News in Brief

ImportanceThe US Preventive Services Task Force (USPSTF) is updating its 2016 recommendation on the use of aspirin for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC).ObjectiveTo provide updated model-based estimates of the net balance in benefits and harms from routine use of low-dose aspirin for primary prevention.Design, Setting, and ParticipantsMicrosimulation modeling was used to estimate long-term benefits and harms for hypothetical US cohorts of men and women aged 40 to 79 years with up to 20% 10-year risk for an atherosclerotic CVD event and without prior history of CVD or elevated bleeding risks.ExposuresLow-dose (≤100 mg/d) aspirin for lifetime use, unless contraindicated by a bleeding event, and with stopping ages in 5-year intervals from age 65 to 85 years.Main Outcomes and MeasuresPrimary outcomes were lifetime net benefits measured in quality-adjusted life-years (QALYs) and life-years. Benefits included reduced nonfatal myocardial infarction and ischemic stroke. Harms included increased nonfatal major gastrointestinal bleeding and intracranial hemorrhage. Reduced CRC incidence was considered in sensitivity analysis.ResultsEstimated lifetime net QALYs were positive for both men and women at 5% or greater 10-year CVD risk when starting between ages 40 and 59 years and at 10% or greater 10-year CVD risk when starting between ages 60 and 69 years. These estimates ranged from 2.3 (95% CI, −2.7 to 7.4) to 66.2 (95% CI, 58.2 to 74.1) QALYs per 1000 persons. Lifetime net life-years were positive for men at 5% or greater and women at 10% or greater 10-year CVD risk starting aspirin at ages 40 to 49 years and for men at 7.5% or greater and women at 15% or greater 10-year CVD risk at ages 50 to 59 years. These estimates ranged from 0.4 (95% CI, −6.1 to 6.9) to 52.4 (95% CI, 43.9 to 60.9) life-years per 1000 persons. Lifetime net life-years were negative in most cases for persons starting aspirin between ages 60 and 79 years, as were lifetime net QALYs for persons aged 70 to 79 years. Stopping aspirin between ages 65 and 85 years generally showed little advantage compared with lifetime use. Sensitivity analyses showed lifetime net benefits may be higher if aspirin reduced CRC incidence or CVD mortality and lower if aspirin increased fatal major gastrointestinal bleeding or reduced quality of life with routine use.Conclusions and RelevanceThis microsimulation study suggested that several population groups may benefit from taking aspirin for the primary prevention of CVD, primarily in persons starting at younger ages with higher 10-year CVD risk.

Prevalence of preeclampsia risk factors: implications for low-dose aspirin prophylaxis

PurposeIn 2002, the US Preventive Services Task Force (USPSTF) recommended use of aspirin for the primary prevention of cardiovascular disease. This study investigates the impact of the recommendation on physician...

OBJECTIVE: To provide an up-to-date review of current guidelines, previous trials, and new trials regarding aspirin use in primary prevention of cardiovascular (CV) disease in the elderly population. DATA SOURCES: A PubMed search of articles published through April 2019 was performed using a combination of the following words: aspirin, bleeding, cardiovascular, elderly, hemorrhage, myocardial infarction, primary prevention, stroke. STUDY SELECTION/DATA EXTRACTION: Relevant randomized controlled trials, meta-analyses, and guidelines were assessed for the use of aspirin in primary prevention of CV disease in older patients. References from the above literature were also evaluated. Articles were selected for inclusion based on relevance to the topic, detailed methods, and complete results. DATA SYNTHESIS: The role of aspirin for primary prevention of CV disease in older adults is not well defined. As a result, the guideline recommendations for the use of aspirin in this setting are inconsistent. In 2018, the ARRIVE, ASCEND, and ASPREE studies were published. These studies tried to address some of the inconsistencies regarding the use of aspirin in primary prevention of CV disease. This article reviews the current recommendations along with previous and recent studies for aspirin use for primary prevention in older adults. CONCLUSION: The role of aspirin for primary prevention of CV disease in older adults should be individualized based on patient's risk factors, including risk of CV disease and likelihood of bleeding. Updated evidence provides more guidance regarding which patient populations will benefit from therapy.

