New USPSTF Recommendation on Aspirin in CVD: No For Primary Prevention, Yes For Secondary Prevention
New guidance from the U.S. Preventive Service Task Force (USPSTF) recommends against initiating the use of low-dose aspirin in patients over 60 years of age for primary prevention of atherosclerotic cardiovascular disease (ASCVD). However, low-dose aspirin continues to be recommended, including by the ACC, for secondary prevention for patients with ASCVD or who have existing heart problems, including a history of a heart attack or stroke, angioplasty, PCI or CABG, based on the clinician judgment and long-term antiplatelet strategy.
In adults ages 40 to 59 years, the updated recommendations on the use of aspirin in the setting of the primary prevention of ASCVD, published in JAMA, call for individualizing low-dose aspirin therapy for those who have a 10% or greater 10-year cardiovascular disease risk. According to the statement, they conclude "with moderate certainty" that low-dose aspirin for primary prevention has a "small net benefit" in relation to risk of bleeding based on the evidence from the systematic review that included 11 randomized trials of low-dose aspirin (100 mg daily or less) in adults 40 to 50 years old and those over 60 years old. It also states that "persons who are not at increased risk for bleeding and are willing to take low-dose aspirin daily are more likely to benefit (C recommendation).
"It is very important to recognize that the USPSTF recommendation on the initiation of aspirin does not apply to patients with a prior history of heart attack, stroke, bypass surgery, or recent stent procedure," emphasizes Eugene Yang, MD, FACC, chair of ACC's Prevention of Cardiovascular Disease Section. He is a clinical professor of medicine at the University of Washington School of Medicine and the co-director of the Cardiovascular Wellness and Prevention Program.
The updated USPSTF recommendations, which replace the previous USPSTF 2016 statement, generally aligns with the guidance from the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease that states aspirin should be used infrequently in the routine primary prevention of ASCVD.
Specifically, the ACC/American Heart Association primary prevention guideline recommends:
- Low-dose aspirin (75-100 mg orally daily) might be considered for the primary prevention of ASCVD among select adults 40 to 70 years of age who are at higher risk ASCVD risk but not at increased bleeding risk (class of recommendation [COR] IIb, level of evidence [LOE] A).
- Low-dose aspirin 75-100 mg orally daily) should not be administered on a routine basis for the primary prevention of ASCVD among adults >70 years of age (COR III [harm], LOEB-R).
- Low-dose aspirin 75-100 mg orally daily) should not be administered for the primary prevention of ASCVD among adults of any age who are at increased risk of bleeding (COR III [harm], LOE C-LD).
Importantly, patients who are already taking low-dose aspirin should not stop taking it until they have a conversation with their physician. "All patients should consult with their physicians about whether they can safely discontinue aspirin. This decision should be made after a careful review of the risks and benefits," says Yang.
Keywords: Cardiovascular Diseases, Secondary Prevention, Percutaneous Coronary Intervention, Primary Prevention, Aspirin, Risk Assessment, Myocardial Infarction, Angioplasty, Physicians, Stents, Stroke, Coronary Artery Bypass
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