Recommendation Regarding Aspirin Use to Prevent Cardiovascular Disease

JAMA Network: Published on April, 2022

CVD remains a leading cause of morbidity and mortality globally. Prevention strategies must address all aspects of a patient’s lifestyle habits, including healthy nutrition, physical activity, smoking cessation, and stress reduction. When an individual’s risk is sufficiently high, pharmacologic therapy is often considered to reduce CVD risk as part of a shared decision-making process for optimal CVD prevention.

Aspirin is a cornerstone of antiplatelet therapy for the secondary prevention of CVD, but its role in primary prevention remains uncertain. Over the past several decades, there has been great interest to identify individuals for whom the clinical benefit of aspirin for the prevention of a first heart attack or stroke (primary prevention) exceeds the risk of bleeding.

The US Preventive Services Task Force (USPSTF) has released its updated 2022 recommendations, supported by an updated evidence report, to guide the use of low-dose aspirin for the primary prevention of atherosclerotic cardiovascular disease (ASCVD), changing the age ranges and recommendation grades and focusing on preventing ASCVD events.

These recommendations are focused on starting aspirin to prevent a first heart attack or stroke.

TAKE-HOME MESSAGE

The new USPSTF guidelines do not recommend routine preventive aspirin for everyone. The USPSTF recommends that the decision to initiate low-dose aspirin for the primary prevention of cardiovascular disease (CVD) events in adults 40–59 years who have a 10% or greater CVD risk with no increased risk for bleeding is an individual one between physician and patient, with moderate certainty that the net benefit is small.


The USPSTF recommends against initiating low-dose aspirin use for the primary prevention of CVD in patients aged 60 or older.

This study showed that aspirin use for primary prevention of CVD events was associated with a decreased risk of myocardial infarction and stroke, but was not associated with a significant decrease in CVD mortality or all-cause mortality.

Low-dose aspirin use was associated with significantly higher risk for gastrointestinal bleeding and intracranial bleeding.

These recommendations explicitly refer to initiation of aspirin, and patients currently taking aspirin should not discontinue it without consulting their clinician.


What should physicians do?

For their patients, physicians should ensure that they are optimized for all their risk factors—lipids, blood pressure, smoking, diabetes, etc. Then aspirin becomes optional and can be avoided the bleeding risk from aspirin. In the end, it is all about the risks and benefits. 

Doctors Liked to Read More

The 2022 USPSTF recommendations suggest that the decision to initiate low-dose aspirin for the primary prevention of CVD in adults ages 40 to 59 years who have a 10% or greater 10-year CVD risk should be an individual one, and recommends against initiating low-dose aspirin use for the primary prevention of CVD in adults aged 60 years or older.

The systematic reviews of 11 RCTs of low-dose aspirin for primary CVD prevention found that aspirin use was significantly associated with reduction in the odds of CVD events, including major CVD events, total MI, and ischemic stroke, although there were no significant reductions in CVD mortality or all-cause mortality at up to 10 years of follow-up.

Low-dose aspirin was significantly associated with increases in bleeding harms, including intracranial and extracranial hemorrhage.

The clinical benefit of low-dose aspirin for primary prevention is marginal and must be carefully balanced against the well-known excess risk of major bleeding. Low-dose aspirin was associated with small absolute risk reductions in major cardiovascular disease events and small absolute increases in major bleeding.

Other guidelines recommend a tailored decision-making process between the patient and the health care professional based on the potential benefit vs risk.

The American College of Cardiology and American Heart Association (ACC/AHA) recommend that low-dose aspirin use (75 to 100 mg/d) might be considered for the primary prevention of atherosclerotic CVD among select adult’s ages 40 to 70 years at higher CVD risk but not at increased risk of bleeding. 

Low-dose aspirin use is not recommended on a routine basis for primary prevention of CVD in adults older than 70 years, or among adults of any age who are at increased risk of bleeding.

The European Society of Cardiology suggests that among individuals at very high CVD risk, low-dose aspirin may be considered for primary prevention.

 

Read In Details


https://jamanetwork.com/journals/jama/fullarticle/2791401
https://jamanetwork.com/journals/jama/fullarticle/2791399
https://pubmed.ncbi.nlm.nih.gov/35471505/

This is for informational purposes only. You should consult your clinical textbook for advising your patients.