USPSTF ends recommendations on initiating aspirin for primary prevention of CVD

26 April 2022

2 minutes to read

Disclosures: Britt and Georges Blake did not report any relevant financial disclosures. Please see the full recommendation statement and evidence review for all relevant financial disclosures by other authors.

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The US Preventive Services Task Force has published a final recommendation that cautions against initiation of low-dose aspirin for primary prevention of CVD in adults 60 years of age or older, a Class D recommendation.

The task force also issued a Class C recommendation that states that low-dose aspirin should be considered for primary prevention of cardiovascular disease on a case-by-case basis in adults aged 40 to 59 years with a risk of cardiovascular disease of 10 % or more for 10 years.

Pictures of aspirin pills
The USPSTF advises against initiating low-dose aspirin for primary prevention of CVD in adults 60 years of age or older. Source: Adobe Stock.

These recommendations are consistent with USPSTF Draft Recommendations which was released in October 2021. It is an update of 2016 Task Force Recommendationswhich supported the initiation of aspirin for primary prevention in adults aged 50-59 years at risk of cardiovascular disease, and stated that aspirin should be considered in adults aged 60-69 years with risk of cardiovascular disease by 10% or more for 10 years.

The current recommendations were based on a systematic review of 11 randomized controlled trials involving more than 134,400 patients.

In the evidence report, Janelle M. Gerges Blake, Physician, Clinical Associate Professor in the Department of Family Medicine at the University of Washington, and colleagues reported that low-dose aspirin was associated with a small but significant reduction in major CVD events (odds ratio = 0.9; 95% confidence interval, 0.85–0.95), although it It did not significantly reduce CVD mortality or all-cause mortality. The researchers also reported that low-dose aspirin was associated with a significant increase in heavy bleeding (OR = 1.44; 95% CI, 1.32-1.57).

During the review, the USPSTF also investigated the effect of aspirin use on colorectal cancer in CVD primary prevention groups, with previous research linking it to: Decreased mortality from colorectal cancer. However, the task force said the evidence is unclear whether aspirin reduces the risk of colorectal cancer or mortality.

In a related editorial, Alan S. Brett, MD, An internist at the University of Colorado School of Medicine in Aurora notes that the recommendation statement specifically refers to initiating aspirin use but lacks “explicit guidance” for patients already taking aspirin for primary prevention of CVD.

Brett wrote: “This omission is unfortunate, given that an estimated 28% of adults 40 or older (and 46% of those 70 or older) were using aspirin for primary prevention as recently as 2019, according to a representative survey on national level.

In a statement on USPSTF recommendations, Donald M. Lloyd-Jones, MD, SCM, FAHA, The president of the American Heart Association (AHA) said the new guidelines do not apply to patients who are already taking low-dose aspirin because they have had a myocardial infarction, stroke, stent or a history of atrial fibrillation. These patients are urged to continue taking aspirin as directed by their physician.

“The new guidance that reviews recommendations for the use of low-dose aspirin applies strictly to adults who have not had cardiovascular disease or any diagnosis of heart disease: Low-dose aspirin is not appropriate to prevent a first heart attack or stroke in most people,” Lloyd-Jones said.

Another concern about the recommendations, according to Brett, is that the decision to start aspirin therapy in patients aged 40 to 59 is “largely dependent” on the 10-year risk of cardiovascular disease, which is often estimated with the American College of Cardiology. (ACC) and AHA calculator.

He wrote: “The USPSTF authors acknowledge that in several external validation studies the calculator is over-predictive of cardiovascular risk, and appropriately remind clinicians that prediction of cardiovascular risk is ‘inaccurate and incomplete at the individual level.'” This source of uncertainty In clear tension with specific use of the 10% threshold guideline for cardiovascular risk, it is a challenge to make individual decisions to initiate aspirin use. Entering the data into the ACC/AHA calculator and generating a certain likelihood ratio creates a sense of accuracy in clinicians and patients that is misleading, despite the temptation of its apparent objectivity.”