BackgroundChronic kidney disease (CKD) is a global health concern and an independent risk factor for cardiovascular disease. Despite optimal treatments, mortality remains high among CKD patients. This meta-analysis aimed to assess the balance between the cardiovascular benefits and the bleeding risks associated with the use of low-dose aspirin in patients with CKD stages 3–5.MethodsRandomized controlled trials (RCTs) regarding the use of low-dose aspirin for cardiovascular primary prevention for patients with CKD were searched in PubMed, Embase, and the Cochrane Library. The Cochrane Collaboration RoB 2.0 tool was used to assess the risk of bias of RCTs. Major adverse cardiovascular events (MACE), including cardiovascular mortality, nonfatal myocardial infarction, and nonfatal stroke, along with other related outcomes, was calculated using a random-effects model to determine hazard ratios and relative risks (RRs). A subgroup analysis was stratified by estimated glomerular filtration rate (eGFR) levels to assess the differential effects of the treatment on patients with varying degrees of kidney function impairment.ResultsFive long-term RCTs were identified through systematic searches. Among them, 2 were at low risk, 2 had bias concerns, and 1 was at high risk. Aspirin significantly reduced the risk of MACE (RR, 0.76; 95% CI, 0.62–0.94), cardiovascular mortality (RR, 0.60; 95% CI, 0.43–0.85) and all-cause mortality (RR, 0.78; 95% CI, 0.63–0.96) in patients with CKD stages 3–5 compared to those not taking aspirin. When eGFR < 45 mL/min per 1.73 m2, the use of aspirin was associated with a significant reduction in the risk of myocardial infarction (RR, 0.47; 95% CI, 0.23–0.96) and cardiovascular mortality (RR, 0.47; 95% CI, 0.24–0.92). However, aspirin increased the risk of major bleeding in patients with CKD stages 3–5 compared to those not taking aspirin (RR, 1.50; 95% CI, 1.12, 2.02).ConclusionsLow-dose aspirin provided significant benefits in preventing MACE, cardiovascular mortality and all-cause mortality in patients with CKD stages 3–5, particularly in preventing myocardial infarction, and cardiovascular mortality in those with an eGFR < 45 mL/min per 1.73 m2. However, the risk of major bleeding tended to increase as the eGFR decreased. For patient populations with a high risk of bleeding, it is necessary to re-evaluate the appropriateness of aspirin use.

Should we recommend universal aspirin for all pregnant women?

Introduction:Aspirin is an effective anti-inflammatory and antiplatelet agent as an irreversible inhibitor of cyclooxygenase. In 2016, the U.S. Preventive Services Task Force recommended aspirin for primary prevention of cardiovascular disease in patients aged 50–69 years with a 10% or greater 10-year cardiovascular disease risk. Current guidelines for patients with prior myocardial infarction or coronary artery disease recommend aspirin use for the secondary prevention of cardiovascular disease. Due to the lack of literature describing adherence to these recommendations in the uninsured patient population, we studied aspirin use for cardiovascular disease prevention in free medical clinics.Methods:We conducted a cross sectional study of uninsured patients who visited nine free medical clinics in 2016–2017. Data from the records of 8857 patients were combined into a database for analysis. 10-year Framingham risk scores for coronary artery disease were calculated for the 50–69-year-old population to evaluate which patients qualified for aspirin usage. Aspirin use was assessed for patients with prior myocardial infarction or coronary artery disease.Results:In total, 1443 patients met the criteria to take aspirin for primary prevention of cardiovascular disease, but just 17% of these patients aged 50–59 years were on the medication. About 15% of the patients aged 60–69 years were taking aspirin. Of the 297 patients who had prior myocardial infarction or coronary artery disease, 50% were taking aspirin for secondary prevention.Conclusion:Among the uninsured population, there are low rates of aspirin use for risk reduction of cardiovascular disease. This study demonstrates that improvements are needed to increase adherence to current guidelines and address barriers uninsured patients may face in maintaining their cardiovascular health.

