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Inpatient Lesson of the Day 7:
I remember the findings from this 2018 @NEJM study that aspirin
bleeding risk but didn't 
CVD risk in the elderly.
What I didn't remember is that "elderly" was defined as >70 for White and >65 for Black/Hispanic.
1/ https://www.nejm.org/doi/10.1056/NEJMoa1805819
I remember the findings from this 2018 @NEJM study that aspirin
bleeding risk but didn't CVD risk in the elderly.What I didn't remember is that "elderly" was defined as >70 for White and >65 for Black/Hispanic.
1/ https://www.nejm.org/doi/10.1056/NEJMoa1805819
According to the study Supplement, the following eligibility criteria were provided:
"...the age differential was permitted to ensure that Black and Hispanic populations could be represented in the trial, given evidence of higher burden of disease necessitating aspirin use." 2/
"...the age differential was permitted to ensure that Black and Hispanic populations could be represented in the trial, given evidence of higher burden of disease necessitating aspirin use." 2/
According the study design manuscript, "minority recruitment has been challenging due to a number of minorities w/o prior cardiovascular events, disability or dementia, who are not taking aspirin, and a reluctance to cease aspirin..." 3/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3919683/
number of minorities w/o prior cardiovascular events, disability or dementia, who are not taking aspirin, and a reluctance to cease aspirin..." 3/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3919683/
"In addition, after an NIH moratorium on recruiting US Caucasians was enacted in 2011, there was increased hesitancy expressed by minorities regarding why ASPREE was only recruiting minorities..." 4/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3919683/
"Facilitation of US minority participation led to a differential age inclusion criterion... due to a prevalence of exclusion criteria, a survival disadvantage and greater risk of other elements of the primary composite endpoint in minorities compared with non-minorities." 5/
prevalence of exclusion criteria, a survival disadvantage and greater risk of other elements of the primary composite endpoint in minorities compared with non-minorities." 5/
In summary, the age-limit, a key outcome of this study was set lower for minority patients because they had:
1. baseline CVD
2. death from CVD
3. hesitancy to join the trial
Achieving #HealthEquity will be impossible without creative & multidisciplinary strategies. 6/6
1.
baseline CVD2.
death from CVD3.
hesitancy to join the trialAchieving #HealthEquity will be impossible without creative & multidisciplinary strategies. 6/6
P.S. What do these data mean for clinical care?
Should I discontinue aspirin in a Black/Hispanic patient >65 because it was too hard to recruit those patients?
Or because those patients have been shown to die earlier?
Are there really two standards for “elderly” in the U.S.?
Should I discontinue aspirin in a Black/Hispanic patient >65 because it was too hard to recruit those patients?
Or because those patients have been shown to die earlier?
Are there really two standards for “elderly” in the U.S.?
