Dallas 2015

TFQO: Wei-Tien Chang COI #321

EVREV 1: Janel Swain COI #412

EVREV 2: Thomas Evans COI #336

Taskforce: First Aid

FA 871 : Aspirin for Chest Pain (Administration)

Dallas 2015 COI Disclosure (specific to this systematic review)

Wei-Tien Chang COI #321

Commercial/industry: No

Potential intellectual conflicts: No

Janel Swain COI #412

Commercial/industry: No

Potential intellectual conflicts: No

Thomas Evans COI #336

Commercial/industry: No

Potential intellectual conflicts: No

Dallas 2015

Treatment Recommendations Administration of aspirin is recommended for chest discomfort if the victim does not have an allergy, a recent episode of bleeding, or other contraindications to aspirin, but administration of aspirin should never delay activation of EMS.

2010 CoSTR

Consensus on Science Evidence from 2 large, randomized LOE 1 trials clearly demonstrated that administration of aspirin within the first 24 hours of onset of chest discomfort in patients with acute coronary syndrome reduced mortality.

Evidence from an LOE 3 retrospective registry showed an association between early prehospital administration of aspirin and lower mortality in patients with AMI.

There is evidence from an LOE 4 retrospective study that prehospital administration of aspirin is safe. This study suggested that prehospital aspirin might facilitate early reperfusion and demonstrated the value of early aspirin administration during AMI.

Dallas 2015

C2015 PICO

Population:

adults experiencing chest pain due to suspected myocardial infarction

Intervention:

administration of aspirin

Comparison:

no administration of aspirin

Outcomes:

Cardiovascular mortality (9-critical)

Adverse effects (8-critical)

Complications (8-critical)

Incidence of cardiac arrest (7-critical)

Cardiac functional outcome (5-important)

Infarct size (5-important)

Hospital length of stay (4-important)

Dallas 2015 Inclusion/Exclusion & Articles Found

Inclusion/Exclusion

Population: included: adults; excluded: children, animal studies

Intervention: included: aspirin administered by patients, laypeople or health care professionals

Outcome: included: mortality, cardiovascular mortality, incidence of cardiac arrest, complications, bleeding, allergy, infarct size, cardiac function, left ventricular ejection fraction, hospital length of stay, resolution of chest pain

The search yielded a total of 2,017 papers (PubMed 1,499, Embase 821, Cochrane 730).

Finally 5 studies (3 RCTs and 2 non-RCT) were included for data collection and GRADE analysis.

Dallas 2015 2015 Proposed Treatment Recommendations

We recommend the administration of aspirin as opposed to no administration of aspirin in patients with chest pain due to suspected myocardial infarction (strong recommendation, high quality of evidence).

GRADE was also used to evaluate the evidence for the undifferentiated chest pain patient. ILCOR could not reach consensus on a TR for a first aid provider administering aspirin for undifferentiated chest pain after consideration of risks and benefits from a global perspective. Regional resuscitation councils/first aid education organizations will create guidelines for local use.

Values and preferences statement: In making this recommendation we place a high value on the importance of decreasing mortality and the risk of complications.

Dallas 2015 Risk of Bias in Studies RCT bias assessment

Study Year Design Total

Patients Population

Industry Funding

Allo

cati

on

: Ge

ne

rati

on

Allo

cati

on

: Co

nce

alm

en

t

Blin

din

g: P

arti

cip

ants

Blin

din

g: A

sse

sso

rs

Ou

tco

me

: C

om

ple

te

Ou

tco

me

: Se

lect

ive

Oth

er

Bia

s

ISIS-2 (162.5 mg,

enteric-coated) 1988 RCT 17,187 AMI Fully Low Low Low Low Low Unclear High

Verheugt (100

mg, capsule) 1990 RCT 100 First Ant AMI Unclear Low High Unclear Unclear Low High High

Elwood (300 mg,

capsule) 1979 RCT 1,705 AMI Partly High High Unclear Unclear Low High High

Non-RCT bias assessment

Study Year Design Total

patients Population

Industry Funding

Elig

ibili

ty

Cri

teri

a

Exp

osu

re/

Ou

tco

me

Co

nfo

un

din

g

Follo

w u

p

Frilling B (500 mg loading, oral/IV,

100 mg maintenance) 2001 Non-RCT

22572 STEMI Unclear Low Low High Low

Quan D (dose not available)

2004

Non-RCT

219 Potential cardiac

patients No Low Low Low High

Dallas 2015 Evidence profile table(s)

Dallas 2015 Evidence profile table(s)

Dallas 2015 Evidence profile table(s)

Dallas 2015 Evidence profile table(s)

Dallas 2015 Evidence profile table(s)

Dallas 2015 Proposed Consensus on Science Statements

For the critical outcome of “cardiovascular mortality” (at 5 weeks) we have identified high quality evidence from one RCT enrolling 17,187 patients with acute myocardial infarction (ISIS-2 1988, 349) showing benefit to aspirin being administered (RR 0.79, CI 0.73-0.87).

