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Cardiology

Aspirin for Secondary Prevention of Cardiovascular Disease in 51 Low-, Middle-, and High-Income Countries

Educational Objective: To identify the key insights or developments described in this article.

1 Credit CME

JAMA

Published Online: August 22/29, 2023

Original Investigation

Article Information and Disclosures

Sang Gune K. Yoo, MD¹;

Grace S. Chung, PhD²;

Silver K. Bahendeka, MD^3,4;

Abla M. Sibai, PhD⁵;

Albertino Damasceno, PhD^6,7;

Farshad Farzadfar, MD⁸;

Peter Rohloff, MD^9,10;

Corine Houehanou, MD¹¹;

Bolormaa Norov, MSc¹²;

Khem B. Karki, MBBS¹³;

Mohammadreza Azangou-Khyavy, MD⁸;

Maja E. Marcus, PhD¹⁴;

Krishna K. Aryal, PhD^15,16;

Luisa C. C. Brant, MD^17,18;

Michaela Theilmann, MA^19,20;

Renata Cífková, MD^21,22;

Nuno Lunet, PhD^23,24,25;

Mongal S. Gurung, PhD²⁶;

Joseph Kibachio Mwangi, MD^27,28;

Joao Martins, PhD²⁹;

Rosa Haghshenas, BSc⁸;

Lela Sturua, PhD^30,31;

Sebastian Vollmer, PhD¹⁴;

Till Bärnighausen, MD^19,32,33;

Rifat Atun, MD^34,35;

Jeremy B. Sussman, MD^2,36;

Kavita Singh, PhD^19,37;

Sahar Saeedi Moghaddam, MSc^38,39;

David Guwatudde, PhD⁴⁰;

Pascal Geldsetzer, ScD⁴¹;

Jennifer Manne-Goehler, MD^42,43;

Mark D. Huffman, MD^44,45,46;

Justine I. Davies, MD^47,48,49;

David Flood, MD^2,9,50

Author Affiliations

¹Cardiovascular Division, Department of Internal Medicine, Washington University in St Louis, St Louis, Missouri
²Department of Internal Medicine, University of Michigan, Ann Arbor
³Department of Internal Medicine, MKPGMS Uganda Martyrs University, Kampala, Uganda
⁴St Francis Hospital, Nsambya, Kampala, Uganda
⁵Epidemiology and Population Health Department, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
⁶Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
⁷Nucleo de Investigaçao, Departamento de Medicina, Hospital Central do Maputo, Maputo, Mozambique
⁸Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
⁹Center for Indigenous Health Research, Wuqu’ Kawoq, Tecpán, Guatemala
¹⁰Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts
¹¹Laboratory of Epidemiology of Chronic and Neurological Diseases, Faculty of Health Sciences, University of Abomey-Calavi, Cotonou, Benin
¹²Nutrition Department, National Center for Public Health, Ulaanbaatar, Mongolia
¹³Department of Community Medicine and Public Health, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
¹⁴Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
¹⁵Bergen Centre for Ethics and Priority Setting in Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
¹⁶Public Health Promotion and Development Organization, Kathmandu, Nepal
¹⁷Serviço de Cardiologia e Cirurgia Cardiovascular, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
¹⁸Departamento de Clínica Médica, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
¹⁹Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
²⁰Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
²¹Center for Cardiovascular Prevention, First Faculty of Medicine, and Thomayer University Hospital, Charles University in Prague, Prague, Czechia
²²Department of Medicine II, First Faculty of Medicine, Charles University in Prague, Prague, Czechia
²³Department of Public Health and Forensic Sciences and Medical Education, Faculty of Medicine, University of Porto, Porto, Portugal
²⁴EPIUnit, Institute of Public Health, University of Porto, Porto, Portugal
²⁵Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
²⁶Health Research and Epidemiology Unit, Ministry of Health, Thimphu, Bhutan
²⁷Division of Non-Communicable Diseases, Ministry of Health, Nairobi, Kenya
²⁸Faculty of Medicine, The Institute of Global Health, University of Geneva, Geneva, Switzerland
²⁹Faculty of Medicine and Health Sciences, National University of East Timor, Dili, Timor-Leste
³⁰Non-Communicable Disease Department, National Center for Disease Control and Public Health, Tbilisi, Georgia
³¹Public Health Department, Petre Shotadze Tbilisi Medical Academy, Tbilisi, Georgia
³²Harvard Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts
³³Africa Health Research Institute, Somkhele and Durban, South Africa
³⁴Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts
³⁵Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts
³⁶Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
³⁷Centre for Chronic Disease Control, New Delhi, India
³⁸Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
³⁹Kiel Institute for the World Economy, Kiel, Germany
⁴⁰Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
⁴¹Division of Primary Care and Population Health, Stanford University, Stanford, California
⁴²Division of Infectious Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
⁴³Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
⁴⁴Department of Medicine and Global Health Center, Washington University in St Louis, St Louis, Missouri
⁴⁵Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
⁴⁶The George Institute for Global Health, University of New South Wales, Sydney, Australia
⁴⁷Institute for Applied Health Research, University of Birmingham, Birmingham, England
⁴⁸Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
⁴⁹Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
⁵⁰INCAP Research Center for Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala

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Key Points

Question What is the prevalence of aspirin use among people with a history of cardiovascular disease in low-, middle- and high-income countries?

