Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet

Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period

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Cardiovascular disease, including stroke, is the leading cause of death in the United States. More than 92.1 million American adults have one or more types of cardiovascular disease. Specifically, more than 16 million adults (20 years and older) have coronary heart disease (CHD), over 8 million adults have angina, more than 7 million adults have had a myocardial infarction (MI), over 7 million adults have had a stroke, and nearly 7 million adults 40 years of age and older have peripheral artery disease (Benjamin et al., 2017). It is estimated that by 2030 more than 44 percent of Americans will have a form of cardiovascular disease (Heidenreich et al., 2011). 

In 2011, the total cost of cardiovascular disease and stroke in the United States was estimated to be $320 billion. This total includes direct costs such as the cost of physicians and other health professionals, hospital services, prescribed medications and home health care, as well as indirect costs due to loss of productivity from premature mortality (Benjamin et al., 2017). By 2030, direct medical costs for cardiovascular disease are projected to increase to nearly $918 billion (Heidenreich, 2011).

Antiplatelet medications, such as aspirin and clopidogrel, are drugs that inhibit platelets from clumping together and forming clots. Their use in the secondary prevention of cardiovascular events is well established.  In patients who are at high risk because they already have occlusive cardiovascular disease, long-term antiplatelet therapy reduces the yearly risk of serious vascular events (MI, stroke, death) by about twenty-five percent (Antiplatelet Trialists' Collaboration, 1994; 2002; 2009). A more recent systematic review of the literature confirmed the benefits of antiplatelet therapy in reducing death from cardiovascular causes, MI, or stroke (Cheng, 2013). Antiplatelet agents also have a beneficial effect in reducing all-cause mortality and fatal cardiovascular events in patients with peripheral arterial disease (Wong et al., 2011).

AHA/ACCF SECONDARY PREVENTION AND RISK REDUCTION THERAPY FOR PATIENTS WITH CORONARY AND OTHER ATHEROSCLEROTIC VASCULAR DISEASE: 2011 UPDATE:

- Aspirin 75-162 mg daily is recommended in all patients with coronary artery disease unless contraindicated. (Level of Evidence: A) Clopidogrel 75 mg daily is recommended as an alternative for patients who are intolerant of or allergic to aspirin. (Level of Evidence: B) Class I

- A P2Y12 receptor antagonist in combination with aspirin is indicated in patients after ACS or PCI with stent placement. (Level of Evidence: A) For patients receiving a bare-metal stent or drug-eluting stent during PCI for ACS, clopidogrel 75 mg daily, prasugrel 10 mg daily, or ticagrelor 90 mg twice daily should be given for at least 12 months. (Level of Evidence: A) Class I

- For patients undergoing coronary artery bypass grafting, aspirin should be started within 6 hours after surgery to reduce saphenous vein graft closure. Dosing regimens ranging from 100 to 325 mg daily for 1 year appear to be efficacious.  (Level of Evidence: A) Class I

- In patients with extracranial carotid or vertebral atherosclerosis who have had ischemic stroke or TIA, treatment with aspirin alone (75-325 mg daily), clopidogrel alone (75 mg daily), or the combination of aspirin plus extended-release dipyridamole (25 mg and 200 mg twice daily, respectively) should be started and continued.  (Level of Evidence: B) Class I

- For patients with symptomatic atherosclerotic peripheral artery disease of the lower extremity, antiplatelet therapy with aspirin (75-325 mg daily) or clopidogrel (75 mg daily) should be started and continued.  (Level of Evidence: A) Class I

- Antiplatelet therapy is recommended in preference to anticoagulant therapy with warfarin or other vitamin K antagonists to treat patients with atherosclerosis. (Level of Evidence: A) Class I

GUIDELINES FOR THE PREVENTION OF STROKE IN PATIENTS WITH STROKE AND TRANSIENT ISCHEMIC ATTACK: 2014:

- For patients with noncardioembolic ischemic stroke or TIA, the use of antiplatelet agents rather than oral anticoagulation is recommended to reduce the risk of recurrent stroke and other cardiovascular events (Class I; Level of Evidence A).

-  Aspirin (50-325 mg/d) monotherapy (Class I; Level of Evidence A) or the combination of aspirin 25 mg and extended-release dipyridamole 200 mg twice daily (Class I; Level of Evidence B) is indicated as initial therapy after TIA or ischemic stroke for prevention of future stroke. (Revised recommendation)

- Clopidogrel (75 mg) monotherapy is a reasonable option for secondary prevention of stroke in place of aspirin or combination aspirin/dipyridamole (Class IIa; Level of Evidence B). This recommendation also applies to patients who are allergic to aspirin.

- For patients with noncardioembolic ischemic stroke or TIA, the use of antiplatelet agents rather than oral anticoagulation is recommended to reduce the risk of recurrent stroke and other cardiovascular events (Class I; Level of Evidence A).

Higher score indicates better quality

Antiplatelet Trialists' Collaboration. Collaborative overview of randomised trials of antiplatelet therapy. I. Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ. 1994;308:81-106.

Antithrombotic Trialists' Collaboration Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002;324:71-86.

Antithrombotic Trialists' (ATT) Collaboration; Baigent C, Blackwell L, Collins R, Emberson J, Godwin J, Peto R, Buring J, Hennekens C, Kearney P, Meade T, Patrono C, Roncaglioni MC, Zanchetti A. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta analysis of individual participant data from randomized trials. Lancet. 2009;373:1849-1860.

Cheng JW. Updates in antiplatelet agents used in cardiovascular diseases. J Cardiovas Pharmacol Ther. 2013;18(6):514-524.

Heidenreich, P.A., J.G. Trogdon, O.A. Khavjou, et al. 2011. "Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association." Circulation.123:933-944.

Benjamin, E.J., M.J. Blaha, et al. 2017. "Heart disease and stroke statistics 2017 update: a report from the American Heart Association." Circulation. 135(10): e146-e603. doi:10.1161/CIR.0000000000000485.

Wong PF, Chong LY, Mikhailidis DP, Robless P, Stansby G. Antiplatelet agents for intermittent claudication. Cochrane Database of Systematic Reviews 2011, Issue 11. Art. No.: CD001272. DOI: 10.1002/14651858.CD001272.pub2.

Smith SC Jr, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, Gibbons RJ, Grundy SM, Hiratzka LF, Jones DW, Lloyd-Jones DM, Minissian M, Mosca L, Peterson ED, Sacco RL, Spertus J, Stein JH, Taubert KA. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011;124: 00-00.

Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, Fang MC, Fisher M, Furie KL, Heck DV, Johnston SC, Kasner SE, Kittner SJ, Mitchell PH, Rich MW, Richardson D, Schwamm LH, Wilson JA; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45:2160-2236.

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TBD

Patients 18 years of age and older with a visit during the measurement period who had an AMI, CABG, or PCI during the 12 months prior to the measurement year or who had a diagnosis of IVD overlapping the measurement year 

Equals Initial Population

Patients who had documentation of use of anticoagulant medications overlapping the measurement year.
Exclude patients whose hospice care overlaps the measurement period.

Patients who had an active medication of aspirin or another antiplatelet during the measurement year

Not Applicable

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For every patient evaluated by this measure also identify payer, race, ethnicity and sex

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