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Original Article

Effect of Sociodemographic Variables and Other Factors on

the Usage of Different Doses of Aspirin in Postmyocardial
Infarction Patients: A Cross‑sectional Study
Syed Raza Shah, Richard Alweis1, Mohammad Yousuf Ul Islam, Maham Khan, Mehwish Hussain2,
Syed Zawahir Hassan3, Aisha Aslam, Waqas Shahnawaz4
Department of Medicine, Dow University of Health Sciences, 2Senior Lecturer of Biostatistics, Dow University of Health
Sciences, 3Sindh Medical College, Dow University of Health Sciences, 4Department of Medicine, Agha Khan University
Hospital, Karachi, Pakistan, 1Department of Internal Medicine, Reading Health System, West Reading, PA, USA

ABSTRACT

Background: Aspirin (acetylsalicylic acid) is commonly prescribed to patients with a history of myocardial infarction (MI) or occlusive
vascular events (e.g., stroke). Due to the complications associated with failure to follow aspirin usage guidelines, determining
predictors of aspirin noncompliance in these patient populations is of clinical value and may help prevent poor outcomes.
Methods: This cross‑sectional study of all patients with a previously diagnosed MI was conducted over a period of 3 months from May
2015 to July 2015 at a government‑based hospital in Karachi, Pakistan. Patients were administered a questionnaire that comprised two
parts. Part A was designed to measure sociodemographic data including age, gender, and marital status. Part B determined whether
the patient was counseled on aspirin significance, and dosage recommendation, and was participating in cardiac rehabilitation therapy.
Results: A total of 456 patients included in the study. Of them, 298 (66.7%) were males. The average age was 59 (standard
deviation 11) years. The outcome from univariate logistic regression revealed that with 1 year increase of age, the usage of
low dose of aspirin was significantly decreased by 2%. Patients with higher education attributed a significantly different effect
on the usage of aspirin. Marital status divulged no significant association with the use of different doses of aspirin. The role
of rehabilitation had no effect when adjusted for age and level of education.
Conclusion: Post‑MI patients with higher education level and undergoing rehabilitative therapy are more likely to take low‑dose
aspirin as compared to those who failed to have these attributes. There is a need for carrying out further work to confirm
these findings and expand our recommendations, particularly the sensitive issue regarding adequate doctor counseling among
these high‑risk patients.

Key words: Aspirin, cardiac, myocardial infarction

INTRODUCTION cerebrovascular events has been well established.[1‑3]

This has subsequently led to the common practice

L
ow‑dose aspirin (acetylsalicylic acid) is
commonly prescribed to patients with a history
of myocardial infarction (MI) or occlusive
vascular events (e.g. stroke). The efficacy of aspirin
in the secondary prevention of cardiovascular and
Address for correspondence: Dr. Syed Raza Shah,
Dow University of Health Sciences, Karachi, Pakistan. of 50,279 patients by Biondi‑Zoccai et al. showed that
E‑mail: syedraza91shah@live.com
Access this article online
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Website:
of prescribing low‑dose aspirin as a cornerstone of
medical management of patients after their first event.
Further support of this approach comes from data
indicating that aspirin nonadherence or discontinuation
is associated with an almost 3‑fold risk of a major
cardiac event.[4] Clinical guidelines in a meta‑analysis
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tweak, and build upon the work non-commercially, as long as appropriate credit is given
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How to cite this article: Shah SR, Alweis R, Ul Islam MY, Khan M,
DOI: Hussain M, Hassan SZ, et al. Effect of sociodemographic variables and
other factors on the usage of different doses of aspirin in postmyocardial
10.4103/1995-705X.244187 infarction patients: A cross-sectional study. Heart Views 2018;19:49-53.

