IMPORTANCE: Aspirin is an effective and low-cost option for reducing atherosclerotic cardiovascular disease (CVD) events and improving mortality rates among individuals with established CVD. To guide efforts to mitigate the global CVD burden, there is a need to understand current levels of aspirin use for secondary prevention of CVD. OBJECTIVE: To report and evaluate aspirin use for secondary prevention of CVD across low-, middle-, and high-income countries. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analysis using pooled, individual participant data from nationally representative health surveys conducted between 2013 and 2020 in 51 low-, middle-, and high-income countries. Included surveys contained data on self-reported history of CVD and aspirin use. The sample of participants included nonpregnant adults aged 40 to 69 years. EXPOSURES: Countries' per capita income levels and world region; individuals' socioeconomic demographics. MAIN OUTCOMES AND MEASURES: Self-reported use of aspirin for secondary prevention of CVD. RESULTS: The overall pooled sample included 124 505 individuals. The median age was 52 (IQR, 45-59) years, and 50.5% (95% CI, 49.9%-51.1%) were women. A total of 10 589 individuals had a self-reported history of CVD (8.1% [95% CI, 7.6%-8.6%]). Among individuals with a history of CVD, aspirin use for secondary prevention in the overall pooled sample was 40.3% (95% CI, 37.6%-43.0%). By income group, estimates were 16.6% (95% CI, 12.4%-21.9%) in low-income countries, 24.5% (95% CI, 20.8%-28.6%) in lower-middle-income countries, 51.1% (95% CI, 48.2%-54.0%) in upper-middle-income countries, and 65.0% (95% CI, 59.1%-70.4%) in high-income countries. CONCLUSION AND RELEVANCE: Worldwide, aspirin is underused in secondary prevention, particularly in low-income countries. National health policies and health systems must develop, implement, and evaluate strategies to promote aspirin therapy.

Africa Health Research Institute Somkhele and Durban South Africa

Bergen Centre for Ethics and Priority Setting in Health Department of Global Public Health and Primary Care University of Bergen Bergen Norway

Brigham and Women's Hospital Harvard Medical School Boston Massachusetts

Cardiovascular Division Department of Internal Medicine Washington University in St Louis St Louis Missouri

Center for Cardiovascular Prevention 1st Faculty of Medicine and Thomayer University Hospital Charles University Prague Prague Czechia

Center for Clinical Management Research VA Ann Arbor Healthcare System Ann Arbor Michigan

Center for Indigenous Health Research Wuqu' Kawoq Tecpán Guatemala

Centre for Chronic Disease Control New Delhi India

Centre for Global Surgery Department of Global Health Stellenbosch University Cape Town South Africa

Departamento de Clínica Médica Universidade Federal de Minas Gerais Belo Horizonte Brazil

Department of Community Medicine and Public Health Institute of Medicine Tribhuvan University Kathmandu Nepal

Department of Epidemiology and Biostatistics School of Public Health Makerere University Kampala Uganda

Department of Global Health and Population Harvard T H Chan School of Public Health Harvard University Boston Massachusetts

Department of Global Health and Social Medicine Harvard Medical School Harvard University Boston Massachusetts

Department of Internal Medicine MKPGMS Uganda Martyrs University Kampala Uganda

Department of Internal Medicine University of Michigan Ann Arbor

Department of Medicine 2 1st Faculty of Medicine Charles University Prague Prague Czechia

Department of Medicine and Global Health Center Washington University in St Louis St Louis Missouri

Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago Illinois

Department of Public Health and Forensic Sciences and Medical Education Faculty of Medicine University of Porto Porto Portugal

Department of Sport and Health Sciences Technical University of Munich Munich Germany

Division of Global Health Equity Brigham and Women's Hospital Boston Massachusetts

Division of Infectious Diseases Brigham and Women's Hospital Harvard Medical School Boston Massachusetts

Division of Non Communicable Diseases Ministry of Health Nairobi Kenya

Division of Primary Care and Population Health Stanford University Stanford California

Endocrinology and Metabolism Research Center Endocrinology and Metabolism Clinical Sciences Institute Tehran University of Medical Sciences Tehran Iran

Epidemiology and Population Health Department Faculty of Health Sciences American University of Beirut Beirut Lebanon

EPIUnit Institute of Public Health University of Porto Porto Portugal

Faculty of Medicine and Health Sciences National University of East Timor Dili Timor Leste

Faculty of Medicine Eduardo Mondlane University Maputo Mozambique

Faculty of Medicine The Institute of Global Health University of Geneva Geneva Switzerland

