By Austin Ulrich, PharmD, BCACP
Consultant Pharmacist, Ulrich Medical Writing LLC, Greensboro, NC
SYNOPSIS: The authors of new recommendations advise avoiding initiating aspirin for primary prevention of cardiovascular disease in adults age 60 years or older, individualizing decisions based on characteristics and preferences for patients.
SOURCE: US Preventive Services Task Force, Davidson KW, Barry MJ, et al. Aspirin use to prevent cardiovascular disease: US Preventive Services Task Force recommendation statement. JAMA 2022;327:1577.
Cardiovascular disease remains a leading cause of death in the United States, causing more than one in four deaths nationwide.1 Additionally, about 605,000 people experience a first myocardial infarction and 610,000 a first stroke each year, highlighting the need for effective preventive therapy.2 In April 2022, the U.S. Preventive Services Task Force (USPSTF) published updated guidance for using aspirin to reduce the risk of cardiovascular events, cardiovascular mortality, and all-cause mortality. The overall benefits and harms with aspirin use also were investigated. The recommendation statement serves as an update to the 2016 USPSTF guidance.3
The population studied for these recommendations were adults age 40 years and older without signs or symptoms of cardiovascular disease and without increased bleeding risk. In addition to conducting a systematic evidence review of aspirin use for primary prevention, a microsimulation model was used to quantify the net benefits and harms, stratified by cardiovascular risk level, age, and sex. The assessment of net benefit forms the basis for updated USPSTF guidance on aspirin use.
They found a small net benefit for preventive aspirin use in adults age 40-59 years, with a 10-year cardiovascular disease risk ≥ 10%. There was no net benefit found for adults age 60 years or older. Thus, the authors recommend against starting aspirin for patients age 60 years and older. For patients age 40 to 59 years, clinicians and patients should work together to create a customized plan based on individual characteristics.
The recommendations also offer practice considerations for clinicians, based on the evidence review. When considering initiating aspirin, account for bleeding risk factors in the overall decision to initiate therapy. Bleeding risk factors include: male sex, diabetes, history of gastrointestinal issues (e.g., peptic ulcer disease), liver disease, smoking, high blood pressure, and use of medications that increase risk of bleeding.
If initiating aspirin, the guidelines suggest a dose of 81 mg. Around age 75 years, it may be reasonable to consider stopping aspirin use. The USPSTF also concluded it is unclear whether aspirin use lowers the risk of colorectal cancer incidence or mortality.
COMMENTARY
The latest USPSTF recommendations update their 2016 guidelines, which indicated adults age 50-59 years could be prescribed low-dose aspirin daily for at least 10 years if 10-year cardiovascular risk is ≥ 10%, if bleeding risk is low, and if life expectancy is at least 10 years.3 The 2016 recommendations suggested individualized decision-making for adults age 60-69 years. Further, the 2016 recommendations stated there was insufficient evidence to determine benefits and harms of aspirin use in adults younger than age 50 years and age 70 years or older.
The 2022 USPSTF recommendations deliver an overall similar message to those of 2016 regarding individualizing therapy. The 2022 update differs with respect to changes in age ranges and the assertion that there is insufficient evidence for reducing colorectal cancer risk.4 The concept of individualized therapy for selecting appropriate candidates for aspirin use may warrant further exploration in future studies that are more precise than the current approach — using cardiovascular risk estimates.4 Platelet activity models in development may be able to further elucidate a personalized medicine approach to identify patients who may benefit more from aspirin preventive therapy.
Clinicians and patients who place more value on potential benefits of aspirin use (e.g., reduction of cardiovascular events) than the potential risks (e.g., higher rates of intracranial or gastrointestinal bleeding) may prefer to initiate low-dose aspirin. Those who place more value on potential risks than potential benefits may prefer to avoid initiating low-dose aspirin. Consistent with other recommendations, including those from the American College of Cardiology/American Heart Association, the USPSTF recommendations affirm the benefits of low-dose aspirin for primary prevention often are marginal and should be weighed against the risk of bleeding.4,5
REFERENCES
- Heron M. Deaths: Leading causes for 2017. Natl Vital Stat Rep 2019;68:1-77.
- Virani SS, Alonso A, Aparicio HJ, et al. Heart disease and stroke statistics — 2021 update: A report from the American Heart Association. Circulation 2021;143:e254-e743.
- Bibbins-Domingo K, U.S. Preventive Services Task Force. Aspirin use for the primary prevention of cardiovascular disease and colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2016;164:836-845.
- Berger JS. Aspirin for primary prevention — Time to rethink our approach. JAMA Netw Open 2022;5:e2210144.
- Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019;140:e596-e646.
The authors of new recommendations advise avoiding initiating aspirin for primary prevention of cardiovascular disease in adults age 60 years or older, individualizing decisions based on characteristics and preferences for patients.
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