49 HEART VIEWS
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Shah, et al.: Aspirin use in post-myocardial patients
aspirin nonadherence or discontinuation is associated
with an almost 3‑fold increased risk of major adverse
cardiac events (recurrence of MI/stroke).[4] Thus, aspirin
is a standard treatment in patients for the secondary
prevention of cardiovascular outcomes. Clinical
guidelines recommend long‑term (usually lifelong)
administration in such patients.[5,6] However, several
factors, such as daily usage and adverse effects, pose
considerable compliance issues, with rates as high as
fifty percentage.[7]
Nonadherence can decrease the quality of life and
can significantly increase the cost of medical care.[8] More
importantly, studies have shown that nonadherence is
the chief reason for many preventative complications.[9]
Many studies have focused and reported nonadherence
regarding specific pharmacological treatment of
different coronary risk factors, with statin nonadherence
associated with elevated LDL levels being an example.
However, few studies have examined compliance
related to different doses of aspirin post‑MI. Since
nonadherence can nullify the effects of optimal medical
management, understanding demographic variables
that can predict potential issues with varying dosages
of aspirin may help forestall preventable complications.
METHODS
This cross‑sectional study was conducted over a
period of 3 months from May 2015 to July 2015 at
a government‑based hospital in Karachi, Pakistan.
Written informed consent was obtained from each
participant, and all ethical considerations were met
in accordance with the World Medical Association
Declaration of Helsinki law.
All patients visiting the cardiology outpatient
department with previously diagnosed MI were
evaluated for the study with the exclusion criteria as
follows: patients not prescribed aspirin; patients with
contraindication to aspirin therapy, such as those with
hemophilia and peptic ulcer disease; and patients
with cognitive impairments. Using the methodology of
Sud et al., a sample size of 375 patients was calculated
to be necessary to determine significance of P < 0.05.[7]
Accounting for nonrespondent bias and incomplete
questionnaires, the sample size was increased to 456.
Nonadherence was defined as failure to take prescribed
dosages of aspirin for more than 2 days per week.
A precoded questionnaire was presented to the
enrolled patients to ensure anonymity of response
available in both English and Urdu languages, along
with a double‑blind system with the investigators to
eliminate any potential bias. The principal investigator
explained the nature and purpose of the study to all
selected participants. Data were collected from randomly
selected patients using survey methodology until the
sample size was achieved. Confounder was managed
HEART VIEWS
Volume 19 / Issue 2 / April-June 2018
through a randomized selection of participants. Data
were collected from every consecutive person until the
required numbers of patients were completed.
The questionnaire comprised two parts: Part A
was designed to measure sociodemographic data
including age, gender, and marital status and Part B
determined whether the patient was counseled by the
doctor on aspirin significance; whether the patient was
on low doses (75 mg) or high doses (300 mg) of aspirin;
and whether the patient was performing rehabilitation
therapy. Uneducated patients were defined as all those
patients who never went to school.
Statistical analysis
After entering data in IBM, statistical analyses were
performed in SPSS version 21 (International Business
Machines, Armonk, New York, USA) software. Since all
variables were categorical, frequencies and percentages
were computed as descriptive measures.
Mean with standard deviation (SD) was reported
for continuous variables, i.e., age of the patients.
Since age was found to be nonnormally distributed by
Shapiro–Wilk test, Mann–Whitney U‑test was run to
compare age of the patients using the two aspirin dose.
Chi‑square test was carried out to assess association of
categorical variables with aspirin dose. Univariate and
multivariate logistical regression was run to measure
effect of factors associated with the use of the two doses
of aspirin. The threshold of significance was set at 0.05.
RESULTS
A total of 456 patients were included in the study. Of
them, 298 (66.7%) were males [Table 1]. The average
age was 59 (SD 11 years) years. A significant minority
of patients met the criteria for “uneducated” (n = 162,
35.2%) [Table 1]. The frequency of married individuals
was high (94.4%). Almost 71.1% of patients were taking
low‑dose aspirin per day. Rehabilitation programs
were attended by 9.6% of patients. Counseling by
doctors regarding aspirin side effects was given to
61.1% (n = 273) of patients [Table 1].
The univariate analysis revealed that patients taking
low dose were significantly younger (P = 0.014) [Table 2].
No significant association of gender and marital status was
found with intake of different doses of aspirin. Nearly 32.7%
of uneducated patients consumed low dose. The frequency
of rehabilitation was significantly lower among patients
on low‑dose aspirin (P = 0.013). About 65% of patients
taking high‑dose aspirin received doctor counseling versus
59.4% on low‑dose aspirin. However, the association was
insignificant in this regard (P = 0.265) [Table 2].
The outcome from univariate logistical regression
revealed that with every year increase of age, the usage
of low dose of aspirin was significantly decreased by
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Shah, et al.: Aspirin use in post-myocardial patients