Harvard Center for Population and Development Studies Harvard University Cambridge Massachusetts

Health Research and Epidemiology Unit Ministry of Health Thimphu Bhutan

Heidelberg Institute of Global Health Faculty of Medicine and University Hospital Heidelberg University Heidelberg Germany

INCAP Research Center for Prevention of Chronic Diseases Institute of Nutrition of Central America and Panama Guatemala City Guatemala

Institute for Applied Health Research University of Birmingham Birmingham England

Kiel Institute for the World Economy Kiel Germany

Laboratory for Integrative and Translational Research in Population Health Porto Portugal

Laboratory of Epidemiology of Chronic and Neurological Diseases Faculty of Health Sciences University of Abomey Calavi Cotonou Benin

Medical Practice Evaluation Center Massachusetts General Hospital Harvard Medical School Boston Massachusetts

Medical Research Council Wits University Rural Public Health and Health Transitions Research Unit Faculty of Health Sciences School of Public Health University of the Witwatersrand Johannesburg South Africa

Non Communicable Disease Department National Center for Disease Control and Public Health Tbilisi Georgia

Non Communicable Diseases Research Center Endocrinology and Metabolism Population Sciences Institute Tehran University of Medical Sciences Tehran Iran

Nucleo de Investigaçao Departamento de Medicina Hospital Central do Maputo Maputo Mozambique

Nutrition Department National Center for Public Health Ulaanbaatar Mongolia

Public Health Department Petre Shotadze Tbilisi Medical Academy Tbilisi Georgia

Public Health Promotion and Development Organization Kathmandu Nepal

Serviço de Cardiologia e Cirurgia Cardiovascular Hospital das Clínicas da Universidade Federal de Minas Gerais Belo Horizonte Brazil

St Francis Hospital Nsambya Kampala Uganda

The George Institute for Global Health University of New South Wales Sydney Australia

doi: 10.1001/jama.2022.4983 PubMed

Zobrazit více v PubMed

Awtry EH, Loscalzo J. Aspirin. Circulation. 2000;101(10):1206-1218. doi:10.1161/01.CIR.101.10.1206 PubMed DOI

Fuster V, Sweeny JM. Aspirin: a historical and contemporary therapeutic overview. Circulation. 2011;123(7):768-778. doi:10.1161/CIRCULATIONAHA.110.963843 PubMed DOI

Baigent C, Blackwell L, Collins R, et al. ; Antithrombotic Trialists’ (ATT) Collaboration . Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009;373(9678):1849-1860. doi:10.1016/S0140-6736(09)60503-1 PubMed DOI PMC

Antithrombotic Trialists’ Collaboration . Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002;324(7329):71-86. doi:10.1136/bmj.324.7329.71 PubMed DOI PMC

Raber I, McCarthy CP, Vaduganathan M, et al. . The rise and fall of aspirin in the primary prevention of cardiovascular disease. Lancet. 2019;393(10186):2155-2167. doi:10.1016/S0140-6736(19)30541-0 PubMed DOI

GBD 2019 Diseases and Injuries Collaborators . Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1204-1222. doi:10.1016/S0140-6736(20)30925-9 PubMed DOI PMC

Institute of Medicine Committee on Quality of Health Care in America . Crossing the Quality Chasm. Institute of Medicine; 2001. doi:10.17226/10027 DOI

NCD Countdown 2030 Collaborators . NCD Countdown 2030: efficient pathways and strategic investments to accelerate progress towards the Sustainable Development Goal Target 3.4 in low-income and middle-income countries. Lancet. 2022;399(10331):1266-1278. doi:10.1016/S0140-6736(21)02347-3 PubMed DOI PMC

NCD Countdown 2030 Collaborators . NCD Countdown 2030: worldwide trends in non-communicable disease mortality and progress towards Sustainable Development Goal Target 3.4. Lancet. 2018;392(10152):1072-1088. doi:10.1016/S0140-6736(18)31992-5 PubMed DOI

Sustainable Development Solutions Network . Indicators and a monitoring framework. Accessed February 27, 2023. https://indicators.report/targets/3-4

World Health Organization . NCD Global Monitoring Framework. Accessed January 18, 2023. https://cdn.who.int/media/docs/default-source/ncds/ncd-surveillance/global-ncds-surveillance-monitoring-framework24c84b44-7924-412d-ab83-2dfb88a45169.pdf?sfvrsn=f0d5925_3&;download=true

