recurrent ischemic Events (CURE) trial. Circulation 2004;110:1202– 8. 3. Berger JS, Frye CB, Harshaw Q, et al. Impact of clopidogrel in patients with acute coronary syndromes requiring coronary artery bypass surgery: a multicenter analysis. J Am Coll Cardiol 2008;52:1693–701. 4. Mehta RH, Chen AY, Pollack JCV, et al. Challenges in predicting the need for coronary artery bypass grafting at presentation in patients with non–ST-segment elevation acute coronary syndromes. Am J Cardiol 2006;98:624 –7. 5. Chew DP, Mahaffey KW, White HD, et al. Coronary artery bypass surgery in patients with acute coronary syndromes is difficult to predict. Am Heart J 2008;155:841–7. 6. Kim JH, Newby LK, Clare RM, et al. Clopidogrel use and bleeding after coronary artery bypass graft surgery. Am Heart J 2008;156: 886 –92. 7. Welsby IJ, Podgoreanu MV, Phillips-Bute B, et al. Genetic factors contribute to bleeding after cardiac surgery. J Thromb Haemost 2005;3:1206 –12. Aspirin for the Masses The recent article by Joshi et al. (1) stressed the need for a nonphysician workforce in cardiovascular disease (CVD) manage- ment in low- and middle-income countries. We believe that there is a need to go one step further, considering the exigency of the situation. The use of aspirin for primary prevention is well established and must be added to this approach at a community level. The combination of nonphysician health care workers (NPHWs) equipped with aspirin can potentially be a very effective strategy. Aspirin is a drug of common social acceptance in developing countries, is often readily available over the counter, and is easily affordable because most payments are out of pocket. Statins and diuretics unfortunately do not share these attributes, at least at present. A program should be developed to teach the NPHWs the administration of aspirin along with lifestyle modification after the identification of high-risk patients. This will not be easy, and a risk assessment tool would need to incorporate the risk of bleeding with aspirin. Routine availability of cholesterol and glucose evaluation at the community level will remain elusive for years to come, and clinical criteria and clinical risk prediction models will have to be relied upon. The use of a national cholesterol average as a substitute is a decent suggestion in these calculations (2). The World Health Organization CVD risk management package has been successfully practiced by NPHWs (3) and can be useful in this regard. Compliance, however, will still be the fundamental problem. There is evidence to suggest that although interventions result in improved knowledge, they do not necessarily translate into practice (4). There is anecdotal evidence to suggest that people in these settings do not comply with medicines for which they see no overt benefits. This necessitates that vessels of established trust be used, where available, to spread prevention and proven intervention hand-in-hand to the current epidemic of CVD in developing countries. There are many examples of effective health care delivery by NPHWs in developing world settings, such as the success of the Integrated Management of Childhood Illness program on an international scale and the Lady Health Visitor program for female health care in Pakistan (4). The latter can also serve to address the gender inequity of health care access more effectively because of its large network, penetration, and reputation. *Fawad Aslam, MD Abdul Waheed, MD *Baylor College of Medicine Houston, Texas 77030 E-mail: [email protected] doi:10.1016/j.jacc.2008.12.081 REFERENCES 1. Joshi R, Jan S, Wu Y, MacMahon S. Global inequalities in cardiovas- cular health care. J Am Coll Cardiol 2008;52:1817–25. 2. Mendis S. Cardiovascular risk assessment and management in devel- oping countries. Vasc Health Risk Manag 2005;1:15– 8. 3. Abegunde DO, Shengelia B, Luyten A, et al. Can non-physician health-care worker assess and manage cardiovascular risk in primary care? Bull World Health Organ 2007;85:532– 40. 4. Nishtar S, Badar A, Kamal MU, et al. The Heartfile Lodhran CVD prevention project— end of project evaluation. Promot Educ 2007;15: 17–27. Reply We thank Drs. Aslam and Waheed for their comments on our recent paper (1). They raise an important issue regarding the role of nonphysician health care workers in the identification of individuals at high risk of cardiovascular disease, such as those with a history of myocardial infarction or ischemic stroke, and their management in the community with low-cost drugs such as aspirin. We agree that nonphysician health care workers (NPHWs) should be able to prescribe aspirin for secondary prevention, but we also believe that they should be able to prescribe other low-cost, low-risk, high-benefit treatments both for second- ary prevention (e.g., blood pressure- and lipid-lowering drugs) and for cardiovascular symptom management (e.g., nitrates, beta- blockers) (2). Low-dose combination therapy for secondary pre- 91 JACC Vol. 54, No. 1, 2009 Correspondence June 30, 2009:90 –2

Aspirin for the Masses

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Page 1: 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: [email protected]

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: [email protected]

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-

lockers) (2). Low-dose combination therapy for secondary pre-