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Aspirin for Chest Pain (Early vs. Late)

Question Type:
Intervention
Full Question:
Among adults who are experiencing chest pain outside of a hospital (P), does prehospital administration of aspirin (I), compared with later administration of aspirin (C), change cardiovascular mortality, complications, incidence of cardiac arrest, cardiac functional outcome, infarct size, hospital length of stay, chest pain resolution (O)?
Consensus on Science:
In this review, early administration of aspirin is defined as prehospital or administration in the first hours from onset of symptoms of MI (ie, median 1.6 hours in 1 study).(Freimark 2002, 381) For the critical outcome of cardiovascular mortality (at 7 days), we identified very-low-quality evidence (downgraded for risk of bias and indirectness) from 2 observational studies(Barbash 2002, 141; Freimark 2002, 381) with a total of 2122 patients with acute MI showing benefit to early aspirin administration (RR, 0.37; 95% CI, 0.23–0.62). For the critical outcome of cardiovascular mortality (at 30 days), we identified very-low-quality evidence (downgraded for risk of bias and indirectness) from 2 observational studies(Barbash 2002, 141; Freimark 2002, 381) with a total of 2122 patients with acute MI showing benefit to early aspirin administration (RR, 0.45; 95% CI, 0.3–0.68). For the critical outcome of cardiovascular mortality (at 5 weeks), we identified low-quality evidence (downgraded for indirectness) from 1 RCT(1988, 349) enrolling 8587 patients with acute MI showing no benefit to aspirin (162.5 mg, enteric-coated) administration within 2 hours of symptom onset (RR, 0.92; 95% CI, 0.76–1.11). For the critical outcome of cardiovascular mortality (at 1 year), we identified very-low-quality evidence (downgraded for indirectness) from 1 observational study(Freimark 2002, 381) with 1200 patients with acute MI showing benefit to early aspirin (160 mg, oral) administration (RR, 0.47; 95% CI, 0.29–0.77). For the critical outcome of complications, we identified very-low-quality evidence (downgraded for indirectness) from 1 observational study (Barbash 2002, 141) with a total of 922 patients with acute MI showing no increase in complication rate with early aspirin (greater than 200 mg, chewable) administration (RR, 0.61; 95% CI, 0.46–0.81). We also identified very-low-quality evidence (downgraded for risk of bias and indirectness) from 1 observational study(Freimark 2002, 381) with a total of 1200 patients with acute MI demonstrating an increase in complications (such as re-ischemia) in the group that received early aspirin (160 mg, oral) administration (RR, 1.22; 95% CI, 1.09–1.37). For the critical outcome of incidence of cardiac arrest, we identified very-low-quality evidence (downgraded for indirectness) from 1 observational study(Barbash 2002, 141) with a total of 922 patients with acute MI showing no benefit to early aspirin (greater than 200 mg, chewable) administration (RR, 0.82; 95% CI, 0.56–1.2) and very-low-quality evidence (downgraded for risk of bias and indirectness) from 1 observational study(Freimark 2002, 381) with a total of 1200 patients with acute MI demonstrating an increased incidence of cardiac arrest in the group that received early aspirin (160 mg, oral) administration (RR, 1.53; 95% CI, 1.13–2.09). We did not identify any evidence to address the important outcomes of cardiac functional outcome, infarct size, or hospital length of stay or the low importance outcome of chest pain resolution.
Treatment Recommendation:
We suggest the early administration of aspirin by first aid providers to adults with chest pain due to suspected MI (weak recommendation, very-low-quality evidence). There is no evidence for the early administration of aspirin by first aid providers to adults with chest pain of unclear etiology. Values, Preferences, and Task Force Insights In making this recommendation, we place a higher value on the benefits of aspirin, such as decreased mortality from MI, which outweigh possible risks of complications. The task force discussed concerns about first aid providers being able to differentiate chest pain of cardiac origin from other causes of chest discomfort. With any treatment recommendations naming a particular clinical pathology, such as in this case with MI or chest pain of cardiac origin, it is very important that guidelines or educational materials clearly indicate what signs and symptoms the first aid provider should look for to recognize that clinical presentation.
CoSTR Attachments:
ASA Early vs Late GRADE tables 2015 01 18.pdf    
ILCOR Data Collection Form - ASA for CP Early vs Late 2014 12 12.xls    

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