Manne-Goehler J, Theilmann M, Flood D, et al. . Data resource profile: the Global Health and Population Project on Access to Care for Cardiometabolic Diseases (HPACC). Int J Epidemiol. 2022;51(6):e337-e349. doi:10.1093/ije/dyac125 PubMed DOI

Marcus ME, Manne-Goehler J, Theilmann M, et al. . Use of statins for the prevention of cardiovascular disease in 41 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data. Lancet Glob Health. 2022;10(3):e369-e379. doi:10.1016/S2214-109X(21)00551-9 PubMed DOI PMC

World Bank . World Bank country and lending groups. Accessed January 18, 2023. https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups

Riley L, Guthold R, Cowan M, et al. . The World Health Organization Stepwise Approach to Noncommunicable Disease Risk-Factor Surveillance: methods, challenges, and opportunities. Am J Public Health. 2016;106(1):74-78. doi:10.2105/AJPH.2015.302962 PubMed DOI PMC

Cífková R, Bruthans J, Wohlfahrt P, et al. . 30-Year trends in major cardiovascular risk factors in the Czech population, Czech MONICA and Czech post-MONICA, 1985-2016/17. PLoS One. 2020;15(5):e0232845. doi:10.1371/journal.pone.0232845 PubMed DOI PMC

American Association for Public Opinion Research . 2023 Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys. 10th ed. American Association for Public Opinion Research; 2023.

World Health Organization . Noncommunicable Disease Global Monitoring Framework: Indicator Definitions and Specifications. Published 2014. Accessed May 26, 2022. https://cdn.who.int/media/docs/default-source/inaugural-who-partners-forum/gmf_indicator_definitions_version_nov2014438a791b-16d3-46f3-a398-88dee12e796b.pdf?sfvrsn=4b337764_1&download=true

Smith SC Jr, Benjamin EJ, Bonow RO, et al. ; World Heart Federation and Preventive Cardiovascular Nurses Association . AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011;124(22):2458-2473. doi:10.1161/CIR.0b013e318235eb4d PubMed DOI

Perk J, De Backer G, Gohlke H, et al. ; European Association for Cardiovascular Prevention & Rehabilitation (EACPR); ESC Committee for Practice Guidelines (CPG) . European guidelines on cardiovascular disease prevention in clinical practice (version 2012). Eur Heart J. 2012;33(13):1635-1701. doi:10.1093/eurheartj/ehs092 PubMed DOI

World Health Organization . WHO Package of Essential Noncommunicable (PEN) Disease Interventions for Primary Health Care. World Health Organization; 2020.

World Health Organization . Prevention of Cardiovascular Disease: Guidelines for Assessment and Management of Cardiovascular Risk. World Health Organization; 2007.

Visseren FLJ, Mach F, Smulders YM, et al. ; ESC National Cardiac Societies; ESC Scientific Document Group . 2021 ESC guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021;42(34):3227-3337. doi:10.1093/eurheartj/ehab484 PubMed DOI

World Bank . GNI per capita, PPP (constant 2017 international $). Published 2020. Accessed January 18, 2023. https://data.worldbank.org/indicator/NY.GNP.PCAP.PP.KD

Global Burden of Disease Network . Global Burden of Disease Study 2019 (GBD 2019) population estimates 1950-2019. Published 2020. Accessed May 26, 2022. https://ghdx.healthdata.org/record/ihme-data/gbd-2019-population-estimates-1950-2019

Ahmad OB, Boschi-Pinto C, Lopez AD, Murray CJ, Lozano R, Inoue M. Age Standardization of Rates: A New WHO Standard. World Health Organization, 2001. GPE Discussion Paper Series No. 31. Accessed January 18, 2023. https://cdn.who.int/media/docs/default-source/gho-documents/global-health-estimates/gpe_discussion_paper_series_paper31_2001_age_standardization_rates.pdf

Chen TC, Clark J, Riddles MK, et al. . National Health and Nutrition Examination Survey, 2015-2018: Sample Design and Estimation Procedures. Department of Health and Human Services; 2020. Accessed February 27, 2023. https://stacks.cdc.gov/view/cdc/88305 PubMed

Health Survey for England. UK Data Service; 2023. Accessed February 28, 2023. https://beta.ukdataservice.ac.uk/datacatalogue/series/series?id=2000021#!/abstract

United Nations Department of Economic and Social Affairs, Population Division . World Urbanization Prospects: The 2018 Revision. United Nations; 2018.