2% (odds ratios [OR]: 0.98, 95% confidence interval [CI]: significant association with the use of different doses
0.96–0.99). Female gender increased likelihood of of aspirin (P = 0.922). Patients on low‑dose aspirin had
low‑dose use but as a nonsignificant trend (OR: 1.16, better rehabilitation as compared to patients on high‑dose
95% CI: 0.75–1.78) [Table 3]. aspirin (P = 0.013) [Table 2]. Doctor counseling was
Patients with higher education attributed a nonsignificantly better for patients with a high‑dose aspirin
significantly different effect as they were found to as compared to those taking low‑dose aspirin (P = 0.265).
be more compliant as compared to people with no Results of multivariate logistic regression stipulated
educational background. Marital status divulged no that all variables retained similar effect except for
rehabilitation [Table 3]. It implied that when effect of
Table 1: Demographic variables (N values) age and qualification was adjusted, rehabilitation had
n (%) no effect on usage of different aspirin doses (OR: 2.08,
Age (mean±SD) 59±11 95% CI: 0.75–5.73) [Table 3].
Gender
Male 298 (66.7) DISCUSSION
Female 149 (33.3)
Qualification Long‑term aspirin therapy confers conclusive net benefits
Uneducated 162 (35.2) on risk of subsequent MI, stroke, and vascular death
School education 77 (17.2) among patients with a wide range of prior manifestations
Matric 73 (16.3)
of cardiovascular disease. Because aspirin confers a
Intermediate 57 (12.8)
risk of major bleeding, the appropriate dose is the lowest
Higher 78 (17.4)
dose that is effective in preventing both MI and stroke
Marital status
as these two diseases frequently coexist.[10]
Married 422 (94.4)
A 2003 analysis of data from the Clopidogrel in Unstable
Unmarried 25 (5.6)
Aspirin dose
Angina to Prevent Recurrent Events trial demonstrated
High dose 129 (28.9) no significant difference in efficacy for low‑dose
Low dose 318 (71.1) aspirin (≤100 mg) versus high‑dose aspirin (≥200 mg),
Rehabilitation but the researchers reported an increase in bleeding
Yes 43 (9.6) complications among high‑dose aspirin users.[11]
No 404 (90.4) The American Heart Association and the American
Doctor counseling College of Cardiology recommend that all individuals
Yes 273 (61.1) with existing cardiovascular disease take a low dose
No 174 (38.9) (75–100 mg) of aspirin daily for prevention of future
SD: Standard deviation cardiovascular events.[5]

Table 2: Demographic vairable (P-values)

Aspirin dose, n (%) P
High dose Low dose
Age* (mean±SD) 61±10 58±11 0.014
Gender
Male 83 (64.3) 215 (67.6) 0.507
Female 46 (35.7) 103 (32.4)
Qualification
Uneducated 58 (45.0) 104 (32.7) 0.001
School education 27 (20.9) 50 (15.7)
Matric 24 (18.6) 49 (15.4)
Intermediate 11 (8.5) 46 (14.5)
Higher 9 (7.0) 69 (21.7)
Marital status
Married 122 (94.6) 300 (94.3) 0.922
Unmarried 7 (5.4) 18 (5.7)
Rehabilitation
Yes 5 (3.9) 38 (11.9) 0.013
No 124 (96.1) 280 (88.1)
Doctor counseling
Yes 84 (65.1) 189 (59.4) 0.265
No 45 (34.9) 129 (40.6)
*Compared by Mann-Whitney U‑test. SD: Standard deviation

