ABCS Aspirin Treatment for Secondary and - PowerPoint Presentation

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ABCS Aspirin Treatment for Secondary and Primary Prevention ASCVD

Jennifer Bannon RN BSN MSHI

Table of Contents

Objectives

Cardiovascular Disease

Cardiovascular Disease (2)

ABCS-Aspirin when appropriate

Anatomy of a Performance Measure

Measure Exceptions

Aspirin and Antiplatelet Drugs in Ischemic Vascular Disease

Other secondary prevention uses

Other secondary prevention uses (2)

Aspirin for Primary Prevention

Aspirin for Primary Prevention Updated April 2016

Aspirin and Antiplatelet Drugs in IVD—Work Flow

Aspirin and Antiplatelet Drugs in Ischemic Vascular

Disea

...

Point of Care Tools

ASCVD Risk Calculator app

NIH Heart attack assessment tool

Point of Care Tools (2)

Aspirin Guide medical app

ePSS

app

Questions????

Objectives

Cardiovascular disease overview

Aspirin quality measure definition

Aspirin in secondary prevention

Aspirin in primary prevention

Possible interventions to improve aspirin measure

Point of care tools to assist in prevention

Cardiovascular Disease

Diseases caused by atherosclerosis (heart attack/MI, angina, sudden death, many strokes, peripheral arterial disease)

Also includes disease of the heart and circulation that may be from causes other than atherosclerosis (some heart failure, some stroke)

Cardiovascular Disease (2)

Leading killer

Huge declines in CVD death in the past 20 years (more than 50%)

Declines are due to a combination of

Better acute care (e.g. for heart attack and stroke)

Better treatment of cardiovascular risk

Secondary prevention (treating people who already have clinical manifestations of the disease)

Primary Prevention (treating people at risk for the development of disease)

ABCS-Aspirin when appropriate

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

Percentage of patients aged 18 years and older with IVD with documented use of aspirin or another antithrombotic

NQF #0068, PQRS #204

Anatomy of a Performance Measure

Denominator: who is eligible to be measured in the first place

Numerator: criteria indicating the measure was met

Exceptions: criteria that may be looked for if the numerator was not met

Data must be in a discrete field in order to be captured as EHR

eCQMs

Data may not be included if start dates are not recorded for medications and diagnosis.

Measure Exceptions

Adverse effect, allergy, or intolerance to Aspirin and Plavix (

Clopidogrel

).

Patient is taking another antithrombotic or anticoagulant such as Coumadin (Warfarin).

Patient is at a high risk for bleeding (i.e. GI hemorrhage, bleeding disorders documented).

Patient is receiving palliative care.

Aspirin and Antiplatelet Drugs inIschemic Vascular Disease

Secondary

prevention

is where the evidence is the best

Reduces risk of vascular events by about 22%

Typical ASA dose 81 to 162 mg per day

Alternatives may be used (e.g. clopidogrel)

Serious bleeding is increased with daily aspirin. Benefits usually outweigh the risks for secondary prevention.

Other secondary prevention uses

For patients undergoing coronary artery bypass grafting, aspirin should be started within 6 hours after surgery to reduce saphenous vein graft closure

In patients with extracranial carotid or vertebral atherosclerosis who have had ischemic stroke or TIA, treatment with aspirin alone (75-325 mg daily), Plavix alone (75 mg daily) or the combination of Aspirin and Dipyridamole should be started and continued.

Other secondary prevention uses (2)

For patients with

symptomatic

atherosclerotic peripheral artery disease of the lower extremity, antiplatelet therapy with Aspirin (75-325 mg daily) or Plavix (75 mg daily) should be started and continued.

Antiplatelet therapy is recommended in preference to anticoagulant therapy with warfarin or other vitamin K antagonists to treat patients with atherosclerosis.

Aspirin for Primary Prevention

http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/aspirin-to-prevent-cardiovascular-disease-and-cancer

Complex because of bleeding risk vs. CVD prevention trade off

Use of warfarin in conjunction with aspirin and/or

plavix

is associated with an increased risk of bleeding and should be monitored closely.

