中国2型糖尿病患者使用阿司匹林预防心脑血管事件的调查研究(CCMR-3B研究)

目的了解中国T2DM患者阿司匹林的使用情况。方法选取2010年8月至2011年3月在全国6个不同地区、104家不同级别医院就诊的T2DM患者25454例,根据既往病史将研究对象分为心脑血管事件一级预防组(n=19757)和二级预防组(n=5697)。按照中华医学会糖尿病学分会《中国2型糖尿病防治指南(2010版)》的推荐,计算各人群中阿司匹林的实际使用率。结果整体人群的阿司匹林使用率为18.78%。其中,推荐采用心脑血管事件一级预防人群的阿司匹林使用率为13.87%,需医师临床判断是否采用一级预防人群的阿司匹林使用率为11.19%;不推荐采用一级预防人群的阿司匹林使用率为6.43%。有心脑血管病史的二级预防人群的阿司匹林使用率为39.72%。结论阿司匹林在中国T2DM患者预防心脑血管事件中整体使用率偏低。     

从国内外指南更新看阿司匹林在心血管疾病一级预防中的作用

正阿司匹林问世已经整整120年,自阿司匹林防治心血管疾病的作用被发现,众多循证医学证据已经证实了阿司匹林在心血管疾病二级预防的基石地位。随着阿司匹林一级预防里程碑式研究——内科医师健康研究(physicians’health study)及众多随机双盲安慰剂对照研究的发布,阿司匹林成为降低心血管事件尤其是首次心肌梗死发生的有效药物,国内外指南相继推荐阿司匹林用于心血管风险增高人群的一     

《ADA／AHA／ACCF阿司匹林用于糖尿病人群心血管事件一级预防》指南解读（二）

ADA／AHA／ACCF指南对阿司匹林用于糖尿病患者心血管病一级预防的推荐如下： ①有理由在既往无心血管疾病史、且无出血危险性（根据既往胃肠道出血或消化道溃疡病史、或正在使用增加消化道出血风险的药物如NSAIDS或华法林）、心血管事件高危的糖尿病患者（10年心血管事件风险大于10％）,     

温州市部分社区老年人群阿司匹林使用情况调查

目的了解温州市区老年人群心脑血管病危险因素及阿司匹林使用情况。方法随机抽查温州市两个社区60岁以上人群233人,测量血压、体重指数(BMI),检验血脂、血糖等与心脑血管病相关的危险因素,调查阿司匹林使用情况。结果温州市区老年人群心脑血管病危险因素比例由高到低依次为血脂异常、高血压、2型糖尿病、肥胖。一级预防人群规律服用阿司匹林22例(13.9%),不规律服用阿司匹林8例(5.1%),未服用司阿匹林128例(81%)。二级预防人群规律服用阿司匹林13例(31.7%),不规律服用阿司匹林2例(4.9%),未服用阿司匹林26例(63.4%)。结论温州市社区老年人群心脑血管病危险因素众多,在社区缺血性心脑血管疾病的一、二级预防中,阿司匹林没有被正确及广泛使用。     

阿司匹林用于预防心血管疾病美国预防服务工作组推荐声明解读

低剂量阿司匹林是心血管疾病防治的基本用药。近年, 阿司匹林相关的出血等不良反应引起广泛关注。美国预防服务工作组基于最新系统证据审查, 通过模型决策分析, 在不同年龄、性别和心血管疾病风险分层的人群中评估阿司匹林用于心血管疾病和结直肠癌一级预防的利弊, 并更新了对阿司匹林一级预防的相关推荐:不推荐≥60岁的成年人启用低剂量阿司匹林进行心血管疾病一级预防, 对于10年心血管疾病风险≥10%的40～59岁成年人可根据个体情况并充分沟通后决定。本文旨在对阿司匹林用于预防心血管疾病最新美国预防服务工作组推荐声明进行解读。     

服用阿司匹林小心别“防卫过当”