Findings Among individuals with a self-reported history of cardiovascular disease, aspirin use for secondary prevention was 40.3% in the pooled sample and ranged from 16.6% in low-income countries to 65.0% in high-income countries.

Meaning The overall findings suggest suboptimal use of aspirin for secondary prevention of cardiovascular disease in many countries around the world.

Abstract

Importance Aspirin is an effective and low-cost option for reducing atherosclerotic cardiovascular disease (CVD) events and improving mortality rates among individuals with established CVD. To guide efforts to mitigate the global CVD burden, there is a need to understand current levels of aspirin use for secondary prevention of CVD.

Objective To report and evaluate aspirin use for secondary prevention of CVD across low-, middle-, and high-income countries.

Design, Setting, and Participants Cross-sectional analysis using pooled, individual participant data from nationally representative health surveys conducted between 2013 and 2020 in 51 low-, middle-, and high-income countries. Included surveys contained data on self-reported history of CVD and aspirin use. The sample of participants included nonpregnant adults aged 40 to 69 years.

Exposures Countries’ per capita income levels and world region; individuals’ socioeconomic demographics.

Main Outcomes and Measures Self-reported use of aspirin for secondary prevention of CVD.

Results The overall pooled sample included 124 505 individuals. The median age was 52 (IQR, 45-59) years, and 50.5% (95% CI, 49.9%-51.1%) were women. A total of 10 589 individuals had a self-reported history of CVD (8.2% [95% CI, 7.7%-8.6%]). Among individuals with a history of CVD, aspirin use for secondary prevention in the overall pooled sample was 40.3% (95% CI, 37.6%-43.0%). By income group, estimates were 16.6% (95% CI, 12.4%-21.9%) in low-income countries, 24.5% (95% CI, 20.8%-28.6%) in lower-middle-income countries, 51.1% (95% CI, 48.2%-54.0%) in upper-middle-income countries, and 65.0% (95% CI, 59.1%-70.4%) in high-income countries.

Conclusion and Relevance Worldwide, aspirin is underused in secondary prevention, particularly in low-income countries. National health policies and health systems must develop, implement, and evaluate strategies to promote aspirin therapy.

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Article Information

Corresponding Author: Sang Gune K. Yoo, MD, Cardiovascular Division, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, 660 S Euclid Ave, MSC 8086-43-13, St Louis, MO 63100 (skyoo@wustl.edu).

Accepted for Publication: June 26, 2023.

Correction: This article was corrected on September 1, 2023, to fix a data error in the abstract.

Author Contributions: Dr Flood had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Yoo, Bolormaa, Vollmer, Bärnighausen, Singh, Guwatudde, Geldsetzer, Flood.

Acquisition, analysis, or interpretation of data: Yoo, Chung, Bahendeka, Sibai, Damasceno, Farzadfar, Rohloff, Houehanou, Bolormaa, Karki, Azangou-Khyavy, Marcus, Aryal, Brant, Theilmann, Cífková, Lunet, Gurung, Mwangi, Martins, Haghshenas, Sturua, Vollmer, Atun, Sussman, Singh, Saeedi Moghaddam, Geldsetzer, Manne-Goehler, Huffman, Davies, Flood.

Drafting of the manuscript: Yoo, Davies, Flood.

Statistical analysis: Bärnighausen, Flood.

Obtained funding: Mwangi, Guwatudde, Flood.

Administrative, technical, or material support: Bahendeka, Farzadfar, Bolormaa, Karki, Marcus, Aryal, Brant, Theilmann, Lunet, Gurung, Mwangi, Martins, Haghshenas, Sussman, Singh, Saeedi Moghaddam, Guwatudde, Manne-Goehler, Flood.

Supervision: Rohloff, Cífková, Bärnighausen, Singh, Guwatudde, Davies, Flood.

Conflict of Interest Disclosures: Dr Atun reported consulting and speaking engagements for Novartis and F. Hoffmann-La Roche unrelated to the study or the subject. Dr Manne-Goehler reported undertaking COVID-19 clinical trials for Regeneron Pharmaceuticals. Dr Huffman reported that his employer, The George Institute for Global Health, has a patent and license, and has received investment funding with intent to commercialize fixed-dose combination therapy through its social enterprise business, George Medicines; Dr Huffman also reported travel support from the World Heart Federation and having a patent pending for heart failure polypills. Dr Flood reported serving as a volunteer physician for the Guatemala-based nongovernmental organization Maya Health Alliance. No other disclosures were reported.

Funding/Support: Dr Flood was supported by the US National Heart, Lung, and Blood Institute (award K23HL161271), the Michigan Center for Diabetes Translational Research (award P30DK092926), the University of Michigan Claude D. Pepper Older Americans Independence Center (award 5P30AG024824), and the University of Michigan Caswell Diabetes Institute Clinical Translational Research Scholars Program.

Role of the Funder/Sponsor: The study supporters had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the US National Institutes of Health.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.