Sperling: Messaging around aspirin could be better
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PHILADELPHIA — The question of who should take aspirin is a complicated one and public messaging on it is sometimes confusing, a speaker said at the Heart in Diabetes CME conference.
Laurence S. Sperling, MD, FACC, FACP, FAHA, FASPC, Katz Professor in Preventive Cardiology and professor of global health at Emory University, said that the U.S. Preventive Services Task Force “mainly got it right” when it recommended against aspirin for primary prevention in most people, but the way in which the message was conveyed by the task force and the media was confusing for some patients. He informally polled the audience to ask if any of their patients with prior CVD or valvular heart disease had asked them if they should stop taking their aspirin, and almost all audience members raised their hand. Aspirin remains recommended for secondary CVD prevention.
Aspirin use for the long term is appropriate in patients with prior MI, stroke, transient ischemic attack, stable angina or peripheral artery disease, he said, citing a meta-analysis of about 135,000 patients by the Antithrombotic Trialists’ Collaboration. He also noted data support aspirin use in patients with valvular heart disease.
The USPSTF and the American College of Obstetricians and Gynecologists recommend aspirin for primary prevention of preeclampsia in women at high risk for it, he said.
Aspirin for primary prevention is a trickier matter for most people, he said. The ASCEND trial found it reduced major adverse CV events in patients with diabetes but no prior atherosclerotic CVD at the cost of elevated risk for major bleeding, while the ASPREE trial of people aged 70 years (65 years if African American) or older and the ARRIVE trial of men aged 55 years or older and women aged 60 years or older at moderate 10-year CVD risk found no benefit of aspirin for primary prevention in those populations, he said.
A meta-analysis of the three trials found that the number needed to treat to prevent one case of CVD was 265 and the number needed to harm one person from major bleeding was 210, Sperling said.
The USPSTF recommendation was nuanced, noting that shared decision-making is important, risk estimates can be flawed, people who have been taking aspirin without bleeding events may continue to benefit from it and modeling data suggest stopping aspirin at age 75 is reasonable if the patient has not had a CV event, he said.
However, headlines such as “A daily aspirin regimen may hurt more than help” and “Aspirin is out” did not convey any such nuance, he said.
“The recommendations apply only to those who do not have a history of CVD and are already taking aspirin,” Sperling said. “Many patients asked their trusted clinician [about whether to stop aspirin] anyway.”
Appropriate messaging should emphasize that people who have a history of CVD and are taking aspirin should continue to do so, he said.
Doctors should estimate 10-year CVD risk in any patient being considered for aspirin for primary prevention and should discuss any risk-enhancing factors and patient concerns before proceeding, he said, noting coronary artery calcium score can be a tiebreaker, as aspirin has shown benefit in people with a CAC score of 100 or more, but has shown harm in people with a CAC score of 0.
“There should be an individualized ASCVD risk/bleeding assessment,” he said. “It should be a partnered decision and should be periodically reassessed and reevaluated.
“Make sure your patients aware that they don’t stop aspirin if they’ve had a stent or a heart attack or a stroke,” he said. “Focus on the net clinical benefit and shared decision making. But we should be really humbled that in 2022, many unanswered questions about aspirin exist.”
References:
- Antithrombotic Trialists’ Collaboration. BMJ. 2002;doi:10.1136/bmj.324.7329.71.
- US Preventive Services Task Force. JAMA. 2022;doi:10.1001/jama.2022.4983.
- Zheng SL, et al. JAMA. 2019;doi:10.1001/jama.2018.20578.
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Sperling LS. Session 5: Aspirin and Antiplatelets’ Role in Therapy. Presented at: Heart in Diabetes; June 24-26, 2022; Philadelphia (hybrid meeting).
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