阿司匹林是公认的能够降低高危人群（有心梗或卒中病史的人群）心血管疾病发病率和死亡率的抗血小板药物,不过它在低危人群中的基础预防作用却始终存在争议。美国糖尿病协会（ADA）公布的2010年糖尿病诊疗指南中有一个瞩目的变化——取消了阿司匹林在糖尿病患者心血管疾病低危人群中的应用。这一变化对于糖尿病患者意味着什么呢？患者应该如何使用阿司匹林才能获益最大而风险最小呢？有请北京大学人民医院心脏中心孙宁玲教授为广大读者一一解答。     

新建议认为低剂量阿司匹林会降低对心脏的益处

正颇具影响力的美国预防服务工作组(USPSTF)认为,年龄在50-59岁的人们每天服用低剂量阿司匹林预防心血管疾病,在未来10年里会有10%或更高的可能性出现心脏病发作或中风。除非是已经患有心血管疾病的人,每日服用阿司匹林预防心脏病发作和中风的实际数量是相对较小的。该草案建议不推荐年龄少于50岁或60岁或以上的人群使用阿司匹林,以证据不足为由提出上述     

2011AHA女性心血管疾病预防指南解读

1999年美国心脏病协会（AHA）第一次发表《女性心血管疾病预防建议》,于2007年发表《女性心血管疾病预防指南》（下称2007指南）,推动了全球对女性心血管疾病的关注。1999年以来,美国通过普及教育,提高了美国女性对心血管疾病的关注。美国女性的心血管疾病死亡率2007年较1997年下降了43％,其中一半获益来自女性心血管疾病二级预防,另一半获益来自对女性心血管病危险因素的干预。2011年AHA再次更新《女性心血管疾病预防指南》（下称2011指南）,该指南改进之处在于,不仅强调心血管危险因素干预对女性心血管健康获益的循证汪据,     

从有效成分和作用机制看血脂康的临床应用

血脂康是从籼米接种特制红曲菌,发酵、精制而成的天然调脂药物,含有天然复合他汀在内多种有效成分,多种成分协同作用,发挥调脂及抗动脉粥样硬化等多种心血管保护作用,是指南推荐的中等强度的降脂药物。除用于血脂异常的治疗外,也可用于高血压、糖尿病等患者的动脉粥样硬化性心血管疾病(ASCVD)一级预防及ASCVD患者的二级预防。     

从COMPASS糖尿病亚组分析看降低稳定动脉粥样硬化患者残余风险的新策略

正尽管采用了标准二级预防策略,每年仍有5%～10%心血管疾病患者再次发生心血管事件[1-3]。在美国心脏病学会2020年会上发表的COMPASS(Cardiovascular Outcomes for People Using Anticoagulation Strategies)糖尿病亚组分析显示,应用低剂量Xa因子抑制药利伐沙班联合阿司匹林(双路径抑制),可以降低稳定动脉粥样硬化(合并有或无糖尿病)患者主要不良心血管事件(major adverse cardiac event,MACE)发生率[4]。     

Antiplatelet strategy in primary and secondary prevention of cardiovascular disease in patients with type 2 diabetes mellitus: A perspective from the guideline appraisal

Aims/IntroductionTo appraise guidelines on the antiplatelet strategy of prevention of cardiovascular disease (CVD) in patients with type 2 diabetes mellitus, and highlight the consensuses and controversies to aid clinician decision‐making.Materials and MethodsA systematic search was carried out for guidelines regarding CVD prevention or focusing on type 2 diabetes patients. Appraisal of Guidelines for Research and Evaluation II instrument was utilized to appraise the quality of included guidelines.ResultsOf the 15 guidelines with discrepant Appraisal of Guidelines for Research and Evaluation II scores (66%; interquartile range 51–71%), 10 were defined as “strongly recommended” guidelines. For secondary prevention, >60% of guidelines advocated that the dual antiplatelet therapy was used within 12 months when the type 2 diabetes patients experienced acute coronary syndrome and/or post‐percutaneous coronary intervention or coronary artery bypass grafting, with subsequent long‐term aspirin use. For primary prevention, 80% of guidelines supported that aspirin should not be routinely used by patients with type 2 diabetes. No consensus on whether to prolong dual antiplatelet therapy in secondary prevention, and whether to use aspirin in type 2 diabetes patients with high CVD risk exists in current guidelines.ConclusionsPhysicians should use the recommendations from “strongly recommended” guidelines to make informed decisions and know the consensuses of current guidelines. Dual antiplatelet therapy should be used within 12 months when type 2 diabetes patients experience acute coronary syndrome and/or percutaneous coronary intervention/coronary artery bypass grafting, with subsequent long‐term aspirin use. In primary prevention, aspirin should not be routinely used by individuals with type 2 diabetes, but might be considered for those with high CVD risk.     