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Shah, et al.: Aspirin use in post-myocardial patients
Table 3: Demographic variables
Age
Female
School education
Matric
Intermediate
Higher
Married
Rehabilitation
Doctor counseling
CI: Confidence interval, COR: Crude odds ratio, AOR: Adjusted odds ratios
In accordance with the current guideline, more
than 70% of our population is taking low‑dose aspirin
as part of their regime. In addition, keeping with
trends, the majority of such patients were married
and males above 50 years of age. [12,13] Men reach
cardiovascular disease risk thresholds at an earlier
age, which leads to a differential prescription pattern
for aspirin treatment between genders based on age
alone as a consideration.[14] The greater frequency of
aspirin resistance found among women may be another
factor in this disparity. [15] Hovens et al.[16] found that
the prevalence of aspirin resistance was less among
patients receiving >300 mg of aspirin per day (19%)
compared to those receiving <100 mg of aspirin per
day (36%). In keeping with the same, Gurbel et al. found
that there is a dose‑dependent inhibition of platelet
function, as assessed by non‑COX‑1 pathways, which
is why females are contemporarily recommended
a higher dose of aspirin as compared to their male
counterparts.[17,18] Women are more likely to have a
lower income than men, and lower‑income individuals
are more likely to go to non‑evidence‑based practices,
so the trend of the underprescription of aspirin between
genders may be explained by these factors.[10,13,19]
Univariate logistic regression of our data shows that
the probability of using high‑dose aspirin increases by
2% with every year increase in age. This trend is not
dissimilar to the ones observed in the United States[20] in
spite of existing data that prove higher doses of aspirin
post‑MI produce an increased risk of side effects, the
most important of which is gastrointestinal bleeding.[21,22]
The secondary prevention with low‑dose aspirin
is widely recommended outside the U.S., with various
national guidelines historically recommending daily
doses of low‑dose tablet.[12] This seems to be the case
here – since from the 456 patients included in the study,
61% (273) had been prescribed low‑dose aspirin along
with some sort of prior counseling from their physician
on the benefits of using the drug.
The term cardiac rehabilitation refers to
coordinated, multifaceted interventions designed to
optimize a cardiac patient’s physical, psychological,
and social functioning, in addition to stabilizing,
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Volume 19 / Issue 2 / April-June 2018
COR (95% CI) AOR (95% CI)
0.98 (0.96-0.99) 0.98 (0.96-0.99)
1.16 (0.75-1.78) ‑
1.03 (0.59-1.82) 0.93 (0.52-1.66)
1.14 (0.64-2.04) 1.01 (0.55-1.84)
2.33 (1.12-4.85) 2.16 (1.03-4.53)
4.28 (1.99-9.19) 3.31 (1.49-7.38)
0.96 (0.39-2.35) ‑
3.37 (1.29-8.76) 2.08 (0.75-5.73)
0.78 (0.51-1.20) ‑
slowing, or even reversing the progression of the
underlying atherosclerotic processes, thereby
reducing morbidity and mortality. [23] These practices
are recommended as useful and effective (Class I)
by the American Heart Association and the American
College of Cardiology in the treatment of patients
with CHD.
Our study showed that from among the 456 patients,
only 9.6% had been given or had participated in
rehabilitation therapy. The low numbers are not surprising,
considering that this seems to be a universal third world
problem with the percentages of MI patients going
through rehabilitation therapy in Pakistan and India being
comparable.[24] The authors believe that this is due to the
low number of rehabilitation centers in the developing
world with their being only 44 cardiac rehabilitation
centers in Pakistan, of which 12 are located in Karachi.
From the low dose, i.e., more evidence‑based
treatment, aspirin group, 11.9% of patients underwent
rehabilitation, while from the high‑dose aspirin group, only
3.9% underwent some form of postoperative intervention.
Limitations
There are several limitations in our study that need
to be considered. First, only patients from a single center
were included in our study due to lack of feasibility
and finances. Second, the hospital considered is a
government‑based hospital; hence, the majority of the
sample belonged to low socio‑economic background.
Third, we did not account for all factors that may impact
adherence to treatment regimens such as income
and concomitant psychiatric illness. Finally, dosage of
aspirin was based on patient self‑report and medications
shown and not on pill counts, electronic monitoring or
refill data, which may be more reliable. To overcome
these limitations, a large sample size was taken to
minimize the effects of potential confounders.
CONCLUSION
Therefore, our study concludes that MI patients
with higher education level and undergoing rehabilitative
therapy are more likely to take low‑dose aspirin as
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Shah, et al.: Aspirin use in post-myocardial patients
compared to those who failed to have these attributes.
Further work is needed to confirm these findings and
expand our recommendations, particularly the sensitive
issue regarding adequate doctor counseling among
these high‑risk patients.
NGOs and governmental institutions can play a
pivotal role in bringing out the true picture as defined
in earlier studies and awareness projects. Further
data regarding these patients should be collected on
a national level, and appropriate measures should be
taken both by the government and by the private sectors
to reduce the mortality rate among these patients by
educating the masses on the role of aspirin usage.
These focused efforts, if successful, would reduce
the burden of related chronic heart disease in the
country and region, as a whole, especially in such an
area dominated with an elderly population.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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