Cardiovascular module

EBM-Systematic Review GROUP Exercise

Group 8:
Edward Eid, Nour Gebara, Lana Khalil, Ali Rteil, Elie Toni Korbani,
Bachar Chaya
Case scenario
Mr. Ibrahim is presenting to your clinic for his yearly check-up. He is a 55 year old
male whos been hypertensive for the past 10 years, and smoker of one pack per
day. Mr. Ibrahim is very concerned since his father passed away with an acute
myocardial infarction at the age of 49. He was once advised to take a baby aspirin
daily for prevention of heart attack. He is worried however, because a friend had
an intracranial hemorrhage while on aspirin for primary prevention of cancer, as
advised by his physician. Mr. Ibrahim knows that aspirin is a blood thinner and
seeks your advice regarding aspirin use.

1. Phrase the question(s) using the PICO strategy

In the case presented, the patient is concerned about the use of aspirin. Specifically, he wants
to know: 1- how effective is aspirin use in preventing the occurrence of heart attack, and
2- the possible side effects of using aspirin (in particular intracranial hemorrhage).
Since this question can be tackled in two ways, we will divide it into two research questions
with a separate PICO.
A- For 1st concern:
Population: A 55 year old, hypertensive male smoker, with a history of familial
myocardial infarction
Intervention: Aspirin prophylaxis
Comparison : no aspirin prophylaxis or placebo
Outcome : Prevention of heart attack
Question: For a 55 year old, smoking, hypertensive male with familial history of
myocardial infarction, could aspirin administration as compared to no aspirin
administration prevent the occurrence of heart attacks?
The PICO question above is a question of therapy.

B- For 2nd concern :

Population : A 55 year old, hypertensive male smoker, with a history of familial

myocardial infarction
Intervention : Aspirin prophylaxis
Comparison : no Aspirin prophylaxis or placebo
Outcome : adverse effect of intracranial hemorrhage

Question: For a 55 year old, hypertensive smoker male with familial history of myocardial
infarction, could the use of aspirin prophylaxis as compared to no aspirin use cause
intracranial hemorrhage?
The PICO question above is a question of harm.

2) Search for a systematic review that addresses the patients

question(s) using PubMed Clinical Queries.
A
1. Initially, our search strategy tackled the first PICO question concerned with the efficacy of
aspirin prophylaxis in the primary prevention of cardiovascular events.
2. On the PubMed Clinical Queries page, we included all of the associated risk factors (smoking,
age, hypertension, male) along with primary intervention, cardiovascular events, and aspirin. We
separated each individual term by AND and all of the synonyms by OR. Ultimately, we
came up short in terms of systematic reviews.
3. Thus, we decided to include hypertension as the sole risk factor in the search for 2 reasons:
Hypertensions association with cardiovascular events is very powerful and we needed to
broaden our search to include more systematic reviews in our findings. The search field read:
(hypertension OR elevated blood pressure OR high blood pressure) AND primary prevention
AND (aspirin OR antitplatelet therapy OR antithrombotic therapy) AND (cardiovascular disease
OR myocardial infarction OR MI OR ischemic events).

4. Our search yielded 458 systematic reviews; it was now time to further narrow our results in
order to find the best one (scroll down and press See All).
5. We now applied filters for: article type (systematic reviews) species (Humans), sex (male),
Ages (45+ years; middle aged) [terms in parentheses were checked]. Our filters yielded a
manageable 117 systematic review whose titles could be scanned to answer our target question.

6. We eventually found a systematic review entitled Meta-analysis of data

from the six primary prevention trials of cardiovascular events using aspirin
that was pertinent in answering the question at hand. Moreover, the review
is dated to 2006, thus ensuring that the results are relatively recent.
Link: http://www.ajconline.org/article/S0002-9149(06)01068-X/pdf

7. After downloading and reading the systematic review, the conclusion was in favor of aspirins
positive effect on preventing the incidence of cardiovascular events but maintains that aspirin
should be utilized as primary prevention only in high-risk patients (since aspirin does contain
harmful side effects).

B-

1. We now shift our focus to the 2nd PICO question dealing with the harmful side effects of
aspirin in the primary prevention of Cardiovascular Disease.
2. In the PubMed Clinical Queries, we looked for the terms relevant to our search including
in the search field: (Cardiovascular events OR myocardial infarction OR MI) AND
primary prevention AND intracranial hemorrhage AND (aspirin OR antiplatelet therapy
OR aspirin prophylaxis). We obtained 11 results as shown below. There was no need to
play with the filters for they had already been selected in the previous search (refer to
step 5 in A) .

3. Of these results, one systematic review stood out. It was one titled
Aspirin in primary prevention of cardiovascular disease and cancer:
a systematic review of the balance of evidence from reviews of
randomized trials from reviews of randomized trials. In addition, the
fact that this review is recent (2013) also makes it a good source.
Link:
http://www.ncbi.nlm.nih.gov.ezproxy.aub.edu.lb/pmc/articles/PMC3855368
/pdf/pone.0081970.pdf

4. The systematic review lent credence to the fact that aspirin does in fact cause a moderate
decrease in the risk of cardiovascular occurrence; however, the negative side effects
associated with it are too dangerous to warrant its use as primary prevention of
cardiovascular events (check the highlighted lines in the picture below).

Conclusion
From the searches conducted aimed at answering the patients concerns, we can conclude
that despite the fact that aspirin administration does decrease the risk of cardiovascular
incidences, its harmful side effects (which include hemorrhage) exceed the benefits. Thus,
given that this patient is at high risk for cardiovascular incidence (male, middle age smoker
with familial history of CVD) we advise him to consider other safer prophylaxis measures.