From the Journals

Aspirin triples major bleeding risk after age 75 years

 

Key clinical point: The risk of serious bleeding was significantly increased in adults aged 85 and older who were taking aspirin to prevent a recurrence of heart attack or stroke.

Major finding: The annual rate of life-threatening or fatal bleeding episodes was less than 0.5% for patients younger than 65 years but rose to 1.5% in those aged 75-84 years and 2.5% in those aged 85 years and older.

Data source: A prospective, population-based cohort study of 3,166 adults who had one transient ischemic attack, ischemic stroke, or MI and who were treated with antiplatelet drugs.

Disclosures: The study data were taken from the Oxford Vascular Study, which was funded by the Wellcome Trust, Wolfson Foundation, British Heart Foundation, Dunhill Medical Trust, the National Institute of Health Research (NIHR), and the NIHR Oxford Biomedical Research Centre. Corresponding author Peter Rothwell, MD, disclosed financial relationships with Bayer.

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Prescribe PPIs to help prevent bleeding

 

In patients with stroke with a cardiac source of embolism who qualify for oral anticoagulation, we obsess about the association between benefit and bleeding risk. Specific risk scores were developed to assess the bleeding risk for patients with atrial fibrillation who qualified for anticoagulation. However, similar risk scores are not applied for patients who undergo long-term prevention with antiplatelet therapy.

On the basis of this study’s results, the benefit-risk association in long-term antiplatelet therapy should be evaluated every 3-5 years in patients older than 75 years, and PPIs should be used in patients on antiplatelet therapy who are at least 75 years old or in patients with a history of gastrointestinal bleeds.

Dr. Hans Christoph Diener
Dr. Hans Christoph Diener
Cardiologists will rarely see intracranial bleeds, and neurologists and cardiologists will rarely see major gastrointestinal bleeds. Therefore, they might underestimate the real risk in patients on antithrombotic therapy.

Hans-Christoph Diener, MD, of the department of neurology at the University Duisburg-Essen in Essen, Germany, made these remarks in an accompanying editorial (Lancet. 2017 Jun 13. doi: 10.1016/S0140-6736[17]31507-6). He disclosed relationships with multiple companies, including AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, Merck, and Novartis.


 

FROM THE LANCET

 

Older adults who take aspirin daily are at greater risk for serious bleeding than previously thought, based on data from roughly 3,000 patients.

“The risk of upper gastrointestinal bleeding on antiplatelet treatment increases with age, but it is uncertain whether older age alone is a sufficient indicator of high risk to justify routine coprescription of PPIs [proton pump inhibitors],” wrote Linxin Li, DPhil, of the University of Oxford (England) and her colleagues.

To assess the rate of bleeding among older adults on long-term aspirin therapy, Dr. Li and her colleagues reviewed data from the Oxford Vascular Study, a prospective population-based study of 3,166 patients. Of those, 1,584 were younger than 75 years, with an average age of 61 years, and 1,582 were at least 75 years old, with average age of 83 years. Patients were followed at 30 days, 6 months, and 1, 5, and 10 years to determine bleeding, recurrent ischemic events, and disability (Lancet. 2017. doi: 10.1016/S0140-6736[17]30770-5).

aspirin ©Darren Hester/Fotolia.com
aspirin bottle © Darren Hester/Fotolia.com
In the first 3 years of follow-up, the annual risk of major bleeding was 1.1% for adults younger than 75 years, but it reached 4.1% among adults 85 years and older. Patterns were similar for life-threatening and fatal bleeding, “reflecting high risks of upper gastrointestinal and intracranial bleeds at older ages,” the researchers wrote. The annual risk of life-threatening or fatal bleeding was less than 0.5% for patients younger than 65 years but increased to 1.5% for those aged 75-84 years and 2.5% for those aged 85 years and older.

In addition, more than twice the major upper GI bleeds were disabling or fatal in adults aged 75 years and older than in the younger patients (62% vs. 25%).

Only a third of the patients in the study were taking proton pump inhibitors (PPIs), partly because current clinical guidelines don’t specifically recommend their use and partly in the absence of an accepted definition of which patients are at high risk for upper GI bleeding, the researchers said. They estimated that the number needed to treat with PPIs to prevent a major GI bleed after 5 years decreased with age: “80 for patients younger than 65 years, 75 for patients aged 65-74 years, 23 for patients aged 75-84 years, and 21 for patients aged 85 years or older.” In addition, the number needed to treat with PPIs to prevent a disabling or fatal upper GI bleed after 5 years was 338 for patients younger than 65 years but dropped to 25 for patients aged 85 years and older.

The findings were limited by the observational nature of the study and inability to show that increased risk of bleeding was caused by aspirin alone, the researchers said. However, based on the data, “age 75 years would be an appropriate threshold to start a PPI both in patients newly initiated on antiplatelet drugs and in patients on established treatment,” they wrote.

The study data were taken from the Oxford Vascular Study, which was funded by the National Institute of Health Research and several other research institutions. Corresponding author Peter Rothwell, MD, disclosed financial relationships with Bayer.

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