Highlights The new USPSTF guidelines do not recommend routine preventive aspirin for everyone. The USPSTF recommends that the decision to initiate low-dose aspirin for the primary prevention of cardiovascular disease (CVD) events in adults aged 40 to 59 years who have a CVD risk of 10% or greater without an increased risk of bleeding is a individual decision between doctor and patient, with moderate certainty that the net benefit is small. The USPSTF recommends against initiating low-dose aspirin for primary prevention of CVD in patients 60 years of age or older. This study showed that aspirin use for primary prevention of CVD events was associated with a decreased risk of myocardial infarction and stroke, but was not associated with a significant decrease in CVD or all-cause mortality. Low-dose aspirin use was associated with a significantly increased risk of gastrointestinal bleeding and intracranial hemorrhage. These recommendations refer explicitly to the initiation of aspirin, and patients currently taking aspirin should not discontinue aspirin without consulting their doctor. |
Importance
Cardiovascular disease (CVD) is the leading cause of mortality in the US, accounting for more than 1 in 4 deaths. Each year, approximately 605,000 people in the US have a first heart attack and approximately 610,000 experience a first stroke.
Aim
To update its 2016 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review of the effectiveness of aspirin in reducing the risk of CVD events (myocardial infarction and stroke), cardiovascular mortality and all-cause mortality in people without a history of CVD.
The systematic review also investigated the effect of aspirin use on colorectal cancer (CRC) incidence and mortality in primary CVD prevention populations, as well as the harms (particularly bleeding) associated with aspirin use.
The USPSTF also commissioned a microsimulation modeling study to evaluate the net balance of benefits and harms of aspirin use for the primary prevention of CVD and CRC, stratified by age, sex, and CVD risk level.
Population
Adults 40 years or older without signs or symptoms of CVD or known CVD (including history of myocardial infarction or stroke) who are not at increased risk of bleeding (e.g., no history of gastrointestinal ulcers, recent bleeding, other medical conditions or use of medications that increase the risk of bleeding).
Evaluation of the evidence
The USPSTF concludes with moderate certainty that the use of aspirin for the primary prevention of CVD events in adults aged 40 to 59 years who have a 10-year CVD risk of 10% or greater has a small net benefit.
The USPSTF concludes with moderate certainty that initiating aspirin for the primary prevention of CVD events in adults aged 60 years and older has no net benefit.
Recommendation
The decision to initiate low-dose aspirin for primary CVD prevention in adults aged 40 to 59 years who have a 10-year CVD risk of 10% or greater should be an individual one. The evidence indicates that the net benefit of aspirin use in this group is small.
People who do not have an increased risk of bleeding and are willing to take low-dose aspirin every day are more likely to benefit. (Recommendation C)
The USPSTF recommends against initiating low-dose aspirin for primary prevention of CVD in adults aged 60 years and older. (Recommendation D).
Clinical practice considerations
Patient population under consideration
This recommendation applies to adults aged 40 years or older without signs or symptoms of CVD or known CVD (including history of myocardial infarction or stroke) who are not at increased risk of bleeding (e.g., no history of gastrointestinal ulcers). , recent bleeding, other medical conditions, or use of medications that increase the risk of bleeding).
In this recommendation statement, the CVD risk and net benefit of aspirin use are discussed using the terms "men" and "women ," although estimates of CVD risk and net benefit are likely determined by sex. (i.e. masculine/feminine ) rather than gender identity.
