Aspirin for PRIMARY prevention is different story

As a cardiovascular pharmacist, you will be asked whether "an aspirin a day" is still good for the heart, based on new U.S. Preventive Services Task Force recommendations. Help patients sort out the facts. This is a case of guidance catching up with the evidence...

Recommend aspirin 81 mg/day for SECONDARY prevention, such as after a heart attack or stroke, or with angina or peripheral artery disease. Remind these patients not to stop aspirin, since it can be lifesaving and cardiovascular (CV) benefits clearly outweigh bleeding risks.

Aspirin for PRIMARY prevention is a different story. A new analysis confirms benefits are generally outweighed by risks. Using aspirin for primary prevention for up to 10 years avoids a CV event in 1 in 250 patients, but leads to major bleeding in 1 in 200. Primary prevention might have a small net benefit in select patients with high CV and low bleeding risk. But it doesn't seem to improve length or quality of life for most patients over 60.

Don't routinely recommend starting aspirin for primary prevention, even for patients with diabetes or multiple CV risks. Clarify that even aspirin 81 mg/day can lead to bleeding. And special forms (enteric-coated, buffered, etc) don't cause less GI bleeding, since risk seems mainly due to aspirin's systemic effects.

Ask if patients take OTC aspirin when you're updating medication lists. Share that evidence about its role in primary prevention has evolved. Weigh patient risks and preferences. For example, point out that bleeding risk goes up with age and aspirin is one more pill to take.

Reinforce other ways to reduce CV risk, such as lifestyle changes, smoking cessation and managing high blood pressure, lipids, and diabetes. Explain that it's usually appropriate to stop aspirin for primary prevention. Discuss with physicians or encourage patients to follow up. Educate that aspirin doesn't need to be tapered, it "self-tapers" as new platelets are made. Plus bleeding risk in primary prevention likely outweighs any theoretical risk of "rebound" events.

References

• US Preventive Services Task Force, Davidson KW, Barry MJ, Mangione CM, Cabana M, Chelmow D, Coker TR, Davis EM, Donahue KE, Jaén CR, Krist AH, Kubik M, Li L, Ogedegbe G, Pbert L, Ruiz JM, Stevermer J, Tseng CW, Wong JB. Aspirin Use to Prevent Cardiovascular Disease: US Preventive Services Task Force Recommendation Statement. JAMA. 2022 Apr 26;327(16):1577-1584. Available at: https://jamanetwork.com/journals/jama/fullarticle/2791399

  Guirguis-Blake JM, Evans CV, Perdue LA, Bean SI, Senger CA. Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Updated Evidence Report and Systematic eview for the US Preventive Services Task Force. JAMA. 2022 Apr 26;327(16):1585-1597. Available at: https://jamanetwork.com/journals/jama/fullarticle/2791401

  Dehmer SP, O'Keefe LR, Evans CV, Guirguis-Blake JM, Perdue LA, Maciosek MV. Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Updated Modeling Study for the US Preventive Services Task Force. JAMA. 2022 Apr 26;327(16):1598-1607. Available at: https://jamanetwork.com/journals/jama/fullarticle/2791400

  Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC Jr, Virani SS, Williams KA Sr, Yeboah J, Ziaeian B. 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. Circulation. 2019 Sep 10;140(11):e596-e646. Available at: https://pubmed.ncbi.nlm.nih.gov/30879355