Aspirin overlooked as an effective and inexpensive means to reduce cardiovascular disease risk in diabetic women and young adults

Dec 20 2004

Cardiovascular disease risk is extremely high in adults with diabetes. Yet women as well as people under 50 who have diabetes do not use aspirin, despite the fact that aspirin has been found an effective and inexpensive means to reduce risk of first and subsequent heart attack.

Previous research has demonstrated less frequent use of invasive cardiovascular procedures and effective medications for acute myocardial infarction, including thrombolytics, beta-blockers and aspirin, in women, compared with men.

"A similar disparity now exists for use of aspirin for primary and secondary cardiovascular disease prevention in diabetes," said Stephen D. Persell, M.D., and David W. Baker, M.D., researchers at Northwestern University Feinberg School of Medicine.

In a study in the Dec. 13/27 Archives of Internal Medicine, Persell, an instructor in medicine, and Baker, associate professor of medicine, assessed self-reported aspirin use among those over 35 with diabetes from 1997 to 2001.

It was in 1997 that the American Diabetes Association first recommended that aspirin be considered for prevention of cardiovascular disease events in any high-risk adult older than 30 years with diabetes.

Although their study found an encouraging increase in aspirin use in recent years among adults with diabetes, Persell and Baker noted a significant disparity in aspirin use between diabetic men and women that was not observed a decade earlier.

Among adults with diabetes without diagnosed cardiovascular disease, 42 percent of men and 34 percent of women used aspirin regularly. Younger and middle-aged adults used aspirin less frequently than did older adults.

Among those with diabetes and diagnosed cardiovascular disease, 83 percent of men and 65 percent of women reported regular aspirin use, and age was associated with lower aspirin use only among those young than 50 years.

There are several possible explanations for low use of aspirin among women, the researchers said.

Physicians may not counsel women with diabetes to use aspirin if the physicians underestimate the women's risk for cardiovascular disease events.

"However, even though women are at lower risk of new-onset cardiovascular disease than men, diabetes greatly reduces this female advantage," Persell said.

Physicians may have concerns that aspirin is less efficacious for women than men in primary prevention of cardiovascular disease events.

"Observational data suggest that aspirin prevents initial myocardial infarction in women, yet women were not well represented in early randomized trials of aspirin for the prevention of initial cardiovascular disease events," Baker said. The low use of aspirin associated with younger age is also noteworthy, the authors said.

"Physicians or patients may think that the risk of cardiovascular disease in younger diabetic adults is too low to justify using aspirin. However, even without other cardiovascular disease risk factors, men and women 45 to 49 years old with diabetes have an estimated 7 percent 10-year risk of major cardiovascular disease events, a risk that is sufficient to justify the consideration of aspirin," they said.

Persell and Baker said aspirin may also be underused because many people with diabetes do not appreciate their cardiovascular disease risk, and although physicians understand the high cardiovascular disease risk associated with diabetes, they place greater importance on glucose control than on blood pressure management, cholesterol lowering or aspirin use as a means of reducing cardiovascular disease risk.

"Health professionals may have a large role to play in increasing appropriate aspirin use among adults with diabetes. Simple interventions such as offering professional advice about aspirin may be adequate to increase appropriate usage given that past studies have shown a strong association between current aspirin use and report of professional counseling," Persell said.

Health professionals are also in the position to help identify patients for whom the risk of aspirin may outweigh the benefits. Interventions that aim to increase professional counseling about aspirin for women, as well as young and middle-aged adults, may be especially helpful, the authors said.