European Heart Journal Advance Access originally published online on October 19, 2006
European Heart Journal 2006 27(22):2667-2674; doi:10.1093/eurheartj/ehl334
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A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50 279 patients at risk for coronary artery disease
1 Interventional Cardiology, Division of Cardiology, University of Turin, corso Bramante 88-90, 10126 Turin, Italy
2 Institute of Cardiology, Catholic University, Rome, Italy
3 Antwerp Cardiovascular Institute Middelheim, AZ Middelheim, Antwerp, Belgium
4 Department of Medicine, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, VA, USA
5 Hemodynamics and Cardiovascular Interventions Service, Abano Terme Hospital, Abano Terme, Italy
6 EMO Centro Cuore Columbus, Milan, Italy
Received 21 September 2006; accepted 5 October 2006; online publish-ahead-of-print 19 October 2006.
* Corresponding author. Tel: +39 3408626829; fax: +39 0184502244. E-mail address: gbiondizoccai{at}gmail.com
Aims The role of aspirin in patients with coronary artery disease (CAD) is well established, yet patients happen to discontinue aspirin according to physician’s advice or unsupervised. We thus undertook a systematic review to appraise the hazards inherent to aspirin withdrawal or non-compliance in subjects at risk for or with CAD.
Methods and results Electronic databases were systematically searched (updated January 2006). Study designs, patient characteristics, and outcomes were abstracted. Pooled estimates for odds ratios (OR) were computed according to random-effect methods. From the 612 screened studies, six were selected (50 279 patients). One study (31 750 patients) focused on adherence to aspirin therapy in the secondary prevention of CAD, two studies (2594) on aspirin discontinuation in acute CAD, two studies (13 706) on adherence to aspirin therapy before or shortly after coronary artery bypass grafting, and another (2229) on aspirin discontinuation among patients undergoing drug-eluting stenting. Overall, aspirin non-adherence/withdrawal was associated with three-fold higher risk of major adverse cardiac events (OR=3.14 [1.75–5.61], P=0.0001). This risk was magnified in patients with intracoronary stents, as discontinuation of antiplatelet treatment was associated with an even higher risk of adverse events (OR=89.78 [29.90–269.60]).
Conclusion Non-compliance or withdrawal of aspirin treatment has ominous prognostic implication in subjects with or at moderate-to-high risk for CAD. Aspirin discontinuation in such patients should be advocated only when bleeding risk clearly overwhelms that of atherothrombotic events.
Key Words: Aspirin • Coronary artery disease • Discontinuation • Meta-analysis • Systematic review
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