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在后他汀时代是否应将阿司匹林用于一级预防
Should Aspirin Be Used for Primary Prevention in the Post-statin Era?


Paul M Ridker ... 心脑血管疾病 • 2018.10.18
相关阅读
• 阿司匹林在一级预防试验中无益 • 阿司匹林用于心血管事件的一级预防 • 阿司匹林用于一级预防的另一项阴性研究

1853—1897年,德国化学家学会了将水杨酸钠与乙酰氯高效结合,生成乙酰水杨酸。该化合物的商标为阿司匹林,被证明是一种具有显著抗炎和抗血栓作用的药物,是制药史上最广泛使用的药物之一。

随着医学界对血小板生物学和动脉粥样硬化血栓形成机制了解的深入,已经明确阿司匹林在心血管事件的二级预防中非常有效。随后的大规模一级预防试验(包括内科医师健康研究[Physicians’Health Study]和女性健康研究[Women’s Health Study])证明阿司匹林对高危患者有小到中度的心血管益处,但会增加出血风险1,2。然而,这些和早期其他阿司匹林预防试验是在吸烟普遍、血压控制欠佳、很少积极降脂的时代进行。因此,阿司匹林预防性用药在当前预防性临床实践中的风险和益处,以及剂量和用药持续时间的标准仍不确定3。有数据提示,使用阿司匹林可降低结直肠癌发病率4,这使得这个问题更加复杂。

本刊这一期和最近一期《柳叶刀》(Lancet)报告了三项阿司匹林一级预防试验的结果:ASCEND(糖尿病患者心血管事件研究[A Study of Cardiovascular Events in Diabetes])试验5,纳入了糖尿病患者;ARRIVE(阿司匹林降低初始血管事件风险[Aspirin to Reduce Risk of Initial Vascular Events])试验6,原计划纳入无糖尿病的高危参与者;以及ASPREE(阿司匹林减少老年人事件[Aspirin in Reducing Events in the Elderly])试验7-9,纳入了老年参与者。这些新试验有一个共同的主题,即阐明在当前的临床实践中,怎样的风险水平(如果有)可证明将阿司匹林用于一级预防合理。





作者信息

Paul M Ridker, M.D., M.P.H.
From the Center for Cardiovascular Disease Prevention, Brigham and Women’s Hospital, Boston.

 

参考文献

1. Steering Committee of the Physicians’ Health Study Research Group. Final report on the aspirin component of the ongoing Physicians’ Health Study. N Engl J Med 1989;321:129-135.

2. Ridker PM, Cook NR, Lee I-M, et al. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med 2005;352:1293-1304.

3. Guirguis-Blake JM, Evans CV, Senger CA, O’Connor EA, Whitlock EP. Aspirin for the primary prevention of cardiovascular events: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2016;164:804-813.

4. Rothwell PM, Wilson M, Elwin CE, et al. Long-term effect of aspirin on colorectal cancer incidence and mortality: 20-year follow-up of five randomised trials. Lancet 2010;376:1741-1750.

5. The ASCEND Study Collaborative Group. Effects of aspirin for primary prevention in persons with diabetes mellitus. N Engl J Med 2018;379:1529-1539.

6. Gaziano JM, Brotons C, Coppolecchia R, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet 2018 August 24 (Epub ahead of print).

7. McNeil JJ, Woods RL, Nelson MR, et al. Effect of aspirin on disability-free survival in the healthy elderly. N Engl J Med 2018;379:1499-1508.

8. McNeil JJ, Wolfe R, Woods RL, et al. Effect of aspirin on cardiovascular events and bleeding in the healthy elderly. N Engl J Med 2018;379:1509-1518.

9. McNeil JJ, Nelson MR, Woods RL, et al. Effect of aspirin on all-cause mortality in the healthy elderly. N Engl J Med 2018;379:1519-1528.

10. Collins R, Reith C, Emberson J, et al. Interpretation of the evidence for the efficacy and safety of statin therapy. Lancet 2016;388:2532-2561.

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