Editorial comment
Aspirin: The end of a myth
Aspirina: o fim de um mito
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BMI: body mass index; CVD: cardiovascular disease; CVRFs: cardiovascular risk factors; LDL: low-density lipoprotein.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Helena Cardoso, Carlos Tavares Bello, Luís Andrade, Francisco Sobral do Rosário, Joana Louro, Cláudia Nogueira, Elisabete Rodrigues, Nuno Bernardino Vieira, Teresa Carqueja" "autores" => array:10 [ 0 => array:2 [ "nombre" => "Helena" "apellidos" => "Cardoso" ] 1 => array:2 [ "nombre" => "Carlos" "apellidos" => "Tavares Bello" ] 2 => array:2 [ "nombre" => "Luís" "apellidos" => "Andrade" ] 3 => array:2 [ "nombre" => "Francisco" "apellidos" => "Sobral do Rosário" ] 4 => array:2 [ "nombre" => "Joana" "apellidos" => "Louro" ] 5 => array:2 [ "nombre" => "Cláudia" "apellidos" => "Nogueira" ] 6 => array:2 [ "nombre" => "Elisabete" "apellidos" => "Rodrigues" ] 7 => array:2 [ "nombre" => "Nuno Bernardino" "apellidos" => "Vieira" ] 8 => array:2 [ "nombre" => "Teresa" "apellidos" => "Carqueja" ] 9 => array:1 [ "colaborador" => "on behalf of the PICT2RE Investigators" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255123000495?idApp=UINPBA00004E" "url" => "/08702551/0000004200000004/v2_202304070551/S0870255123000495/v2_202304070551/en/main.assets" ] "itemAnterior" => array:17 [ "pii" => "S0870255123000501" "issn" => "08702551" "doi" => "10.1016/j.repc.2022.03.007" "estado" => "S300" "fechaPublicacion" => "2023-04-01" "aid" => "2100" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2023;42:307-13" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Adherence to European guidelines for the use of aspirin in primary health care" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "307" "paginaFinal" => "313" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Adesão às recomendações europeias para o uso de ácido acetilsalicílico nos cuidados de saúde primários" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 896 "Ancho" => 1500 "Tamanyo" => 44173 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Antiplatelet therapy prescribed in the units under study in individuals without previous cardiovascular events. USFSJ: S. Julião Family Health Unit; USFSMA: S. Martinho de Alcabideche Family Health Unit.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Catarina Ferreira Moita, Gonçalo Marau, Susana Corte-Real, Ana Dantas" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Catarina" "apellidos" => "Ferreira Moita" ] 1 => array:2 [ "nombre" => "Gonçalo" "apellidos" => "Marau" ] 2 => array:2 [ "nombre" => "Susana" "apellidos" => "Corte-Real" ] 3 => array:2 [ "nombre" => "Ana" "apellidos" => "Dantas" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255123000501?idApp=UINPBA00004E" "url" => "/08702551/0000004200000004/v2_202304070551/S0870255123000501/v2_202304070551/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Aspirin: The end of a myth" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "315" "paginaFinal" => "317" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Luís Bronze" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Luís" "apellidos" => "Bronze" "email" => array:1 [ 0 => "luis.bronze@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Naval School, Portuguese Navy, Lisboa, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "University of Beira Interior (UBI), Covilhã, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Aspirina: o fim de um mito" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1690 "Ancho" => 3000 "Tamanyo" => 446950 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The spectrum of aspirin use in cardiovascular disease over the years. Low-dose aspirin (a COX 1 inhibitor) has been widely used in the prevention of arterial atherothrombosis and sometimes as an adjunctive agent in venous thromboembolism; it has also been proposed as possibly able to curb vascular inflammation. At higher dosages, it is still used in pericarditis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">From ancient times salicylate-containing plants, such as the willow, have been commonly used to relieve pain and fever. In the 20th century, scientists discovered the details of aspirin's anti-inflammatory and analgesic properties, including its molecular mechanism of action. In addition, in the latter half of the century, the use of daily low-dose aspirin was associated with the prevention of myocardial infarction and stroke.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1,2</span></a> Aspirin is now widely used in human medicine and has effectively become a household drug, mainly due to its widespread use as an analgesic and general anti-inflammatory agent.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The main capabilities of aspirin in cardiovascular disease are depicted in <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> and are widely accepted.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> Some authors still associate aspirin with capabilities in other areas, like the prevention of colon cancer or the prevention of dementia.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3,4</span></a> These connections are still unproven.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> There was also a relatively recent suggestion that low-dose aspirin can curb vascular inflammation, the biological genesis of atherosclerosis.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> This assumption is also hotly debated.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">It is clear that the side effects (especially gastrointestinal bleeding) of this widely used agent have not deterred patients and health authorities everywhere from over-the-counter sales of the drug. As a result, low-dose aspirin has become the cornerstone of primary and secondary prevention in cardiovascular medicine.