New Gender and Age-specific USPSTF Aspirin Recommendations
Abstract & Commentary
By Harold L. Karpman, MD, FACC, FACP, Clinical Professor of Medicine, UCLA School of Medicine. Dr. Karpman reports no financial relationship to this field of study.
Synopsis: Aspirin reduces the risk for myocardial infarction in men ages 45-79 and for stroke in women ages 55-79; however, its use must be balanced against the increased risk of serious bleeding events in each individual patient.
Source: Wolff T, et al. Aspirin for the primary prevention of cardiovascular events: An update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2009;150:405-410.
It is widely accepted that cardiovascular disease (CVD) is the underlying and/or contributing cause for approximately 58% of deaths in the United States and it is clearly accepted as being the leading cause of death in the United States. In 2003, 2 of 3 men and 1 of 2 women older than age 40 years suffered from one form of CVD or another.1 In 2002, the U.S. Preventive Services Task Force (USPSTF) strongly recommended that clinicians discuss the use of aspirin with adults who have an increased risk of coronary heart disease, but steered clear of making specific recommendations.2 Subsequent to 2002, important data were published, including the large Women's Health Initiative (WHI),3 and the USPSTF therefore decided that it was necessary to update the 2002 guidelines and focus on the new evidence regarding the benefits and harms of aspirin for the primary prevention of CVD, which had been published since the 2002 USPSTF review and recommendations.
Wolff and her colleagues analyzed multiple studies published in the medical literature between Jan. 1, 2001, and Aug. 28, 2008.4 In addition, they reviewed relevant studies in the Cochrane Central Register of Controlled Trials and the reference lists included in other important articles and consulted extensively with experts in the field of CVD. The reviewed studies were abstracted and rated for quality by using predefined USPSTF criteria and the USPSTF finally concluded that aspirin reduces the risk for myocardial infarctions (MIs) in men and strokes in women, but that its use also increases the risk for serious bleeding events in both sexes.
Commentary
In the past, many guidelines that incidentally were based upon studies that were performed primarily in men have supported the widespread practice of prescribing aspirin for asymptomatic women for the prevention of MIs, but these guidelines had been called into question after the publication of a recent large study in women, which reported no benefit from the use of aspirin in MI prevention in asymptomatic women.3,5 New evidence from the WHI and supported by a sex-specific meta-analysis helped clarify the differing benefits of aspirin for men and women.3,6 Aspirin was found to reduce the number of CVD events in patients of both sexes without known CVD men in theses studies experienced fewer MIs and the women experienced fewer ischemic strokes, but aspirin use did not seem to affect CVD mortality or all-cause mortality in either men or women. The reasons for the observed differing effects on men and women are unknown although several postulates have been suggested such as differences in aspirin resistance in women.6 It should be noted that the USPSTF concluded that further research is needed to establish whether there is a benefit in the use of aspirin in diabetic patients for the primary prevention of CVD events and in the prevention of CVD events in patients afflicted with hypertension only. Finally, the task force concluded that the optimum dose of aspirin for preventing CVD events is not known for certain, but noted that the published primary prevention trials have clearly demonstrated benefits with various aspirin regimens including doses of 75-100 mg daily which appears to be as effective as the higher dose of 100-325 mg every other day, which also has been recommended. The task force also noted that since the risk for gastrointestinal bleeding may increase with increasing aspirin dosage, 75 mg per day would appear to be the best dose to consider using at this time in most patients.
In 2002, the USPSTF had based its recommendations on a systematic review of the evidence regarding the benefits and harms and an assessment of the net benefit of aspirin on various medical conditions at that time and it was strongly recommended that clinicians simply discuss the use of aspirin with all adults who had an increased risk for CVD.2 The current updated 2009 gender- and age-specific guidelines recommend the use of aspirin for men ages 45-79 years when the potential benefits due to a reduction in the rate of MIs outweigh the potential harm that might occur due to an increase in gastrointestinal hemorrhages and similarly, for women ages 55-79 years when the potential benefits of a reduction in ischemic strokes outweigh the harms resulting from an increase in the rate of gastrointestinal hemorrhages.7 Furthermore, the task force has concluded that the current evidence was insufficient to assess the balance of benefits and harms of aspirin for CVD prevention in men and women 80 years of age or older and finally, it recommends against the use of aspirin for stroke prevention in women younger than 55 years and for MI prevention in men younger than 45 years. In conclusion, it must be noted that the USPSTF guidelines emphasized the importance of shared decision-making and recommended that physicians discuss the benefits and risks of initiating aspirin therapy and the need to individualize decision-making for the specific patient or situation in each and every case based upon the individualized cardiovascular risk profile balanced against the risk of hemorrhage with aspirin therapy.
References
1. Thom T, et al; American Heart Association Statistics Committee and Stroke Statistics Committee. Heart disease and stroke statistics – 2006 update: A report from the American Heart Association Statistics Committee and Stroke Statistics Committee. Circulation 2006;113:e85-e151.
2. Wolf PA, et al. Probability of stroke: A risk profile from the Framingham Study. Stroke 1991;22:312-318.
3. Ridker PM, et al. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med 2005;352:1293-1304.
4. Wolff T, et al. Aspirin for the primary prevention of cardiovascular events: An update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2009; 150:405-410.
5. Whitlock EP, et al. Using existing systematic reviews in complex systematic reviews. Ann Intern Med 2008;148: 776-782.
6. Berger JS, et al. Aspirin for the primary prevention of cardiovascular events in women and men: A sex-specific meta-analysis of randomized controlled trails. JAMA 2006;295:306-313.
7. U.S. Preventive Services Task Force. Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009:150:396-404.
Aspirin reduces the risk for myocardial infarction in men ages 45-79 and for stroke in women ages 55-79; however, its use must be balanced against the increased risk of serious bleeding events in each individual patient.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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