For the critical outcome of “cardiovascular mortality” (at 3 months) we have identified very low quality evidence (downgraded for risk of bias, indirectness, and imprecision) from one RCT enrolling 100 patients with acute myocardial infarction (Verheugt 1990, 267) not showing benefit to aspirin being administered (RR 0.83, CI 0.4-1.75).

For the critical outcome of “cardiovascular mortality” (at 28 days) we have identified low quality evidence (downgraded for risk of bias and indirectness) from one RCT enrolling 1,705 patients with acute myocardial infarction (Elwood 1979, 413) showing no benefit to aspirin being administered (RR 0.98, CI 0.81-1.19).

For the critical outcome of “cardiovascular mortality” (in-hospital) we have identified very low quality evidence (downgraded for risk of bias and indirectness) from one observational study with a total of 22,572 patients with acute myocardial infarction (Frilling 2001, 200) showing benefit to aspirin administration (RR 0.33, CI 0.31-0.35).

Dallas 2015

For the critical outcome of “adverse effects” (bleeding) we have identified high quality evidence from one RCT enrolling 16,981 patients with acute myocardial infarction (ISIS-2 1988, 349) showing harm with aspirin administration (RR 1.25, CI 1.04-1.51).

For the critical outcome of “adverse effects” (allergic reaction) we have identified very low quality evidence (downgraded for risk of bias and imprecision) from one observational study with 219 patients with suspected acute myocardial infarction (Quan 2004, 362) showing no harm with aspirin administration (unable to calculate RR as there was no control group).

Proposed Consensus on Science Statements

Dallas 2015

For the critical outcome of “complications” we have identified high quality evidence from one RCT enrolling 16,981 patients with acute myocardial infarction (ISIS-2 1988, 349) showing benefit to aspirin administration (RR 0.62, CI 0.52-0.73), very low quality evidence (downgraded for risk of bias and indirectness) from one observational study with a total of 22,572 patients with acute myocardial infarction (Frilling 2001, 200) showing no benefit with aspirin administration (RR 1.05, CI 0.78-1.42), and very low quality evidence (downgraded for risk of bias, imprecision and indirectness) from one RCT enrolling 100 patients with acute myocardial infarction (Verheugt 1990, 267) showing benefit to aspirin administration (RR 0.11, CI 0.05-0.98).

Proposed Consensus on Science Statements

Dallas 2015

For the critical outcome of “incidence of cardiac arrest” we have identified high quality evidence from one RCT enrolling 16,981 patients with acute myocardial infarction (ISIS-2 1988, 349) showing benefit to aspirin administration (RR 0.87, CI 0.79-0.96).

For the important outcome of “infarction size” we have identified very low quality evidence (downgraded for risk of bias, imprecision and indirectness) from one RCT enrolling 89 patients with acute myocardial infarction (Verheugt 1990, 267) not showing benefit to aspirin administration (MD -161, CI -445.57-230.57).

We did not identify any evidence to address the important outcomes of “cardiac functional outcome” or “hospital length of stay”

Proposed Consensus on Science Statements

Dallas 2015 Draft Treatment Recommendations

We recommend the administration of aspirin as opposed to no administration of aspirin in patients with chest pain due to suspected myocardial infarction (strong recommendation, high quality of evidence).

GRADE was also used to evaluate the evidence for the undifferentiated chest pain patient. ILCOR could not reach consensus on a TR for a first aid provider administering aspirin for undifferentiated chest pain after consideration of risks and benefits from a global perspective. Regional resuscitation councils/first aid education organizations will create guidelines for local use.

Values and preferences statement: In making this recommendation we place a high value on the importance of decreasing mortality and the risk of complications.

Dallas 2015 Knowledge Gaps

Is aspirin safe if given to patients with chest pain who are not having a myocardial infarction?

Is aspirin safe to be given by a first aid provider?

Is there high quality evidence to indicate that the administration of aspirin post-MI is time critical?

Dallas 2015

Next Steps

This slide will be completed during Task Force Discussion (not EvRev) and should include:

Consideration of interim statement

Person responsible

Due date