It is uncertain whether concurrent use of low-dose aspirin removes the gastrointestinal benefit displayed by COX-2 selective inhibitors (coxibs) when compared to traditional nonsteroidal anti-inflammatory drugs (NSAIDs). To evaluate the gastrointestinal risks associated with coxibs and traditional NSAIDs and the interaction with concurrent use of low-dose aspirin. We searched MEDLINE, EMBASE and the Cochrane Library through April 2016 to identify randomised trials comparing the gastrointestinal risk between coxibs and traditional NSAIDs in patients taking or not taking low-dose aspirin. Results were combined using random effects meta-analysis. Subgroup analyses by concurrent use of aspirin were undertaken. Eleven trials (84 150 participants) were included. The overall relative risk (RR) of coxibs vs. traditional NSAIDs for complicated gastrointestinal events was 0.54 (95% CI, confidence interval 0.32-0.92), with a significant subgroup difference (P = 0.04) according to concurrent use of aspirin (used: RR = 0.96, 95% CI 0.66-1.24; not used: RR = 0.33, 95% CI 0.14-0.83). The overall RR for clinical gastrointestinal events was 0.59 (95% CI 0.47-0.75), with a significant subgroup difference according to aspirin usage (P = 0.008; used: RR = 0.77, 95% CI 0.62-0.95; not used: RR = 0.50, 95% CI 0.39-0.64). Overall coxibs were associated with significantly lower risk of symptomatic ulcers (RR = 0.60, 95% CI 0.50-0.72) and endoscopic ulcers (RR = 0.29, 95% CI 0.16-0.53) than traditional NSAIDs; a significant subgroup difference was shown for endoscopic ulcers (P = 0.05) but not for symptomatic ulcers (P = 0.27). Concomitant use of low-dose aspirin reduces but does not completely eliminate the gastrointestinal benefit of coxibs over traditional NSAIDs.

The 2022 US Preventive Services Task Force (USPSTF) recommendation notes that the decision to initiate daily aspirin therapy for primary prevention of cardiovascular disease (CVD) should be made on a case-by-case basis for adults ages 40 to 59 with a 10% or greater 10-year CVD risk. The recommendation applies to those without signs or symptoms of clinically evident CVD who are not at an increased risk of bleeding. Clinicians are encouraged to use their judgment in weighing the risks and benefits of aspirin therapy, while taking patient preference into account for patients ages 40 to 60.