Aspirin,NSAIDs, and COX-2 inhibitors in cardiovascular disease: Possible interactions and implications for treatment of rheumatoid arthritis

Aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), and cyclooxygenase-2 (COX-2) inhibitors are widely used in patients with rheumatoid arthritis. Aspirin has the largest and most persuasive body of randomized trial evidence to support its use in secondary prevention for cardiovascular disease (CVD) and primary prevention for myocardial infarction. There is, however, a possible deleterious interaction between aspirin and NSAIDs on CVD that requires further research. Aspirin, NSAIDs, and to a lesser extent COX-2 inhibitors are associated with increased gastrointestinal side effects and bleeding, alone and in combination. The more widespread and appropriate use of aspirin in patients with rheumatoid arthritis will avoid many premature deaths in secondary prevention for CVD and first myocardial infarctions in primary prevention.     

中国退休军人2型糖尿病患者心血管病风险控制现状

目的了解中国退休军人2型糖尿病患者血糖、血压、血脂的控制率及抗血小板的治疗现状。方法2012年3至8月对我国18个地区军队门诊部或干休所进行问卷调查,收集军队退休干部中2型糖尿病患者的一般资料、病史、心血管病危险因素、相关实验室检查结果以及治疗方案等资料。分析统计受试者血糖、糖化血红蛋白（HbAlC）、血压和血脂的控制率及阿司匹林的应用率。对影响综合达标的相关因素进行logistic回归分析。结果共收回有效问卷4976份。受访者均为确诊的2型糖尿病患者（男性占77．0％）,其中46．0％的受访者自我血糖监测频率≥1次／周,16．5％监测频率〈1R／月;以最近一次检测的HbAlc值统计,HbAlc〈7．0％的控制率为45．3％;受访者血压控制率（〈140／80mmHg,1mmHg=0．133kPa）为33．9％;低密度脂蛋白胆固醇（LDL-C）控制率（〈2．6mmoVL）为63．3％,血压、血糖、血脂三项综合控制率为10．0％。59．8％的受访者有心脑血管病史,其中阿司匹林使用率为64．3％;无心脑血管病史受访者中,心血管病高危患者（50岁以上男性或60岁以上女性）占94．1％,其阿司匹林使用率为56．7％。使用阿司匹林有助于提高综合达标率（比值比=1．382,95％可信区间：1．131—1．688,P=0．002）。结论中国退休军人系统管理的2型糖尿病患者有良好的综合管理制度,定期查体、监测血糖、血压、血脂、应用阿司匹林,四项达标率高,这将有利于预防糖尿病并发症。     

Cardiovascular disease and prevention among people living with HIV in South Florida

Antiretroviral therapy (ART) has improved survival of patients living with HIV (PLWH); however, this has been accompanied by an increase in cardiovascular disease (CVD). Although preventative measures for CVD among the general population are well described, information is limited about CVD prevention among PLWH. The goal of this study was to characterize the prevalence of CVD in our population and to assess the use of primary and secondary prevention.We performed a retrospective review of PLWH receiving primary care at a large academic center in Miami, Florida. We characterized the prevalence of CVD, CVD risk, and the use of aspirin and statins for primary and secondary CVD prevention.A total of 985 charts were reviewed (45% women, 55% men). Average age was 52.2 years. Average CD4 count was 568 cells/microL. 92.9% were receiving ART, and 71% were virologically suppressed. The median 10-year ASCVD risk was 7.3%. The prevalence of CVD was 10.4% (N = 102). The odds of having CVD was lower in patients on ART (OR 0.47, 95% CI: 0.25–0.90, P = .02). The use of medications for primary and secondary prevention of CVD based on current guidelines was low: 15% and 37% for aspirin respectively, and 25% and 44% for statins.CVD risk and rates of CVD are high among PLWH and receiving ART could protect against CVD. However, the use of medications for primary and secondary prevention is low. Increased awareness of CVD risk-reduction strategies is needed among providers of PLWH to decrease the burden of CVD.     

