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.
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