John is a 72-year-old male with long-standing hypertension, angina, and heart failure. He is aware that his obesity and lack of exercise contribute to his diagnoses. He takes aspirin daily but is starting to have gastric irritation. He asks if there are alternatives. He proudly reports that his cardiologist tells him he has “Class I angina risk.” Explain the rationale for using ASA in this patient. What are the alternatives, if any, to ASA therapy? Help clarify the use of enumerated scales for CV diseases such as angina. Does Class I angina equate to low risk?

John is a 72-year-old male with long-standing hypertension, angina, and heart failure. He is aware that his obesity and lack of exercise contribute to his diagnoses. He takes aspirin daily but is starting to have gastric irritation. He asks if there are alternatives. He proudly reports that his cardiologist tells him he has “Class I angina risk.” Explain the rationale for using ASA in this patient. What are the alternatives, if any, to ASA therapy? Help clarify the use of enumerated scales for CV diseases such as angina. Does Class I angina equate to low risk?

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Cardiovascular diseases are greatly associated with morbidity and mortality. Surprisingly, these diseases have been extensively studied. For instance, the risk factors for cardiovascular diseases are well highlighted in literature including both modifiable and non-modifiable factors. According to Owlia et al. (2019), non-modifiable risk factors include age, gender, geriatric factors, race, ethnicity, and genetic factors while modifiable risk factors include smoking, diabetes mellitus, hypertension, hyperlipidemia, physical inactivity, and obesity. This assignment focuses on a case study of John, a 72-year-old male with hypertension, angina, and heart failure as well as obesity and physically inactive who is taking aspirin but has developed gastric irritation. Subsequently, the paper outlines the rationale for aspirin, considers alternatives to aspirin, and elaborates on enumerated scales for cardiovascular diseases, particularly angina.

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Rationale for Aspirin

Acetylsalicylic acid (ASA) has been available as early as 1900. The medication acts by inhibiting cyclooxygenase-1 (COX-1) and COX -2. Aspirin covalently and irreversibly attaches an acetyl group to COX. COX-1 inhibition eventually inhibits thromboxane (TXA2) synthesis in platelets hence inhibiting platelet aggregation (Arif & Aggarwal, 2021). In addition to the antithrombotic effect, aspirin exhibits analgesic, antipyretic and anti-inflammatory effects through inhibition of prostacyclin and prostaglandin synthesis. According to Arif and Aggarwal (2021), aspirin is principally indicated for treatment and prophylaxis of angina pectoris, prophylaxis of ischemic stroke and myocardial infarction, acute myocardial infarction, giant cell arteritis, rheumatoid arthritis, fever, and prevention of stent thrombosis among other indications.

As already highlighted, cardiovascular diseases such as angina and heart failure are life-threatening as they are associated with cardiovascular events such as acute coronary syndrome and stroke. Similarly, John exhibits several risk factors for cardiovascular diseases including physical inactivity, hypertension, obesity, male gender, and being elderly. Furthermore, he demonstrates a prothrombotic state as the aforementioned risk factors predispose him to vascular stasis, hypercoagulability, and endothelial injury. Consequently, this necessitates prompt preventive measures. This is the basis for aspirin in his case. He takes aspirin for primary and secondary prevention of cardiovascular diseases, prophylaxis against acute myocardial infarction and acute ischemic stroke, and prophylaxis and treatment of angina.

Alternatives to Aspirin

Aspirin as forementioned is vastly indicated for diverse pathologies. Despite its widespread use, it is associated with a spectrum of adverse effects ranging from mild to life-threatening. For instance, Peters and Mutharasan (2020) in the Journal of American Medical Association highlight these side effects including gastrointestinal bleeding, dyspepsia, gastric ulceration, epigastric distress, hepatotoxicity, tinnitus, anaphylaxis, acute kidney injury, and salicylate toxicity. From the case scenario, John indispensably requires an alternative to aspirin therapy as he has developed gastric irritation. Consequently, he can benefit from other antiplatelet agents such as clopidogrel which is indicated in patients for whom aspirin is contraindicated due to hypersensitivity or gastric irritation.