Changing aspirin use in patients with Type 2 diabetes in the UKPDS.

AIMS: To examine the proportion of UK Prospective Diabetes Study (UKPDS) patients with Type 2 diabetes taking aspirin regularly for the primary and secondary prevention of cardiovascular disease (CVD) before and after publication of the 1997 American Diabetes Association (ADA) Clinical Practice Recommendations and the 1998 Joint British Recommendations on the Prevention of Coronary Disease in Clinical Practice. METHODS: UKPDS annual review data from 1996/7 (n = 3190) and 2000/1 (n = 2467) were used to determine the prevalence of patients taking aspirin regularly in relation to known CVD risk factors and pre-existing CVD. RESULTS: Patients taking aspirin regularly were more often male than female (24 vs. 20%, P = 0.0033), older (66 +/- 8 vs. 62 +/- 9 years, P < 0.0001) and less often Afro-Caribbean than White Caucasian or Indian Asian (11 vs. 23 vs. 22%, respectively, P < 0.0001). Between 1996/7 and 2000/1 aspirin use in patients without pre-existing CVD increased from 17 to 31% (P < 0.0001) and for those with pre-existing CVD from 76 to 82% (P = 0.032). CONCLUSION: The majority of patients with pre-existing CVD were taking aspirin regularly. Although aspirin use in those without pre-existing CVD approximately doubled after publication of the ADA and Joint British Recommendations, less than two-thirds of these high-risk patients were being treated according to guidelines. This may relate to a lack of convincing evidence for primary CVD prevention or failure to adhere to guidelines. It may be that more trial data is needed to convince clinicians of the value of aspirin therapy in Type 2 diabetes.     

Prevention of Cardiovascular Complications of Diabetes Mellitus by Aspirin

Eighteen million Americans have type 2 Diabetes Mellitus (DM) while another 40 million have impaired glucose tolerance. Atherosclerotic heart disease is the leading cause of death in patients with diabetes mellitus. In addition to the increased risk for Cardio Vascular Disease (CVD), patients with diabetes have a worse prognosis than nondiabetics when they suffer an ischemic event. Insulin resistance is increasingly recognized as a chronic, low‐level, inflammatory state. Hyperinsulinemia has been proposed as the forerunner of hypertension, low high‐density lipoprotein cholesterolemia, hypertriglyceridemia, abdominal obesity, and altered glucose tolerance, linking all these abnormalities to the development of coronary vascular disease. Atherosclerosis and insulin resistance share similar pathophysiological mechanisms, due to the actions of proinflammatory cytokines. The dynamic inflammatory milieu found in diabetes explains the susceptibility of diabetics to CVD and the potential mechanism by which aspirin may prevent CVD in diabetics. Aspirin decreases the risk for CVD in diabetic patients by a variety of established and novel mechanisms. Therapeutic strategies that lesson the CVD risk in diabetic patients, including the use of aspirin for primary and secondary prevention, are potentially very important. This review article addresses the antiatherosclerotic effects of aspirin, the potential anti‐diabetic effects of aspirin, and the clinical trial evidence for CVD prevention by aspirin in diabetics. We also present recommendations for the use of aspirin in the diabetic population and the current guidelines put forth by the American Heart Association and by the American Diabetes Association.     

Low-dose aspirin for primary prevention of cardiovascular events in patients with diabetes: Benefit or risk?

