USPSTF advises against starting aspirin for primary CVD prevention in older adults
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The U.S. Preventive Services Task Force no longer recommends starting aspirin for primary CVD prevention in adults aged 60 years or older, according to a draft recommendation issued today.
The draft statement also recommends that use of aspirin for primary CVD prevention in adults aged 40 to 59 years at high risk for CVD should be considered on a case-by-case basis.
The new recommendations are different from those issued by the task force in 2016, which supported aspirin for primary prevention in adults aged 50 to 59 with a 10-year CVD risk of at least 10% and stated adults aged 60 to 69 with a 10-year CVD risk of at least 10% could be considered for aspirin for primary prevention on a case-by-case basis.
In the interim, trials such as ARRIVE, ASCEND and ASPREE suggested the benefits of aspirin for primary prevention of CVD may not outweigh the risks, and the American College of Cardiology and American Heart Association issued a primary prevention guideline that advised against the use of aspirin for primary prevention except in patients at very high CVD risk.
According to the statement, CVD accounts for about 1 in 3 deaths in the U.S., and each year, an approximately 605,000 Americans experience a first MI and about 610,000 experience a first stroke.
The updated recommendations
The USPSTF issued a grade C recommendation regarding the use of aspirin for primary prevention in adults aged 40 to 59 years with a 10% or greater 10-year CVD risk. A grade C recommendation is dependent on a patient’s unique situation.
According to the statement, the decision to initiate low-dose aspirin for primary prevention of CVD in this population should be made on an individual basis, as evidence of net benefit in this group is small. In addition, patients who are not at increased risk for bleeding and are willing to take low-dose aspirin daily are more likely to benefit, the task force wrote.
The recommendation regarding the use of aspirin for primary prevention in adults aged 60 years or older was Grade D, which indicates that a treatment is not recommended for a specific group.
“Daily aspirin use may help prevent heart attacks and strokes in some people, but it can also cause potentially serious harms, such as internal bleeding,” John Wong, MD, interim chief scientific officer, vice chair for clinical affairs, chief of the division of clinical decision making and primary care clinician in the department of medicine at Tufts Medical Center, and member of the USPSTF, said in a press release. “It’s important that people who are 40 to 59 years old and don’t have a history of heart disease have a conversation with their clinician to decide together if starting to take aspirin is right for them.”
Recommendation rationale
To evaluate the benefits of aspirin for primary prevention of CV morbidity and mortality, the task force pooled the results of 13 randomized clinical trials, which included a total of 161,680 participants.
According to the statement, the findings from of the pooled analysis indicated that aspirin for the primary prevention of CVD is associated with decreased risk for MI and stroke but not CV or all-cause mortality. Moreover, findings were similar when trials using various doses of aspirin were compared with studies of low-dose aspirin.
To evaluate the harms of aspirin for primary prevention of CV morbidity and mortality, the task force pooled the results of 14 randomized clinical trials that reported on bleeding events associated with aspirin use.
Researchers reported that the increased risk for bleeding associated with aspirin use occurred soon after aspirin initiation. According to the statement, the relative bleeding risk associated with aspirin use did not change based on patients age, sex, diabetes status, level of CVD risk or race/ethnicity. Despite this, the absolute bleeding risk, and subsequently the magnitude of bleeding harm, does increase with age, especially in adults aged 60 years or older.
“The latest evidence is clear: starting a daily aspirin regimen in people who are 60 or older to prevent a first heart attack or stroke is not recommended,” Chien-Wen Tseng, MD, MPH, MSEE, the Hawaii Medical Service Association endowed chair in health services and quality research, professor and research director in the department of family medicine and community health at the University of Hawaii John A. Burns School of Medicine, and USPSTF member, said in the release. “However, this Task Force recommendation is not for people already taking aspirin for a previous heart attack or stroke; they should continue to do so unless told otherwise by their clinician.”
The USPSTF stated that more research is needed in the following areas:
- gastrointestinal bleeding risk associated with aspirin use in populations representative of the U.S. primary prevention population;
- accuracy of CVD risk prediction in all racial/ethnic and socioeconomic groups;
- characterizing of patient preferences across the spectrum of CV risk after patients are informed about the benefits and harms of aspirin; and
- the effects of low-dose aspirin on colorectal cancer incidence and mortality over the long-term in primary prevention populations, and in the context of current colorectal cancer screening practices.
Please see the USPSTF statement for full detail on this draft recommendation.
Reference:
- Task Force Issues Draft Recommendation Statement on Aspirin Use to Prevent Cardiovascular Disease. https://www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/aspirin-use-to-prevent-cardiovascular-disease-preventive-medication. Published and accessed Oct. 12, 2021.
Perspective
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C. Noel Bairey Merz, MD, FACC, FAHA
We always appreciate updated guidance related to new evidence. The two new clinical trials suggest that seniors in Westernized societies with access to health care including BP and lipid treatment who are living decades after their 65th year do not have overall health benefit from primary prevention daily aspirin use. The challenge in these new studies is the relative equivalence of CVD events (MI, stroke) to bleeding (gastrointestinal, urologic, cerebral) as overall health metrics. Most patients and physicians would agree that the former causes serious morbidity while the latter predominantly does not.
Unfortunately, these updated guidances typically result in patients with established CVD stopping their aspirin, and/or calling their physician’s offices asking for guidance.
Most humans in the world do not live in Westernized societies with access to health care, and more research is needed regarding these populations. Further, because the two new trials were conducted in Australia and the U.K. with safety net socialized health care systems, which have higher quality of health care and lower rates of adverse health outcomes, we should address aspirin utility in the U.S., particularly in middle and low socioeconomic status populations that do not have access to quality health care other than emergency care.
Perspective
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Equating CV events with irreversible tissue loss (in the form of MI and/or stroke) with bleeding, most of which is currently handled as an outpatient in the gastrointestinal or genitourinary clinic, is unfortunate and will contribute to discontinuation of aspirin in many who would benefit.
Also important, the USPSTF conclusion about dose is the same as that found in the ADAPTABLE trial among patients at high risk for events randomized to either 81 or 325 mg of aspirin daily (Jones WS, et al. N Engl J Med. 2021;doi:10.1056/NEJMoa2102137.)
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U.S. Preventive Services Task Force. Aspirin Use to Prevent Cardiovascular Disease: U.S. Preventive Services Task Force Draft Recommendation Statement. Published and accessed Oct. 12, 2021.
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