Meeting NewsPerspective

ARRIVE: Aspirin does not reduce initial vascular events in low-to-moderate risk population

MUNICH — In a moderate-risk population with low event rates, aspirin did not significantly reduce initial vascular events, according to the ARRIVE study presented at the European Society of Cardiology Congress.

Among 12,546 patients randomly assigned to receive enteric-coated aspirin (Bayer) 100 mg daily or placebo and followed for a median of 60 months, the primary efficacy endpoint of time to first occurrence of CV death, MI, unstable angina, stroke or transient ischemic attack occurred in 4.29% of the aspirin group vs. 4.48% of the placebo group (HR = 0.96; 95% CI, 0.81-1.13), according to results of an intention-to-treat analysis.

“ARRIVE attempted to address the issue of aspirin for primary prevention in subjects at moderate risk for cardiovascular disease in a pragmatic, primary-care-based study,” J. Michael Gaziano, MD, MPH, chief of the division of aging at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, said during a press conference. “We ended up with a lower-risk population than we had intended. The results showed that aspirin did not significantly reduce a composite of vascular events in the intention-to-treat population. The effects of aspirin tended to be the same as in other primary prevention studies.”

All patients enrolled in the ARRIVE study were considered to be at moderate risk based on number of risk factors and were free from diabetes and elevated bleeding risk. Patients enrolled had a mean age of 64 years and 30% were women. Men were aged at least 55 years and women were aged at least 60 years. Enrollment occurred at 501 centers in seven countries.

In other results presented here, gastrointestinal bleeding events were mostly mild, but occurred approximately twice as often in the aspirin group (0.97% vs. 0.46%; HR = 2.11; 95% CI, 1.36-3.28), according to the researchers.

Serious adverse events occurred in 20.19% of the aspirin group vs. 20.89% in the placebo group, while overall adverse events occurred in 82.01% of the aspirin group vs. 81.72% of the placebo group.

aspirin
Aspirin did not reduce vascular events in the ARRIVE trial
Source: Adobe Stock

Treatment-related adverse events were higher in the aspirin group (16.75% vs. 13.54%; P < .0001), but death rates were nearly identical in the intention-to-treat population (aspirin group, 2.55%; placebo group, 2.57%; HR = 0.99; 95% CI, 0.8-1.24), according to the researchers.

Rates of MI did not differ in the intention-to-treat population, but favored the aspirin group in the per-protocol population (HR = 0.53; 95% CI, 0.36-0.79).

“The use of aspirin remains a decision that should involve a thoughtful discussion between a clinician and a patient that requires a need to weigh the cardiovascular and cancer benefits against the bleeding risks,” Gaziano said during a press conference.

The data were simultaneously published in The Lancet.

Davide Capodanno, MD, PhD
Davide Capodanno

Davide Capodanno, MD, from the division of cardiology, AOU “Policlinico Vittorio Emanuele,” Catania, Italy, and Cardiology Today’s Intervention Editorial Board Member Dominick J. Angiolillo, MD, PhD, medical director of the Cardiovascular Research Program, program director of the Interventional Cardiology Fellowship Program and professor of medicine at the University of Florida College of Medicine Jacksonville, discussed the findings in a related editorial also published in The Lancet.

Dominick J. Angiolillo, MD, PhD
Dominick J. Angiolillo

“Overall, the consistent trend in negative results from trials of aspirin in primary prevention, particularly in patients without diabetes, suggests that new avenues of research are needed for the prevention of cardiovascular events.” – by Erik Swain

References:

Gaziano JM, et al. Hot Line Session 1. Presented at: European Society of Cardiology Congress; Aug. 25-29, 2018; Munich.

Gaziano JM, et al. Lancet. 2018;doi:10.1016/S0140-6736(18)31924-X.

Disclosures: The study was funded by Bayer. Gaziano reports receiving personal fees from Bayer. Please see the study for the other authors’ relevant financial disclosures. Angiolillo reports financial ties with multiple pharmaceutical and device companies. Capodanno reports he received speaker’s and consultant honoraria from AstraZeneca and Bayer.

MUNICH — In a moderate-risk population with low event rates, aspirin did not significantly reduce initial vascular events, according to the ARRIVE study presented at the European Society of Cardiology Congress.

Among 12,546 patients randomly assigned to receive enteric-coated aspirin (Bayer) 100 mg daily or placebo and followed for a median of 60 months, the primary efficacy endpoint of time to first occurrence of CV death, MI, unstable angina, stroke or transient ischemic attack occurred in 4.29% of the aspirin group vs. 4.48% of the placebo group (HR = 0.96; 95% CI, 0.81-1.13), according to results of an intention-to-treat analysis.