Background It is unclear to what extent the 2019 European Society of Cardiology (ESC), 2018 American College of Cardiology/ American Heart Association (ACC/AHA), 2016 US Preventive Services Task Force (USPSTF), and 2016 Canadian Cardiovascular Society (CCS) guidelines differ in assigning levels of evidence and classes of recommendations (LOE/class) to lipid-lowering treatment recommendations in primary prevention of cardiovascular disease (CVD). Purpose To compare LOE/class from four commonly used guidelines at population level. Methods A total of 7262 participants, aged 45–75 years of age and without history of CVD, from the prospective population-based Rotterdam Study were included. Per guideline, proportions of the population recommended statin therapy by LOE/class, sensitivity and specificity, and numbers needed to treat at 10 years (NNT10y) were calculated. Results Mean age was 61.1 (SD 6.9) years, and 58.2% were women. ESC, ACC/AHA, USPSTF and CCS strongly recommended statin use for a respective 33.8%, 48.1%, and 40.2% and 73.0% of the eligible population based on high-quality evidence, while in an additional 55.3%, 7.1%, 8.4% and 9.2% of participants statins use could or should be considered based on varying LOE/class. The sensitivity for treatment recommendations supported with strong, high quality evidence was 61.6% for ESC (“IA”), 74.6% for ACC/AHA (“IA or IB”), 69.4% for USPSTF (“USPSTF-B”) and 92.5% for CCS (“strong”). Specificity was highest for the ACC/AHA at 46.8% and lowest for ESC at 11.4%. Estimated NNT10y for those with the strongest LOE/class were comparable across all guidelines, ranging from 18 to 26 for moderate-intensity statin use, and 11 to 16 for high-intensity statin use. NNT10y reflective of recommendations supported with moderate strength of LOE/class varied substantially among guidelines for both moderate-intensity and high-intensity statin use, ranging from 33 for ESC and USPSTF to 91 for CCS. Conclusions Assigned LOE/class varied greatly among four clinical practice guidelines for primary prevention of CVD. Efforts for harmonized and comparable evidence grading system for clinical practice guidelines in primary prevention of CVD may reduce ambiguity, and reinforce updated evidence-based recommendations for appropriate treatment of populations for whom clear evidence for benefit of statin use is available. Funding Acknowledgement Type of funding source: None

Objective:The aim of this study was to describe the current status of aspirin use and the demographic characteristics of patients on aspirin for primary and secondary prevention of cardiovascular diseases.Methods:The Appropriateness of Aspirin Use in Medical Outpatients: A Multicenter, Observational Study (ASSOS) trial was a multicenter, cross-sectional, and observational study conducted in Turkey. The study was planned to include 5000 patients from 14 cities in Turkey. The data were collected at one visit, and the current clinical practice regarding aspirin use was evaluated (ClinicalTrials.gov number NCT03387384).Results:The study enrolled all consecutive patients who were admitted to the outpatient cardiology clinics from March 2018 until June 2018. Patients should be at least 18 years old, have signed written informed consent, and on aspirin (80–325 mg) therapy within the last 30 days. Cardiologists from the hospital participates in the study. Patients were divided into 2 categories according to presence or absence of atherosclerotic cardiovascular disease, namely secondary prevention group and primary prevention group, respectively. The appropriate use of aspirin in the primary and secondary prevention groups was assessed according to the European Society of Cardiology guidelines and US Preventive Services Task Force. The patients’ gastrointestinal bleeding risk factors and colorectal cancer risk were evaluated.Conclusion:The ASSOS registry will be the most comprehensive and largest study in Turkey evaluating the appropriateness of aspirin use. The results of this study help understand the potential misuse of aspirin in a real-world setting.

Background: Current national prevention guidelines recommend use of low dose aspirin (ASA) for both the primary prevention (PP) and secondary prevention (SP) of heart attack and stroke. ASA use for SP has been documented to have increased over the past decade. Since the publication of the 2009 United States Preventative Services Task Force (USPSTF) recommendations for PP ASA use, data describing the trends in PP ASA use in primary care are sparse. This study evaluates trends in PP and SP ASA use in primary care clinics from a large, regional health system over an 8 year period (2005-2013). Methods: A bi-annual cross-sectional electronic medical record (EMR) chart extraction was performed from 2005 to 2013 to evaluate documented ASA use for all patient encounters within primary care clinics in the Fairview Health System (Minnesota). Primary prevention candidates were defined as individuals within the USPSTF guideline age and sex target populations (men aged 45-79, and women aged 55-79 years) with no documented history of an atherosclerotic syndrome or contraindication to ASA use (aspirin allergy, peptic ulcer disease, or concurrent antithrombotic therapy). Secondary prevention candidates were defined as adults within the same age and gender range with a history of coronary artery disease, peripheral artery disease or ischemic stroke. The ASA treatment to candidacy ratio was calculated for the PP and SP populations. Results: Over 225,000 unique encounters at 66 primary care clinics were analyzed over the 8 year study period. The PP population was younger (60.4±8.7 vs. 66.2±8.3 years), with lower prevalence of hypertension (49 vs. 79%), hyperlipidemia (54 vs. 84%), and diabetes (17 vs. 35%) compared to the SP cohort. The mean SP ASA use of 86% was high, concordant with national trends, and did not change over this period. In contrast, PP ASA average use was 44% with no increase after publication of the 2009 USPSTF guideline. Documented contraindications to ASA use were uncommon (ASA allergy, 2.1 and 2.8%; peptic ulcer disease, 3.2 and 7.2%; and use of other antithrombotic medications, 4.6 and 32.6% in PP and SP populations respectively). Conclusion: Secondary prevention ASA use in primary care settings remains high, but ASA use for primary prevention of cardiovascular events is low. Despite creation of national guidelines, aspirin use in the PP population is half the rate of ASA use for secondary prevention. Additional methods to safely and effectively disseminate this primary prevention aspirin use recommendation, targeting both the public and health care providers, are warranted.

