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!