Data show aspirin has limited role in patients without CAD
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Among adults without CAD, the absolute risk for major bleeding with aspirin as primary prevention therapy exceeds the any absolute MI benefits for every level of atherosclerotic CVD risk, data from a meta-analysis show.
“We noted that adding aspirin would lead to higher major bleeding events among patients without CAD, which exceeds the ischemic benefits of aspirin,” Safi U. Khan, MD, MS, a cardiovascular disease fellow at Houston Methodist and DeBakey Heart and Vascular Center, told Healio. “Furthermore, if such patients are already on preventive statin therapy, adding aspirin to statin is unlikely to achieve additional meaningful cardiovascular benefits but would enhance bleeding risk.”
Khan and colleagues analyzed 16 randomized controlled trials assessing aspirin (at least 75 mg every other day) in 171,215 participants without ASCVD and follow-up of at least 1 year (median age, 64 years; 46% women). Studies compared aspirin with placebo or no aspirin in adults without known ASCVD risk factors. Researchers estimated relative and absolute risks for CV outcomes, major bleeding and mortality over 5 years, calculating absolute risk differences assuming constant relative risks across statin use and ASCVD risks. Researchers used the Cholesterol Treatment Trialists Collaboration and the ASCEND trial to estimate baseline risks.
The findings were published in JACC: Advances.
Across trials, overall median proportion of statin use was 35%.
Compared with control, aspirin reduced MI (RR = 0.85; 95% CI, 0.77-0.95) but increased major bleeding risk (RR = 1.48; 95% CI, 1.32-1.66). Aspirin did not reduce mortality.
Statin vs. no statin was associated with lower bleeding and MI risk; the bleeding and MI risk were proportional to ASCVD risk.
Additionally, for every 10,000 adults, aspirin reduced MI and increased major bleeding proportional to baseline ASCVD risk, according to the researchers.
“Aspirin has a significant role in secondary prevention,” Khan told Healio. “However, we noted that the risk-benefit equilibrium might be tilted toward more harm with aspirin for primary prevention. Beyond lifestyle modifications, smoking cessation, exercise and preventive statin therapy, aspirin has a limited role in patients without coronary artery disease.”
Khan noted the researchers did not have patient-level information; an individual-level meta-analysis, stratifying absolute effects based on baseline statin therapy, may confirm observations.
“Furthermore, since uncertainty exists about whether aspirin may have a role in younger populations at high absolute risk, an analysis among younger adults might be informative,” Khan told Healio.
For more information:
Safi U. Khan, MD, MS, can be reached at safinmc@gmail.com; Twitter: @safinmc.
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