Clopidogrel, is a P2Y12 receptor antagonist. This agent inhibits the P2Y12 receptor (ADP receptor) on platelets decreasing the expression of Gp IIb/IIIa receptors on platelets which results in inhibition of platelet aggregation(Patti et al., 2020). ADP usually attaches to P2Y12 receptors activating the Gp IIb/IIIa receptors with subsequent platelet aggregation. Clopidogrel is principally used in combination with aspirin for dual antiplatelet therapy which is effective for the treatment of unstable angina, ST-segment elevation myocardial infarction, and non-ST segment elevation myocardial infarction as well as secondary prevention of cardiac events (Patti et al., 2020). Additionally, it is also used as an alternative to aspirin to prevent thromboembolic events including acute ischemic stroke and acute myocardial infarction. Adverse effects of these drugs include allergic reactions, hemorrhage, abdominal pain, diarrhea, neutropenia, and thrombocytopenic purpura among others (Patti et al., 2020).

Enumerated Scales for Cardiovascular Diseases

Enumerated scales for cardiovascular diseases such as angina are critical as they give a glimpse of patient-reported health status which aids in assessing the burden of the disease, determining the treatment plan, assessing the functional status of the patient, and determining the health-related quality of life (Hermiz & Sedhai, 2021). However, this paper limits itself to scales for angina. The scale used to assess the risk of angina is the Canadian Cardiovascular Society (CCS) angina severity classification. The CCS angina severity classification scale is a physician-reported symptom severity scale deployed to evaluate and grade physical activity symptoms on four levels (Owlia et al., 2019). Owlia et al. (2019) extensively describe classes of angina based on CCS angina severity classes as follows; Class I correlates with angina on strenuous exertion, class II indicates angina with walking more than 200 yards on a flat surface, climbing stairs rapidly, in cold or emotional situation. Meanwhile, class III indicates angina on walking 100-200 yards on flat surfaces while class IV correlates with angina at rest or any physical activity.

Class, I angina equates to low risk. Patients in this class have a low incidence of mortality and myocardial infarction in contrast to other classes. For instance, a study by Owlia et al. (2019)demonstrated all-cause mortality rate correlated with angina classes was 4.58, 4.60, 6.22, and 6.83 per 100 person-years for CCS classes I, II, III, and IV respectively.

Conclusion

Aspirin, as well as clopidogrel, are essential for primary and secondary prevention of angina, acute myocardial infarction, and acute ischemic stroke as dual therapy. Clopidogrel can be used as an alternative to aspirin. Cardiovascular disease scales are critical for symptom severity assessment as well as predicting all-cause mortality.

References

Arif, H., & Aggarwal, S. (2021). Salicylic Acid (Aspirin). StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519032/

Hermiz, C., & Sedhai, Y. R. (2021). Angina. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557672/

Owlia, M., Dodson, J. A., King, J. B., Derington, C. G., Herrick, J. S., Sedlis, S. P., Crook, J., DuVall, S. L., LaFleur, J., Nelson, R., Patterson, O. V., Shah, R. U., & Bress, A. P. (2019). Angina severity, mortality, and healthcare utilization among veterans with stable angina. Journal of the American Heart Association, 8(15), e012811. https://doi.org/10.1161/JAHA.119.012811

Patti, G., Micieli, G., Cimminiello, C., & Bolognese, L. (2020). The role of clopidogrel in 2020: A reappraisal. Cardiovascular Therapeutics, 2020, 8703627. https://doi.org/10.1155/2020/8703627

Peters, A. T., & Mutharasan, R. K. (2020). Aspirin for prevention of cardiovascular disease. JAMA: The Journal of the American Medical Association, 323(7), 676. https://doi.org/10.1001/jama.2019.18425

John is a 72-year-old male with long-standing hypertension, angina, and heart failure. He is aware that his obesity and lack of exercise contribute to his diagnoses. He takes aspirin daily but is starting to have gastric irritation. He asks if there are alternatives. He proudly reports that his cardiologist tells him he has “Class I angina risk.” Explain the rationale for using ASA in this patient. What are the alternatives, if any, to ASA therapy? Help clarify the use of enumerated scales for CV diseases such as angina. Does Class I angina equate to low risk?