Flood D, Geldsetzer P, Agoudavi K, et al. . Rural-urban differences in diabetes care and control in 42 low- and middle-income countries: a cross-sectional study of nationally representative individual-level data. Diabetes Care. 2022;45(9):1961-1970. doi:10.2337/dc21-2342 PubMed DOI PMC

Yusuf S, Islam S, Chow CK, et al. ; Prospective Urban Rural Epidemiology (PURE) Study Investigators . Use of secondary prevention drugs for cardiovascular disease in the community in high-income, middle-income, and low-income countries (the PURE Study): a prospective epidemiological survey. Lancet. 2011;378(9798):1231-1243. doi:10.1016/S0140-6736(11)61215-4 PubMed DOI

Lu J, Zhang L, Lu Y, et al. . Secondary prevention of cardiovascular disease in China. Heart. 2020;106(17):1349-1356. doi:10.1136/heartjnl-2019-315884 PubMed DOI

Boakye E, Uddin SMI, Obisesan OH, et al. . Aspirin for cardiovascular disease prevention among adults in the United States: trends, prevalence, and participant characteristics associated with use. Am J Prev Cardiol. 2021;8:100256. doi:10.1016/j.ajpc.2021.100256 PubMed DOI PMC

García Rodríguez LA, Cea Soriano L, de Abajo FJ, et al. . Trends in the use of oral anticoagulants, antiplatelets and statins in four European countries: a population-based study. Eur J Clin Pharmacol. 2022;78(3):497-504. doi:10.1007/s00228-021-03250-6 PubMed DOI PMC

Zhu JZ, Manne-Goehler J, Agarwal A, et al. ; Global Health and Population Project on Access to Care for Cardiometabolic Disease (HPACC) . Medication use for cardiovascular disease prevention in 40 low- and middle-income countries. J Am Coll Cardiol. 2023;81(6):620-622. doi:10.1016/j.jacc.2022.12.003 PubMed DOI PMC

World Health Organization . Monitoring the Building Blocks of Health Systems: A Handbook of Indicators and Their Measurement Strategies. World Health Organization; 2010. Accessed January 25, 2023. https://apps.who.int/iris/bitstream/handle/10665/258734/9789241564052-eng.pdf

Jacobsen AP, Lim ZL, Chang B, et al. . Contextualizing national policies regulating access to low-dose aspirin in America and Europe using the full report of a transatlantic patient survey of aspirin in preventive cardiology. J Am Heart Assoc. 2022;11(8):e023995. doi:10.1161/JAHA.121.023995 PubMed DOI PMC

Bahiru E, de Cates AN, Farr MR, et al. . Fixed-dose combination therapy for the prevention of atherosclerotic cardiovascular diseases. Cochrane Database Syst Rev. 2017;3(3):CD009868. doi:10.1002/14651858.CD009868.pub3 PubMed DOI PMC

Castellano JM, Pocock SJ, Bhatt DL, et al. ; SECURE Investigators . Polypill strategy in secondary cardiovascular prevention. N Engl J Med. 2022;387(11):967-977. doi:10.1056/NEJMoa2208275 PubMed DOI

World Health Organization . HEARTS Technical Package. World Health Organization; 2018.

World Health Organization . Improving Hypertension Control in 3 Million People: Country Experiences of Programme Development and Implementation. World Health Organization; 2020. Accessed February 27, 2023. https://www.who.int/publications/i/item/improving-hypertension-control-in-3-million-people-country-experiences-of-programme-development-and-implementation

El-Sadr WM, Goosby E. Building on the HIV platform: tackling the challenge of noncommunicable diseases among persons living with HIV. AIDS. 2018;32(suppl 1):S1-S3. doi:10.1097/QAD.0000000000001886 PubMed DOI

Fakhouri THI, Martin CB, Chen TC, et al. . An investigation of nonresponse bias and survey location variability in the 2017-2018 National Health and Nutrition Examination Survey. Vital Health Stat 2. 2020;185(185):1-36. PubMed

Hafferty JD, Campbell AI, Navrady LB, et al. . Self-reported medication use validated through record linkage to national prescribing data. J Clin Epidemiol. 2018;94:132-142. doi:10.1016/j.jclinepi.2017.10.013 PubMed DOI PMC

Richardson K, Kenny RA, Peklar J, Bennett K. Agreement between patient interview data on prescription medication use and pharmacy records in those aged older than 50 years varied by therapeutic group and reporting of indicated health conditions. J Clin Epidemiol. 2013;66(11):1308-1316. doi:10.1016/j.jclinepi.2013.02.016 PubMed DOI

Global Prevalence of Aspirin Use for Primary Prevention of Cardiovascular Disease: A Cross-Sectional Study of Nationally Representative, Individual-Level Data