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Aspirin for Chest Pain (administration)

Question Type:
Intervention
Full Question:
Among adults experiencing chest pain due to suspected myocardial infarction
 (P), does administration of aspirin
 (I), compared with no administration of aspirin
 (C), change cardiovascular mortality , complications, adverse effects, incidence of cardiac arrest, cardiac functional outcome, infarct size, hospital length of stay (O)?
Consensus on Science:
For the critical outcome of cardiovascular mortality (at 5 weeks), we identified high-quality evidence from 1 RCT(1988, 349-360) enrolling 17 187 patients with acute MI showing benefit to aspirin (162.5 mg, enteric-coated) administration (RR, 0.79; 95% CI, 0.73–0.87). For the critical outcome of cardiovascular mortality (at 3 months), we identified very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 RCT(Verheugt 1990, 267) enrolling 100 patients with acute MI showing no benefit to aspirin (100 mg, capsule) administration (RR, 0.83; 95% CI, 0.4–1.75). For the critical outcome of cardiovascular mortality (at 28 days), we identified low-quality evidence (downgraded for risk of bias and indirectness) from 1 RCT(Elwood 1979, 413) enrolling 1705 patients with acute MI showing no benefit to aspirin (300 mg, capsule) administration (RR, 0.98, CI, 0.81–1.19). For the critical outcome of cardiovascular mortality (in-hospital), we identified very-low-quality evidence (downgraded for risk of bias and indirectness) from 1 observational study(Frilling 2001, 200) with a total of 22 572 patients with acute MI showing benefit to aspirin (500 mg, oral or intravenous loading dose; 100 mg, oral; maintenance recommended) administration (RR, 0.33; 95% CI, 0.31–0.35). For the critical outcome of adverse effects (bleeding), we identified high-quality evidence from 1 RCT(1988, 349) enrolling 16 981 patients with acute MI showing adverse effects (minor bleeding) with aspirin (162.5 mg, enteric-coated) administration (RR, 1.25; 95% CI, 1.04–1.51). For the critical outcome of adverse effects (allergic reaction), we identified very-low-quality evidence (downgraded for risk of bias and imprecision) from 1 observational study(Quan 2004, 362) with 219 patients with suspected acute MI showing no adverse effects (allergic reaction) with aspirin (dose not available) administration (unable to calculate RR as there was no control group). For the critical outcome of complications, we identified high-quality evidence from 1 RCT(1988, 349) enrolling 16 981 patients with acute MI showing benefit to aspirin (162.5 mg, enteric-coated) administration (RR, 0.62; 95% CI, 0.52–0.73). We also found very-low-quality evidence (downgraded for risk of bias, imprecision, and indirectness) from 1 RCT(Verheugt 1990, 267) enrolling 100 patients with acute MI showing benefit to aspirin (100 mg, capsule) administration (RR, 0.11; 95% CI, 0.05–0.98). We identified very-low-quality evidence (downgraded for risk of bias and indirectness) from 1 observational study(Frilling 2001, 200) with a total of 22 572 patients with acute MI showing no benefit to aspirin (500 mg oral or intravenous loading, 100 mg oral maintenance recommended) administration (RR, 1.05; 95% CI, 0.78–1.42). For the critical outcome of incidence of cardiac arrest, we identified high-quality evidence from 1 RCT(1988, 349) enrolling 16 981 patients with acute MI showing benefit to aspirin (162.5 mg, enteric-coated) administration (RR, 0.87; 95% CI, 0.79–0.96). For the important outcome of infarction size, we identified very-low-quality evidence (downgraded for bias, imprecision, and indirectness) from 1 RCT(Verheugt 1990, 267) enrolling 89 patients with acute MI showing no benefit to aspirin (100 mg, capsule) administration (MD, −161; 95% CI, −445.57 to 230.57). We did not identify any evidence to address the important outcomes of cardiac functional outcome or length of hospital stay.
Treatment Recommendation:
We recommend the administration of aspirin to adults with chest pain due to suspected MI (strong recommendation, high-quality evidence). Values, Preferences, and Task Force Insights In making this recommendation, we place a higher value on decreasing mortality and decreased complications of MI over the risks of adverse effects, such as bleeding. Public comments for this question requested a suggestion for the optimal aspirin dose and form. Our PICO question was not designed to look at changes in outcomes based on various doses of aspirin, as all the articles selected for review compared administration to no administration, as opposed to 1 dose compared with another. Due to the heterogeneity in study design in the articles that were included in this review, the dose and form (eg, chewable or nonchewable, enteric-coated or nonenteric coated) of aspirin varied, and no recommendation could be made regarding the optimal dose or form of aspirin administered. Where available, the dose of aspirin used for each study has been identified in the consensus on science statement.
CoSTR Attachments:
ASA for chest pain GRADE tables 2015 01 05.pdf    
FA 871 - Aspirin for chest pain (administration) 2.pdf    
ILCOR Data Collection Form - ASA for CP - First Aid 2014 12 12.xls    

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