背景:由于成本的降低和简单性,polypill策略可以在心血管预防中被广泛接受,促进合规。阿司匹林通常作为一级预防的复方制剂的组成部分,但最近三项有力的试验未能显示即使在高风险亚组中也有任何有利的净获益.我们的目的是评估与阿司匹林相关的心血管一级预防的净获益。
方法:我们模拟了普伐他汀,雷米普利,氢氯噻嗪,有或没有阿司匹林,在35至65岁之间的真实法国虚拟人口中。我们评估了这种对心肌梗死和中风的影响如何根据性别而变化,糖尿病,动脉高血压.我们确定了个体的亚组,其从阿司匹林中的特定益处大于其引起的严重出血风险的两倍。
结果:联合处方降低了与阿司匹林相关的绝对获益。没有女性亚组受益于阿司匹林,在529421人中,有128名妇女是有明确净福利的妇女。心血管死亡风险高的男性,或者患有糖尿病和高血压,从阿司匹林中获益超过了引起出血的风险,但这种风险占收益的一半以上。没有分析的亚组显示出超过出血风险两倍的益处。预期从阿司匹林获益超过出血风险两倍的男性比例占所有男性的3%。在35岁至65岁之间的一级预防中,一种最佳的polypill策略,结合三种药物而不是阿司匹林,可以希望挽救三个中风中的两个和两个心肌梗塞中的一个以上。根据所考虑的亚组,每16至193名个体治疗一次重大心血管事故。
结论:除非另有证明,阿司匹林在35至65岁无心血管病史的个体中的地位有限。我们展示了如何在现实的虚拟人群上模拟治疗策略可用于最佳应用现有证据。
BACKGROUND: The polypill strategy could become widely accepted in cardiovascular prevention due to reduced costs and its simplicity, which promote compliance. Aspirin is often included as a component of the polypill for primary prevention, but three powerful recent trials failed to show any favorable net benefit even in high-risk subgroups. Our objective is to estimate the net benefit associated with aspirin in primary cardiovascular prevention.
METHODS: We simulated the impact of different polypill compositions combining pravastatin, ramipril, hydrochlorothiazide, with or without aspirin, on a realistic French virtual population between 35 and 65 years old. We assessed how this impact on myocardial infarction and stroke varied according to gender, diabetes, and arterial hypertension. We identified the subgroup of individuals whose specific benefit from aspirin was greater than twice the risk of serious bleeding it induced.
RESULTS: The absolute benefit associated with aspirin was reduced by co-prescriptions. No subgroup of women benefited from aspirin, and the subgroup of women with a clear net benefit represented 128 women out of 529,421. Men at high risk of cardiovascular death, or with diabetes and hypertension, had a benefit from aspirin exceeding the risk of bleeding induced, but this risk represented more than half of the benefit. No subgroup analyzed did show a benefit greater than twice the risk of bleeding. The proportion of men whose expected benefit from aspirin was greater than twice the risk of bleeding represented 3% of all men. An optimal polypill strategy in primary prevention between the ages of 35 and 65, combining three drugs but not aspirin, can hope to save two out of three strokes and more than one out of two myocardial infarctions. It would prevent a major cardiovascular accident every 16 to 193 individuals treated according to the subgroups considered.
CONCLUSIONS: Until proven otherwise, aspirin has only a limited place in individuals between 35 and 65 years without a cardiovascular history. We showed how simulating therapeutic strategies on a realistic virtual population could be used for best applying available evidence.