ABCS Aspirin Treatment for Secondary and Primary Prevention
ABCS Aspirin Treatment for Secondary and Primary Prevention ASCVD Jennifer Bannon RN BSN MSHI
Table of Contents 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Objectives Cardiovascular Disease (2) ABCS-Aspirin when appropriate Anatomy of a Performance Measure Exceptions Aspirin and Antiplatelet Drugs in Ischemic Vascular Disease Other secondary prevention uses (2) Aspirin for Primary Prevention Updated April 2016 Aspirin and Antiplatelet Drugs in IVD—Work Flow Aspirin and Antiplatelet Drugs in Ischemic Vascular Disea. . . Point of Care Tools ASCVD Risk Calculator app NIH Heart attack assessment tool Point of Care Tools (2) Aspirin Guide medical app e. PSS app Questions? ?
Objectives • • • Cardiovascular disease overview Aspirin quality measure definition Aspirin in secondary prevention Aspirin in primary prevention Possible interventions to improve aspirin measure • Point of care tools to assist in prevention
Cardiovascular Disease • Diseases caused by atherosclerosis (heart attack/MI, angina, sudden death, many strokes, peripheral arterial disease) • Also includes disease of the heart and circulation that may be from causes other than atherosclerosis (some heart failure, some stroke)
Cardiovascular Disease (2) • Leading killer • Huge declines in CVD death in the past 20 years (more than 50%) • Declines are due to a combination of – Better acute care (e. g. for heart attack and stroke) – Better treatment of cardiovascular risk • Secondary prevention (treating people who already have clinical manifestations of the disease) • Primary Prevention (treating people at risk for the development of disease)
ABCS-Aspirin when appropriate • Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic Percentage of patients aged 18 years and older with IVD with documented use of aspirin or another antithrombotic NQF #0068, PQRS #204
Anatomy of a Performance Measure • Denominator: who is eligible to be measured in the first place • Numerator: criteria indicating the measure was met • Exceptions: criteria that may be looked for if the numerator was not met • Data must be in a discrete field in order to be captured as EHR e. CQMs • Data may not be included if start dates are not recorded for medications and diagnosis.
Measure Exceptions • Adverse effect, allergy, or intolerance to Aspirin and Plavix (Clopidogrel). • Patient is taking another antithrombotic or anticoagulant such as Coumadin (Warfarin). • Patient is at a high risk for bleeding (i. e. GI hemorrhage, bleeding disorders documented). • Patient is receiving palliative care.
Aspirin and Antiplatelet Drugs in Ischemic Vascular Disease • Secondary prevention is where the evidence is the best • Reduces risk of vascular events by about 22% • Typical ASA dose 81 to 162 mg per day • Alternatives may be used (e. g. clopidogrel) • Serious bleeding is increased with daily aspirin. Benefits usually outweigh the risks for secondary prevention.
Other secondary prevention uses • For patients undergoing coronary artery bypass grafting, aspirin should be started within 6 hours after surgery to reduce saphenous vein graft closure • In patients with extracranial carotid or vertebral atherosclerosis who have had ischemic stroke or TIA, treatment with aspirin alone (75 -325 mg daily), Plavix alone (75 mg daily) or the combination of Aspirin and Dipyridamole should be started and continued.
Other secondary prevention uses (2) • For patients with symptomatic atherosclerotic peripheral artery disease of the lower extremity, antiplatelet therapy with Aspirin (75 -325 mg daily) or Plavix (75 mg daily) should be started and continued. • Antiplatelet therapy is recommended in preference to anticoagulant therapy with warfarin or other vitamin K antagonists to treat patients with atherosclerosis.
