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Posted By: Ben Taylor, PA-C, PhD, DFAAPA
April 02, 2019
For decades aspirin has been a staple of primary prevention of atherosclerotic cardiovascular disease (ASCVD) in at-risk populations, based on recommendations by almost all major healthcare organizations. However, recent studies have shown that aspirin should not be used in the routine primary prevention of ASCVD due to lack of net benefit. More importantly, use of aspirin should always be avoided in persons with increased risk of bleeding, including those with a history of GI bleeding, peptic ulcer disease, bleeding from other sites, age >70 years, thrombocytopenia, coagulopathy, chronic kidney disease, or concurrent use of nonsteroidal anti-inflammatory drugs, steroids, or anticoagulants.
While it has previously been recommended that most patients age >40 years take aspirin for primary prevention, recent trials suggest that the benefits and harms are closely balanced, and thus no net benefit exists. So, the decision of whether to use aspirin for primary prevention should be made only after a detailed discussion between the patient and his/her healthcare provider, guided by personal patient preferences and estimated benefits and harms relative to the specific patient. The balance between benefits and harms may weigh more heavily for harms over benefits in those age >70 years.
The following recommendations are based on meta-analysis and recent trials with subsequent perspectives from the 2019 American College of Cardiology/American Heart Association Guideline on the Primary Prevention of Cardiovascular Disease:
- Low-dose aspirin might be considered for primary prevention of ASCVD in select adults aged 40 to 70 years who are not at increased bleeding risk
- Low-dose aspirin should not be administered on a routine basis for primary prevention of ASCVD among adults >70 years
- Low-dose aspirin should not be administered for primary prevention among adults at any age who are at increased bleeding risk
- 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol. 2019;17.
- ASCEND Study Collaborative Group, Bowman L, Mafham M, et al. Effects of aspirin for primary prevention in persons with diabetes mellitus. N Engl J Med. 2018;379:1529.
- Gaziano JM, Brotons C, Coppolecchia R, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet. 2018;392:1036.
- McNeil JJ, Nelson MR, Woods RL, et al. Effect of aspirin on all-cause mortality in the healthy elderly. N Engl J Med. 2018;379:1519.
- McNeil JJ, Wolfe R, Woods RL, et al. Effect of aspirin on cardiovascular events and bleeding in the healthy elderly. N Engl J Med. 2018;379:1509.
- McNeil JJ, Woods RL, Nelson MR, et al. Effect of aspirin on disability-free survival in the healthy elderly. N Engl J Med. 2018;379:1499.