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Aspirin under scrutiny: How good is the oldest cardiovascular drug really? It started as a fever remedy, then became the wonder drug for cardiac patients. Now its role in primary prevention is uncertain, but it remains crucial in acute myocardial infarction. Hear the whole story in a nutshell on #InsideCardiology

Hi this is tom luscher again this week we speak about a very old drug and that is aspirin which comes from the willow bark and even the romans knew about it but on july 10 1763 the irreverent stone reported at the royal society in london on his successes with willow bark in patience with fever and as such it became a fever remedy and but this wasn’t aspirin

Yet but on august 10th uh 19 18 8 98 the chemist felix hoffman actually uh produced in his laboratory as you can see in this lab book for the first time aspirin and it became really the blockbuster of all times by fire buyer pharmaceutical and initially they said as you can see in this advertisement it should not be used in patients with heart disease as

You see down below and so initially it was just a fever remedy for for the spanish flu and any other flu over decades until in the 60s sergeant wayne did some seminal experiments where he actually showed that platelets as you can see here can of course aggregate we knew that and then they formed the clots but aspirin blocks this uh by interfering with a very

Specific enzyme and eventually for that he got the nobel prize in the 80s in addition to his work for prostaglandins and so today we know that this complex interaction between the coagulation cascade starting with tissue factor on the right and forming a fibrin interfering with platelets that are activated eventually forming a solid clot aspirin is involved

Very importantly and inhibits specifically thromboxane by acetylating the enzyme leading to its formation cyclooxygenase one in particular so what does it really do in patients well there was a hype curve as you can see initially we were using it for every everybody and everybody swallowed it if i asked once at the symposium physicians who takes aspirin if we

Did it anonymously most of them took aspirin in an attempt to to live longer to prevent stroke and myocardial infarction but today we know that this is not so easy in fact there’s three trials the arrived trial where i was involved in the events education committee showed no effect whatsoever in patients at mild risk for cardiovascular disease then there was

Another trial in the middle with diabetics where you can see that in a sense that in fact there was a little effect on outcome with aspirin compared to placebo but there was more bleeding so overall the balance was really neutral and eventually it was also looked at in the elderly on the right and there also there was a little minute effect on outcomes but more

Bleeding and so essentially i think at this point in time aspirin really cannot be recommended in primary prevention but that doesn’t mean that it doesn’t work under other conditions this is a seminal trial from the 80s by peter slide published in the lancet and you can see this is aspirin and streptokinase in patients with acute stemi as we would call it today

And you can see that there is a significant 10 percent almost reduction in mortality by aspirin as it as with streptokinase so platelets anticoagulation are additive if inhibited so aspirin has a place in acute myocardial infarction no doubt now what those should we use after myocardial infarction that’s a very recent trial published in the new england journal

Of medicine that looked at the low and medium 325 milligram dose of aspirin and concluded there is no difference so we can take 80 or 100 milligrams of aspirin on the roll conditions and we have the same effects and possibly a bit less bleeding although this wasn’t dramatic so overall we can say in secondary prevention uh if we had a stent an acs we would

Recommend aspirin forever and initially up to three six or 12 months depending on the clinical situation we combine it with a p2y 12 inhibitor be it clopidogrel pressure or tichraglor but with that we are not giving this a long term so in patients at time bleeding risk maybe one or three months in those with low bleeding risk maybe a year particularly in those

With an acute event and in those with very low bleeding risk but a high ischemic risk maybe even longer now in stroke we know that aspirin does not work to prevent a stroke in patients with atrial fibrillation or a pfo so we shouldn’t recommend it there so we there we would recommend no ox in particular and if the patient has a very high bleeding risk of course

Mechanical devices such as la occluders or pfo occluders could be considered in tia and stroke as such aspirin is recommended in secondary prevention so it’s a very old drug long journey from a fever drug to a cardiac drug and now again restricted to secondary prevention in primary prevention other things work better your lifestyle that you’re responsible for

It and possibly a statin or an anti-diabetic drug if you suffer from these conditions so thank you very much i hope you enjoyed this little history lesson this afternoon bye bye

Transcribed from video
Aspirin By InsideCardiology