Aspirin: To Give or Not to Give for Primary Prevention

Shalon Buchs | Skin Bones CME
By: Shalon Buchs, MHS, PA-C

Are the guidelines changing?

Aspirin has long been a recommended therapy for the
prevention of coronary vascular disease (CVD). It has been used for both
primary and secondary prevention strategies. Low dose aspirin was regularly
recommended for patients with any significant risk of CVD. Now, however, there
is new controversy surrounding the low dose aspirin we have been advocating for
decades in the setting of primary prevention of coronary vascular disease. There
is substantial evidence that the low dose aspirin is providing a relative risk
reduction of first-time myocardial infarction or stroke, but the risk of a
gastrointestinal bleed could outweigh this benefit.

The United States Preventive Service Task Force (USPSTF)
currently recommends adults 50-59 years of age take a daily low dose aspirin if
their 10 year CVD risk is 10% or higher, they don’t have bleeding risk factors,  and they are willing to take the drug for at
least ten years. The USPSTF rates this a Grade B recommendation. Their
recommendations for initiation of low-dose aspirin use in other age groups are
either Grade C or I. These recommendations were released in 2016 and are based
on data published through 2014. To see the current full recommendations related
to aspirin by the USPSTF, click here: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/aspirin-to-prevent-cardiovascular-disease-and-cancer

The American College of Cardiology and the American Heart
Association (ACC/AHA) published new guidelines in March 2019 regarding Primary
Prevention of Cardiovascular Disease. (http://www.onlinejacc.org/content/74/10/e177?_ga=2.57935850.1325622184.1574200725-1158206344.1573307753)
Their message about aspirin was based on more recent data, including the ARRIVE
and ASCEND trials published in 2018, as well as several other more recent
trials looking at aspirin as primary preventive therapy. The take-home points
from the ACC/AHA regarding aspirin for prevention include:

  • Aspirin (low-dose) can be considered for primary
    prevention in certain high-risk adults between the ages of 40-70 who do not
    have an increased risk for bleeding.
  • Aspirin should not be used for primary
    prevention in adults >70 years of age.
  • Aspirin should be avoided in people with any
    increased risk of bleeding.

While the USPSTF and the ACC/AHA both point out that bleeding risk
should be considered before recommending aspirin for primary prevention, the
new ACC/AHA guidelines define ‘high risk’ asymptomatic adults as those with a
score >20% risk on the ASCVD Risk Estimator Plus calculator. As noted above, the USPSTF recommends
low-dose aspirin when the ten year CVD risk is >10%. The age range is wider
with the ACC/AHA than it is currently with the USPSTF recommendation, as well

To follow the newer guidelines regarding the use
of aspirin for primary prevention of CVD according to the latest data, the
following are essential:

  • Evaluate patients between the
    ages of 40-70
  • Calculate a 10-year ASCVD
    risk
  • Determine a patient’s risk of
    bleeding
  • Start low dose aspirin if:
    • The risk of ASCVD is at least
      20%
    • The patient does not have an
      increased risk of bleeding

To hear more about primary prevention of CVD, be sure to attend
one of my sessions!

See Shalon Buchs, MHS, PA-C speak at a 2020 Skin, Bones, Hearts & Private Parts event in DestinMyrtle BeachSan AntonioLas Vegas