Also, recent studies have shown that aspirin may prevent

colo

-rectal cancer

Aspirin for Primary Prevention Updated April 2016

 U.S. Preventive Services Task Force (USPSTF) Draft recommendations (September, 2015)

Population

Recommendation

Grade

Adults ages 50 to 59 years

The USPSTF recommends low-dose aspirin use for the primary prevention of cardiovascular disease (CVD) and colorectal cancer in adults ages 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years.

B

Adults ages 60 to 69 years

The decision to use low-dose aspirin to prevent CVD and colorectal cancer in adults ages 60 to 69 years who have a greater than 10% 10-year CVD risk should be an individual one. Persons who are not at increased risk for bleeding, have a life expectancy of at least 10 years, and ar1e willing to take low-dose aspirin daily for at least 10 years are more likely to benefit. Persons who place a higher value on the potential benefits than the potential harms may choose to use low-dose aspirin.

C

Adults younger than age 50 years

The current evidence is insufficient to assess the balance of benefits and harms of aspirin use to prevent CVD and colorectal cancer in adults younger than age 50 years.

I

Adults age 70 years and older

The current evidence is insufficient to assess the balance of benefits and harms of aspirin use to prevent CVD and colorectal cancer in adults age 70 years and older

I

Aspirin and Antiplatelet Drugs inIVD—Work Flow

Drugs, including aspirin must be captured on EHR medication lists; it needs to be documented like a regular prescription

Point of Care (POC) Clinical Decision Support (CDS) can be used to prompt clinicians at point of care.

Population Management (PM): Lists of patients not meeting measure can be generated and used for outreach (staff generated calls, mailings, portal)

Aspirin and Antiplatelet Drugs inIschemic Vascular Disease (2)

Address how to record medical or other reasons for deviating from recommendation (options: within CDS, annotated problem list, encounter note, other)

Goal is to inform future action

Example aspirin held because of a bleeding ulcer but after appropriate treatment the ulcer has healed and the patient uses acid suppression

 how will clinician remember to restart the aspirin

Point of Care Tools

ASCVD External Calculator

: Calculate your 10-year risk of heart disease or stroke using the ASCVD algorithm published in

2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk

.

http://www.cvriskcalculator.com/

ASCVD Risk Calculator app

This app is intended as a companion tool to the 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk and the 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to reduce Atherosclerotic Cardiovascular Risk in Adults.

The ASCVD Risk Estimator provides easy access to recommendations specific to the risk estimates produced by the calculator. Additionally, the app includes readily accessible guideline reference information for both providers and patients related to therapy, monitoring, and lifestyle.

NIH Heart attack assessment tool

http://cvdrisk.nhlbi.nih.gov/

The risk assessment tool uses information from the Framingham Heart Study to predict a person’s chance of having a heart attack in the next 10 years.

This tool is designed for adults aged 20 and older who do not have heart disease or diabetes.

Point of Care Tools (2)

The

Aspirin Guide medical app

http://www.imedicalapps.com/2016/06/aspirin-guide-uses-evidence-based-medicine-bring-uspstf-aspirin-recommendations-life/#

Calculates a patient’s risk of cardiovascular disease using the AHA/ACC pooled equations calculator, a bleeding risk score using the most current evidence on bleeding and aspirin use to derive a patient’s likely benefits and risks of aspirin therapy.

Aspirin Guide medical app

Free

Simple to use interface with easy data input and includes graphic of algorithm.

Provides explanation of results including patient-friendly statistics.

Contains links to references and the USPSTF guideline.

Not available

for Android at this time.

ePSS app

ePSS

(Electronic Preventive Services Selector)

http://epss.ahrq.gov/PDA/index.jsp

The

ePSS

is an app designed to help primary care clinicians identify clinical preventive services that are appropriate for their patients. Use the tool to search and browse U.S. Preventive Services Task Force (USPSTF) recommendations on the web or on your PDA or mobile device.

Questions????

Jennifer Bannon RN BSN MSHI

jennifer.bannon@ama-assn.org

312-623-3934