The pattern of epistaxis recurrence in patients taking prophylactic acetylsalicylic acid (ASA) from a 10 year cohort

The findings of our study are that epistaxis patients taking low-dose ASA for CVD prevention are extremely burdened by recurrence. This is supported by evidence of a higher recurrence rate in the ASA group when compared to that of the control group (17.1% vs 10.1%, p = 0.034), the fact that more recurrences per patient occurred in the ASA group (1.83 ± 0.47 vs 1.2 ± 0.3, p = 0.002), and more frequent changes in bleeding localisation in the ASA group (35.7% vs 10%, p = 0.038). There is discrepancy in previous evidence of recurrence rates in large cohorts, some studies concurring with our findings [5, 15] and others differing [15,16,17]. The comparability of the groups may seem to be diminished by the older age and decreased kidney function of the ASA patients and the raised diastolic BP and increased lowering of BP in the NoASA patients. However, literature reports ambiguous results concerning the impact of old age [16,17,18] and BP [15, 17] on epistaxis recurrence and as a result these factors should be considered with reservation.

The recurrences were more likely to happen within 1 month of discharge in the ASA group compared to the control group (p = 0.008). These facts highlight pressure on the health system as each stationary treatment incurs high costs: 7000–22,000 USD in the USA [19] and 11,000 USD on average in Switzerland (with currency conversion) [20].

Regarding the dynamics of the initial recurrence episode, we found that in a follow-up period of over 5 years, 80% of first recurrence episodes in both groups occurred within 6 months of discharge. Our results are in concordance with current literature [15]. However, we are the first to report the dynamics of ASA and NoASA patients separately. These results show a steeper trend in the ASA group with 60% of all first recurrences occurring within the first month compared to 44.6% in the control group (p = 0.033). In addition, univariate analysis revealed low haemoglobin values as a significant factor leading to recurrence in the ASA group.

This indicates the need for intensive nasal mucosa care with ointment as well as rigorous anaemia control and post discharge treatment of these patients. Anaemia was also found to be a risk factor for recurrence, independent of ASA intake, in the study of Cohen et al. [15]. Existing evidence points out a strong relationship between lower baseline haemoglobin values and major bleeding in CVD patients [21]. Furthermore, it has been shown that low-dose ASA for primary prevention has a negative impact on the haemoglobin values of the elderly [22]. It may, therefore, be assumed that a vicious circle exists in which ASA intake in the elderly leads to lower haemoglobin values, which in turn is compounded by more frequent epistaxis recurrences.

In the light of these facts, particularly concerning the elderly with ASA intake for primary prevention, the importance of the correct indication cannot be emphasized strongly enough. We identified 157 patients (63.8%) with primary prevention as indication and 89 patients (36.2%) with secondary prevention in our cohort of 246 epistaxis patients in the ASA group. After thoroughly reviewing the patient documentation to justify primary prevention in light of the recent guideline changes, we found that 99 of the 157 patients taking ASA for primary prevention did not have a valid indication. As previously mentioned, the newest guidelines question primary prevention in patients with a low CVD risk profile who are younger than 40 and older than 70 years [11,12,13]. Accordingly, 40% (99/246) of patients in the ASA group in our cohort that had no justification for low dose ASA intake. This thorough analysis was unfortunately performed post-hoc and not in “real-time”, because we initially relied on the indication identified by the family doctor. Therefore, ASA was not stopped at the time of the first bleeding episode despite the fact that it was not indicated according to the most recent guidelines.

In surveys of general population, low-dose ASA is predominantly taken for primary prevention and accounts for just over 50% of all ASA intake patients, whereby 20% do not have a legitimate indication [23]. Only ¾ of primary prevention patients are in the appropriate age group of 40 to 70. This means that the potential fraction of ASA patients in the general population without a significant indication exceeds 50%.

Bearing the aforementioned treatment costs in mind, it would be interesting to calculate hospital/health system expenses for treating epistaxis in patients without a justified indication for ASA intake. These costs should be weighed against actual cardiovascular events in patients taking aspirin for primary prevention.

The patients with inappropriate indication in our cohort were significantly older, highlighting widespread ASA therapy of the elderly for inappropriate primary prevention and mirroring the recommendations of studies from the 2000s [9, 10]. The need for surgical intervention in the case of a recurrent epistaxis episode was significantly higher in this group of patients. It seems, according to our results, that a plethora of patients are exposed to unnecessary ASA intake which in turn leads to more epistaxis recurrence and more surgery for recurrence. Consequently, the indication for low-dose ASA intake needs to be verified immediately during the first inpatient treatment for epistaxis, because, as previously mentioned, up to 40% of patients do not have a reasonable indication for drug intake and most recurrences occur within 30 days.

To determine the CVD risk of patients, we estimated the systematic coronary risk using the SCORE2 scale, according to the European guidelines [13] for CVD prevention. This scale was chosen, because it is the newest, most relevant (class I recommendation [13]) and validated prediction score available. The scale range of 1–49 is determined by age, sex, smoking status, systolic BP, and non-HDL cholesterol and it stratifies patients into low to moderate, high, and very high CVD risk. This allowed the assessment of drug indication for primary prevention. On univariate analysis, SCORE2 was not a significant factor leading to recurrence in general. However, a significant relationship between the number of recurrence episodes of individual patients and SCORE2 in the ASA group was observed. Potential patients with ASA intake and SCORE2 > 20 need to be screened and drug indication thoroughly checked as this group has a high probability of 2 + epistaxis recurrences, according to our findings.

Concerning the NoASA group, we found that previous surgery was a significant risk factor for recurrent epistaxis. Bleeding points that are not easily accessible, as found in posterior epistaxis, have previously been identified as a risk factor for recurrence [16]. It can be postulated that in this group of patients, early recurrent bleeding episodes were likely the result of insufficient bleeding control in the initial treatment. This cannot be applied to the ASA group as a significant change of localisation was found in these patients. Therefore, global factors due to ASA intake must be heldaccountable.

Existing evidence states that epistaxis occurs more often in winter [18]. Our results showed that first episodes in spring led to more recurrence in the NoASA group. We defined winter according to the meteorological definition as December to February, whereas the aforementioned study used the approximate astronomical definition of January to March and registered most cases in January and March. This could explain the discrepancy. Nevertheless, it seems that seasonal variation, predominantly the cold months, plays a significant role in NoASA patients while having less impact on ASA patients.

Limitations

Certain limitations of our study need to be disclosed. The retrospective methodology of the study is definitely a drawback as unintentional errors in data acquisition cannot be ruled out. We were able to obtain very few cholesterol values as this is not routinely done in our institution. We, therefore, approximated the SCORE2 in patients with missing values in a uniform way, using the median value. It is possible that this led to data distortion concerning this scale. We only analysed recurrence episodes requiring in-hospital treatment to determine the burden on the tertiary health system thereby excluding outpatient episodes that are very relevant to primary care.

Further noteworthy limitations are: no control group of patients taking ASA without epistaxis could be put together, data concerning bleeding in other locations as well as data about drugs interacting with ASA was not provided, and the data from excluded patients taking anticoagulants could have been used as a comparative group.

Finally, adherence to ASA therapy was not analysed in our study. It is possible that some of the ASA patients did not take ASA regularly in the days prior to admission, which may in turn have interfered with our results.

留言 (0)

沒有登入
gif