Adults aged 50 to 59 who are at risk of cardiovascular disease should take low dose aspirin for primary prevention, the US Preventive Services Task Force has concluded in draft...

Randomized evidence for aspirin in the primary prevention of cardiovascular disease (CVD) among women is limited and suggests at most a modest effect for total CVD. Lack of compliance, however, can null-bias estimated effects. We used marginal structural models (MSMs) to estimate the etiologic effect of continuous aspirin use on CVD events among 39,876 apparently healthy female health professionals aged 45 years and older in the Women's Health Study, a randomized trial of 100 mg aspirin every other day versus placebo. As-treated analyses and MSMs controlled for time-varying determinants of aspirin use and CVD. Predictors of aspirin use differed by randomized group and prior use and included medical history, CVD risk factors, and intermediate CVD events. Previously reported intent-to-treat analyses found small non-significant effects of aspirin on total CVD (hazard ratio (HR) = 0.91, 95 % confidence interval (CI) = 0.81-1.03) and CVD mortality (HR = 0.95, 95 % CI = 0.74-1.22). As-treated analyses were similar for total CVD with a slight reduction in CVD mortality (HR = 0.88, 95 % CI = 0.67-1.16). MSMs, which adjusted for non-compliance, were similar for total CVD (HR = 0.93; 95 % CI: 0.81, 1.07) but suggested lower CVD mortality with aspirin use (HR = 0.76; 95 % CI: 0.54, 1.08). Adjusting for non-compliance had little impact on the estimated effect of aspirin on total CVD, but strengthened the effect on CVD mortality. These results support a limited effect of low-dose aspirin on total CVD in women, but potential benefit for CVD mortality.

Cardiovascular disease (CVD) persists as the leading cause of death and disability in many Americans including Hispanics. Primary prevention for CVD may be achieved through regular aspirin use in high risk individuals. This study examined regular aspirin use and specific attitudes and social norms toward CVD and aspirin use within an urban Hispanic population in Minnesota. A sample of primary prevention Hispanics aged 45-79years were surveyed about CVD history and risk factors, aspirin use, demographic characteristics, and health beliefs and social norms in relation to CVD and aspirin. Relative risk estimation using Poisson regression with robust error variance was used to examine associations with aspirin use. In this sample of 152 Hispanics (55% women), the mean age was 53years, 70% had a regular healthcare provider, and 22% used aspirin. Aspirin discussions with a regular healthcare provider were strongly associated with aspirin use (adjusted risk ratio 3.02, 95% CI 1.20-7.60). There was a positive association between health beliefs and social norms that affirm preventive behaviors and aspirin use (adjusted linear risk ratio 1.23, 95% CI 1.04-1.45) while uncertainty about the role of aspirin for individual use and in the community was negatively associated with aspirin use (adjusted linear risk ratio 0.85, 95% CI 0.70-1.03). This growing population may benefit from health education about CVD risk and the role of aspirin in prevention.