Examining the Key Elements of Evidence Based Practice

Definition of Clinical Question

The clinical question of focus in this discussion deals with analyzing the effectiveness of aspirin therapy in managing myocardial infarction. Aspirin is a known drug that has been used to immediately manage symptoms of cardiovascular disease through its action on platelet activation and aggregation (Djarv et al., 2020). Although this drug is supported to manage acute symptoms of cardiac disease including ST-elevation myocardial infarction (STEMI), there is a debate on its early versus late use. Several studies exist to explain the benefits of initiating aspirin therapy before hospitalization while others find it essential to delay aspirin administration. To investigate this problem, a PICOT question was generated, and searching for relevant evidence from Cochrane, PubMed, and the National Institute of Cardiovascular Diseases databases was initiated.

PICOT Question

In adult patients presenting to the emergency department with suspected myocardial infarction, does the immediate administration of aspirin, compared to delayed administration, result in a decrease in mortality rates and improvement in cardiac outcomes, within the first 24 hours of presentation?

NRNP-6565-Synthesis in Advanced Nursing Practice Final Exam

Review of Database Results

A total of three articles were found to contain relevant data regarding the use of aspirin at different stages to manage myocardial infarction. The first article containing relevant data was a systematic review that analyzed the impact of first aid versus in-hospital administration of aspirin for non-traumatic chest pain. The researchers utilized Medline, Embase, and Cochrane databases to find randomized controlled studies that analyzed the clinical question. Based on evidence from the literature, oral antiplatelet medications like aspirin have been shown to improve survival among patients with chest pain due to acute coronary syndrome (Djarv et al., 2020). Acute coronary syndrome in this case includes both ST-elevation myocardial infarction and non-ST-elevation acute coronary syndrome. The systematic review showed that early administration of aspirin is associated with increased survival compared to late administration at seven days (Djarv et al., 2020). It is recommended to administer this medication during first aid management of non-traumatic chest pain to improve patient outcomes.

The second article identified is a systematic review article discussing the benefits of prehospital administration of aspirin and nitroglycerine in patients with acute coronary syndrome. The researchers utilized evidence from randomized controlled trials and observational studies published in the PubMed database. Based on the evidence from this article, early administration of aspirin to patients with acute myocardial infarction reduced 30-day and one-year mortality compared with no administration (Nakayama et al., 2022). It was also observed that the administration of aspirin to patients with STEMI upon arrival at the hospital can result in treatment delay.

D025: Essentials of Advanced Nursing Roles and Interprofessional Practice, STIs Education Program for Youths

 

Another research article found to be significant was a prospective study analyzing the early use of aspirin for patients with STEMI undergoing percutaneous coronary intervention. The study examined 657 patients and found out that those who received aspirin before hospitalization experienced decreased length of hospital stay (Mal et al., 2023). In addition, the death rate in the pre-hospital aspirin group was lower compared to those who waited to be medicated in the hospital. Overall, the frequency of pre-hospital aspirin administration for patients with STEMI was high across the three studies. Evidence from these researches indicates that early administration of aspirin is linked with better patient outcomes compared to late administration of the medication.

Descriptive Statistics

The descriptive statistics used to describe the data in the first source included mean, median, and confidence interval. For instance, early administration of aspirin had a median time interval of 1.6 hours from the time of pain onset. Early administration of aspirin demonstrated a confidence level of 97.5% compared with 93.5% in the late administration group in a sample size of 2122 subjects. These values translated to confidence interval p<0.001, RR, 1.04; 95% CI, 1.02-1.06 (Djarv et al., 2020). The same study also evaluated critical outcomes of early versus late aspirin administration within 30 days. Early administration demonstrated a 95.2% confidence level compared to 91.2% in the late administration group. Analysis of a second study that contained 8587 participants demonstrated a confidence level of 91.2% compared to 90.5% in the late administration group (Djarv et al., 2020). This study represents level I evidence because it is a systematic review of randomized controlled trials.

The second study used odds ratios (OR) and 95% confidence intervals to analyze the outcomes. The study focused on 4350 patients who were grouped into 2193 for the pre-hospital and 2157 for the control group. The findings indicated that the prehospital administration group had significantly lower 30-day and 1-year mortality than the control group (OR 0.59 [95% CI: 0.35–0.99; P<0.01] and 0.47 [95% CI: 0.36–0.62; P<0.01], respectively) (Nakamaya et al., 2022). Despite these findings, the level of evidence from the utilized studies was low because the administration of aspirin was not performed by healthcare professionals. The level of evidence of this study can be classified as level II because lesser quality articles that did not use the RCT approach were used.

The prospective study that focused on the use of aspirin for STEMI utilized descriptive statistics like mean, median, and p-value. For instance, the mean age of participants was 54.60 and the majority were male. About 254 patients received pre-hospital aspirin while 403 received aspirin after arrival. The mean length of stay for those who received aspirin demonstrated a p=0.001 value. A p-value of ≤ 0.05 was taken as the criterion for statistical significance and the overall results showed no statistical significance given a p=0.434 value (Mal et al., 2023). This research represents level II evidence because it is a prospective study involving 657 patients diagnosed with STEMI.

References

Djarv, T., Swain, J. M., Chang, W. T., Zideman, D. A., & Singletary, E. (2020). Early or first aid administration versus late or in-hospital administration of aspirin for non-traumatic adult chest pain: A systematic review. Cureus, 12(2), e6862. https://doi.org/10.7759/cureus.6862

Mal, V., Ahmed, R., Asad, A., Batra, M. K., Ammar, A., Kumar, R., Hakeem, A., Khan, N. U., Sial, J. A., & Saghir, T. (2023). Early use of aspirin after symptoms in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention. Pakistan Heart Journal, 56(1), 17-21. https://doi.org/10.47144/phj.v56i1.2393

Nakayama, N., Yamamoto, T., Kikuchi, M., Hanada, H., Mano, T., Nakashima, T., … & Nonogi, H. (2022). Prehospital administration of aspirin and nitroglycerin for patients with suspected acute coronary syndrome―A Systematic review―. Circulation reports, 4(10), 449-457. http://dx.doi.org/10.1253/circrep.CR-22-0060