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">7,8</span></a> Its mechanisms (and the ways in which they fail) have been extensively studied.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Some of the readers of the study by Moita et al.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> in this issue of the <span class="elsevierStyleItalic">Journal</span> might find the analysis presented awkward. In fact, the guidelines on both sides of the Atlantic have changed and aspirin in primary prevention is now reserved for high-risk patients (sometimes a difficult assessment). However, low-dose aspirin remains the cornerstone for secondary prevention.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">11,12</span></a> This change of attitude has occurred, as the authors rightly point out, due to the risk of gastric bleeding associated with chronic aspirin use.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Moita et al.’s work is important, firstly because the prevalence of aspirin use in primary prevention in the Portuguese general practice setting under study was still relatively high, albeit mostly associated with high or very high cardiovascular risk (>50% of patients). However, hypertension was the most prevalent risk factor. This raises an important issue, since the relationship between hypertension and aspirin is still problematic, mainly due to vasomotor changes induced by chronic aspirin use and in the interaction between aspirin and some antihypertensive drugs.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> The risk of cerebrovascular bleeding in uncontrolled hypertensive patients (a common occurrence in this common condition) is also higher, so aspirin should not be used in hypertensive patients unless previously established cardiovascular disease is present.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">This paper is also important because it depicts the idiosyncrasy of Portuguese medical practice concerning the dosages used, in both primary and secondary prevention. In fact, the lowest possible dosage should be used, ‘low-dose’ being universally defined as between 75 and 100 mg/day.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">11,12</span></a> For reasons related to the Portuguese medical reimbursement system, as Moita et al. explain, the 150 mg dose is predominant in both primary and secondary prevention, because it is cheaper. Unfortunately, to my knowledge, there has been no study in Portugal comparing the use of lower dosages (<150 mg daily) versus 150 mg in terms of the risk of gastric bleeding. Nevertheless, higher doses would be expected to entail a higher gastrointestinal bleeding risk. This is clearly an important point that merits the attention of the country's health authorities, as the authors duly point out.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Generally, I believe this information to be crucial in alerting us to important problems currently facing physicians regarding the use of aspirin. Firstly, it is common knowledge among patients themselves that aspirin is important in preventive cardiovascular medicine, so those already taking aspirin for primary prevention (sometimes for years) may find it strange if they are told not to take it (even if they have gastric lesions induced by chronic aspirin use, or are forced to take a proton pump inhibitor). On the other hand, many patients do not adhere to aspirin prescription in secondary prevention, as Moita et al.’s study demonstrates. Non-adherence to treatment is a real problem in many chronic non-transmissible conditions, and is also related to physicians’ own therapeutic inertia.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, this work should make us rethink our practice, in order to ensure careful selection of patients to be placed in primary prevention. This selection should include a detailed analysis of their cardiovascular risk, especially in older people in whom the bleeding risk is higher.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">11,16</span></a> We should also have the courage to discontinue aspirin in doubtful cases.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The myth of ‘aspirin for all’ in cardiovascular medicine is gone. The current paradigm requires active doctors and informed patients. This is, I believe, the underlying message of the present study, for which the authors are to be congratulated. Aspirin will still be an important and cheap drug all over the world, especially in very low-income countries, where it is still a valuable antipyretic and anti-inflammatory agent. In some of these countries, in which I have had the honor of working, one is truly happy to have this universal drug. Thus, many believe this ‘all-terrain’ pharmaceutical wonder will still be around for a long while. I am glad it will be so.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1690 "Ancho" => 3000 "Tamanyo" => 446950 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The spectrum of aspirin use in cardiovascular disease over the years. Low-dose aspirin (a COX 1 inhibitor) has been widely used in the prevention of arterial atherothrombosis and sometimes as an adjunctive agent in venous thromboembolism; it has also been proposed as possibly able to curb vascular inflammation. At higher dosages, it is still used in pericarditis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Discovery and pre-clinical development of antithrombotics from hematophagous invertebrates" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Ledizet" 1 => "L.M. Harrison" 2 => "R.A. 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