Primary prevention aims to avert the onset of cardiovascular disease (CVD) by targeting its natural causes and risk factors; secondary prevention includes strategies and therapies that address preclinical or clinical evidence of CVD progression. The value of aspirin for primary CVD prevention is controversial because of increased bleeding, which may offset the overall modest benefits in patients with no overt CVD. In contrast, the benefits of aspirin for secondary prevention have been repeatedly and convincingly demonstrated to outweigh the risk of bleeding. Diabetes mellitus is a strong risk factor for cardiovascular events, and has been associated with an increased risk of both first and recurrent atherothrombotic events. Therefore, prevention of CVD, the major cause of mortality in patients with diabetes, is one of the most important therapeutic goals. Although the benefit of low-dose aspirin for secondary prevention of CVD is well established, its role for primary prevention remains inconclusive and controversial in diabetes patients. The benefit of aspirin for patients with CVD clearly exceeds the risk of bleeding, and even though a modest benefit has also been demonstrated in primary prevention, the trade-off for aspirin initiation against the increased risk of intracranial and gastrointestinal bleeding is more uncertain. Thus, aspirin for primary CVD prevention should be highly individualized, based on a benefit–risk ratio assessment for the given patient. In conclusion, the mere presence of diabetes is apparently not enough for aspirin to confer a benefit that clearly outweighs the risk of bleeding, and further evidence to the contrary is now needed.     

阿司匹林在心血管病一级预防的地位

阿司匹林作为急性心肌梗死和冠心病二级预防的基础药物已得到广泛认可，然而近年来关于阿司匹林对心血管疾病的一级预防依然存在争议。阿司匹林可降低心脑血管事件的发生率，但同时又可增加出血事件。如何将其合理地运用在心血管疾病一级预防中使更多的患者获益是临床工作者的一大难题。越来越多的大规模临床研究表明阿司匹林作为心血管疾病一级预防药物的关键在于把握危险分层,进一步评价患者的状况，规范使用阿司匹林将会有效地减少心血管疾病的风险。与此同时国外许多指南及我国专家的共识均能指导医生在心血管疾病一级预防中规范地运用阿司匹林。     

Aspirin in the primary prevention of cardiovascular disease: Current knowledge and future research needs

In secondary prevention, among a very wide range of survivors of prior occlusive cardiovascular disease (CVD) events and those suffering acute myocardial infarction (MI) or occlusive stroke, aspirin decreases risks of MI, stroke, and CVD death. In these high risk patients, the absolute benefits are large and absolute risks are far smaller so aspirin should be more widely prescribed. In contrast, in primary prevention, aspirin reduces risks of first MI but the evidence on stroke and CVD death remain inconclusive. Based on the current totality of evidence from predominantly low risk subjects where the absolute benefits is low and side effects the same as in secondary prevention, any decision to prescribe aspirin for primary prevention should be an individual clinical judgment by the healthcare provider that weighs the absolute benefit in reducing the risk of a first MI against the absolute risk of major bleeding. If the ongoing trials of intermediate risks subjects show net benefits then general guidelines may be justified with several caveats. First, any decision to use aspirin should continue to be made by the healthcare provider. Second, therapeutic lifestyle changes and other drugs of life saving benefit such as statins should be considered with aspirin as an adjunct, not alternative. The more widespread and appropriate use of aspirin in primary prevention is particularly attractive, especially in developing countries where CVD is emerging as the leading cause of death. In addition, aspirin is generally widely available over the counter and is extremely inexpensive.     

Reducing Cardiovascular and Cancer Risk: How to Address Global Primary Prevention in Clinical Practice

Emerging evidence suggesting the possibility that interventions able to prevent cardiovascular disease (CVD) may also be effective in the prevention of cancer have recently stimulated great interest in the medical community. In particular, data from both experimental and observational studies have demonstrated that aspirin may play a role in preventing different types of cancer. Although the use of aspirin in the secondary prevention of CVD is well established, aspirin in primary prevention is not systematically recommended because the absolute cardiovascular event reduction is similar to the absolute excess in major bleedings. By adding to its cardiovascular prevention benefits, the potential beneficial effect of aspirin in reducing the incidence of mortality and cancer could tip the balance between risks and benefits of aspirin therapy in primary prevention in favor of the latter and broaden the indication for treatment with aspirin in populations at average risk. Prospective and randomized studies are currently investigating the effect of aspirin in prevention of both cancer and CVD; however, clinical efforts at the individual level to promote the use of aspirin in global (or total) primary prevention already could be made on the basis of a balanced evaluation of the benefit/risk ratio.