“ARRIVE attempted to address the issue of aspirin for primary prevention in subjects at moderate risk for cardiovascular disease in a pragmatic, primary-care-based study,” J. Michael Gaziano, MD, MPH, chief of the division of aging at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, said during a press conference. “We ended up with a lower-risk population than we had intended. The results showed that aspirin did not significantly reduce a composite of vascular events in the intention-to-treat population. The effects of aspirin tended to be the same as in other primary prevention studies.”

All patients enrolled in the ARRIVE study were considered to be at moderate risk based on number of risk factors and were free from diabetes and elevated bleeding risk. Patients enrolled had a mean age of 64 years and 30% were women. Men were aged at least 55 years and women were aged at least 60 years. Enrollment occurred at 501 centers in seven countries.

In other results presented here, gastrointestinal bleeding events were mostly mild, but occurred approximately twice as often in the aspirin group (0.97% vs. 0.46%; HR = 2.11; 95% CI, 1.36-3.28), according to the researchers.

Serious adverse events occurred in 20.19% of the aspirin group vs. 20.89% in the placebo group, while overall adverse events occurred in 82.01% of the aspirin group vs. 81.72% of the placebo group.

aspirin
Aspirin did not reduce vascular events in the ARRIVE trial
Source: Adobe Stock

Treatment-related adverse events were higher in the aspirin group (16.75% vs. 13.54%; P < .0001), but death rates were nearly identical in the intention-to-treat population (aspirin group, 2.55%; placebo group, 2.57%; HR = 0.99; 95% CI, 0.8-1.24), according to the researchers.

Rates of MI did not differ in the intention-to-treat population, but favored the aspirin group in the per-protocol population (HR = 0.53; 95% CI, 0.36-0.79).

“The use of aspirin remains a decision that should involve a thoughtful discussion between a clinician and a patient that requires a need to weigh the cardiovascular and cancer benefits against the bleeding risks,” Gaziano said during a press conference.

The data were simultaneously published in The Lancet.

Davide Capodanno, MD, PhD
Davide Capodanno

Davide Capodanno, MD, from the division of cardiology, AOU “Policlinico Vittorio Emanuele,” Catania, Italy, and Cardiology Today’s Intervention Editorial Board Member Dominick J. Angiolillo, MD, PhD, medical director of the Cardiovascular Research Program, program director of the Interventional Cardiology Fellowship Program and professor of medicine at the University of Florida College of Medicine Jacksonville, discussed the findings in a related editorial also published in The Lancet.

Dominick J. Angiolillo, MD, PhD
Dominick J. Angiolillo

“Overall, the consistent trend in negative results from trials of aspirin in primary prevention, particularly in patients without diabetes, suggests that new avenues of research are needed for the prevention of cardiovascular events.” – by Erik Swain

References:

Gaziano JM, et al. Hot Line Session 1. Presented at: European Society of Cardiology Congress; Aug. 25-29, 2018; Munich.

Gaziano JM, et al. Lancet. 2018;doi:10.1016/S0140-6736(18)31924-X.

Disclosures: The study was funded by Bayer. Gaziano reports receiving personal fees from Bayer. Please see the study for the other authors’ relevant financial disclosures. Angiolillo reports financial ties with multiple pharmaceutical and device companies. Capodanno reports he received speaker’s and consultant honoraria from AstraZeneca and Bayer.

    Perspective

    The position of the ESC is that we have become more and more cautious about aspirin for primary prevention, mainly because we have so many things we can do in primary prevention, and it is difficult for healthy people to take many drugs. It should not be for everybody. In recent years, the swing has been more to positive side, but this study, while very well done, was not conclusive and offers little to help the cause of aspirin for primary prevention.

    • Heinz Drexel, MD
    • Professor of Medicine
      Bern University Hospital, University of Bern, Switzerland
      Vorarlberg Institute for Vascular Investigation and Treatment, Feldkirch, Austria

    Disclosures: Drexel reports no relevant financial disclosures.

    Perspective
    Ileana L. Piña

    Ileana L. Piña

    It has become common popular knowledge that aspirin prevents events. I have a lot of friends and even colleagues who, when they hit age 50, start taking an aspirin daily. But the data just aren’t there. Here is another trial showing that, at least in a nondiabetic population, aspirin did not make much difference.

    We need to reconsider our guidelines and what we clinicians tell our patients. The bleeding with aspirin is significant and is worrisome to patients and clinicians. Thirty-five percent of our patients on left ventricular assist devices bleed, and they are on aspirin and warfarin. When bleeding in those patients is first noticed, it can’t be assumed that it’s from the aspirin or the warfarin. You have to work them up, which is expensive. This is especially true for gastrointestinal bleeding, where we don’t know the source initially, and we have to do upper and lower endoscopy, and in some patients do capsule studies. These patients often also see drops in hemoglobin, and some of my colleagues think that is from the aspirin and not the warfarin

    • Ileana L. Piña, MD, MPH
    • Cardiology Today Editorial Board Member
      Montefiore Medical Center
      Albert Einstein College of Medicine

    Disclosures: Piña reports no relevant financial disclosures.

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