Aspirin for Primary Prevention • http: //www. uspreventiveservicestaskforce. org/Page/Doc ument/Recommendation. Statement. Final/aspirin-toprevent-cardiovascular-disease-and-cancer • Complex because of bleeding risk vs. CVD prevention trade off • Use of warfarin in conjunction with aspirin and/or plavix is associated with an increased risk of bleeding and should be monitored closely. • Also, recent studies have shown that aspirin may prevent colo-rectal cancer
Aspirin for Primary Prevention Updated April 2016 U. S. Preventive Services Task Force (USPSTF) Draft recommendations (September, 2015) Population Recommendation Grade Adults ages 50 to 59 years The USPSTF recommends low-dose aspirin use for the primary prevention of cardiovascular disease (CVD) and colorectal cancer in adults ages 50 to 59 years who have a 10% or greater 10 -year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years. B Adults ages 60 to 69 years The decision to use low-dose aspirin to prevent CVD and colorectal cancer in adults ages 60 to 69 years who have a greater than 10% 10 -year CVD risk should be an individual one. Persons who are not at increased risk for bleeding, have a life expectancy of at least 10 years, and ar 1 e willing to take low-dose aspirin daily for at least 10 years are more likely to benefit. Persons who place a higher value on the potential benefits than the potential harms may choose to use low-dose aspirin. C Adults younger than age 50 years The current evidence is insufficient to assess the balance of benefits and harms of aspirin use to prevent CVD and colorectal cancer in adults younger than age 50 years. I Adults age 70 years and older The current evidence is insufficient to assess the balance of benefits and harms of aspirin use to prevent CVD and colorectal cancer in adults age 70 years and older I
Aspirin and Antiplatelet Drugs in IVD—Work Flow • Drugs, including aspirin must be captured on EHR medication lists; it needs to be documented like a regular prescription • Point of Care (POC) Clinical Decision Support (CDS) can be used to prompt clinicians at point of care. • Population Management (PM): Lists of patients not meeting measure can be generated and used for outreach (staff generated calls, mailings, portal)
Aspirin and Antiplatelet Drugs in Ischemic Vascular Disease (2) • Address how to record medical or other reasons for deviating from recommendation (options: within CDS, annotated problem list, encounter note, other) • Goal is to inform future action – Example aspirin held because of a bleeding ulcer but after appropriate treatment the ulcer has healed and the patient uses acid suppression how will clinician remember to restart the aspirin
Point of Care Tools • ASCVD External Calculator: Calculate your 10 -year risk of heart disease or stroke using the ASCVD algorithm published in 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. • http: //www. cvriskcalculator. com/
ASCVD Risk Calculator app This app is intended as a companion tool to the 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk and the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to reduce Atherosclerotic Cardiovascular Risk in Adults. The ASCVD Risk Estimator provides easy access to recommendations specific to the risk estimates produced by the calculator. Additionally, the app includes readily accessible guideline reference information for both providers and patients related to therapy, monitoring, and lifestyle.
NIH Heart attack assessment tool http: //cvdrisk. nhlbi. nih. gov/ • The risk assessment tool uses information from the Framingham Heart Study to predict a person’s chance of having a heart attack in the next 10 years. • This tool is designed for adults aged 20 and older who do not have heart disease or diabetes.
Point of Care Tools (2) • The Aspirin Guide medical app http: //www. imedicalapps. com/2016/06/aspirin-guideuses-evidence-based-medicine-bring-uspstf-aspirinrecommendations-life/# • Calculates a patient’s risk of cardiovascular disease using the AHA/ACC pooled equations calculator, a bleeding risk score using the most current evidence on bleeding and aspirin use to derive a patient’s likely benefits and risks of aspirin therapy.
Aspirin Guide medical app • Free • Simple to use interface with easy data input and includes graphic of algorithm. • Provides explanation of results including patient-friendly statistics. • Contains links to references and the USPSTF guideline. • Not available for Android at this time.
e. PSS app e. PSS (Electronic Preventive Services Selector) http: //epss. ahrq. gov/PDA/index. jsp The e. PSS is an app designed to help primary care clinicians identify clinical preventive services that are appropriate for their patients. Use the tool to search and browse U. S. Preventive Services Task Force (USPSTF) recommendations on the web or on your PDA or mobile device.
Questions? ? Jennifer Bannon RN BSN MSHI jennifer. bannon@ama-assn. org 312 -623 -3934
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