The use of aspirin as a protective agent for the prevention of cardiovascular events in the population at 10 years of cardiovascular risk of 10% or greater is now under investigation, according to the latest data from the US Health Preventive Group USPSTF.
The latest guidelines from the relevant scientific team do not recommend the preventive administration of low-dose aspirin (less than 100 mg per day) to anyone. It is highly recommended that people aged 60 and over do not start taking aspirin.
However, for people aged 40 to 59 with a 10-year cardiovascular risk of 10% or greater, the recommendation advises clinicians and patients to make individualized decisions about initiating aspirin prophylaxis, noting in any case that the net benefit is small.
The new guidelines came after reviewing 11 studies using low-dose aspirin for primary prevention, which showed a 10% reduction in cardiovascular events without reducing mortality, but also a 44% increase in bleeding episodes, in some cases. use of aspirin for 4-10 years. In absolute numbers, however, cardiovascular events ranged from 2,5 less to 1,2 more per 100 aspirin users, while bleeding episodes ranged from 0.07 less to 1 more per 100 aspirin users. Also the data were insufficient to include the prevention of colon cancer in the evaluation.
In addition, in three large clinical primary prevention clinics in 47.000 patients with 5-7 years of follow-up, the following were found:
- In individuals 55 years of age and older with multiple risk factors without diabetes and an estimated cardiovascular risk of 10 years 17% found no cardiovascular benefit data, while the increase in gastrointestinal bleeding was small but statistically significant.
- No significant cardiovascular benefit was found in people 65 years of age or older (with or without cardiovascular risk factors); on the other hand, there was a 0,7% increase in mortality and a 1% increase in major bleeding.
- In people with diabetes (40 years and older) a 1% reduction in cardiovascular events and a 1% increase in major bleeding was found.
An article in the scientific journal JAMA notes that these findings, which led to the new recommendation, leave clinicians without explicit guidance for primary prevention in patients, despite the fact that 28% of adults 40 years and older (and 46% of patients 70 years and older above) used aspirin for primary prevention only from 2019.
It is also pointed out that while the preventive treatment group recommends stopping aspirin use around the age of 75, it does not clearly state that these are obviously people who started aspirin before the age of 60. This creates the dilemma: in two 55-year-old patients with the same cardiovascular and bleeding risk profile, one starts aspirin and the other does not. Reaching the age of 60, it is not clear why one will continue to take aspirin until the age of 75 and the other will never take aspirin.
The author of the JAMA article, Alan Brett, of the Department of Internal Medicine at Colorado Medical School, notes that the decision to start aspirin therapy in people aged 40 to 59 depends largely on the ten-year risk of cardiovascular events, as estimated on the widely used scale compiled by the American College of Cardiology and the American Society of Cardiology. But the authors of the new directive acknowledge that the prediction of cardiovascular risk is "inaccurate and incomplete at the individual level".
Among other things, Dr. Brett wonders how clinicians should use this new recommendation, noting that for patients 60 years of age and older, clinicians should not start aspirin for primary prevention.
However, for patients aged 40 to 59 years, the recommendation states that interventions can be "offered selectively… based on professional judgment and patient preferences", thus allowing clinicians to initiate discussions about aspirin prophylaxis in patients. of this age group.
Asked what the "personalization" of the decision entails, Dr. Brett notes that patients whose general care philosophy is "do not prescribe medication for me unless there is strong evidence to support it" should not start aspirin prophylaxis. while those who prefer preventive interventions even in extreme cases could reasonably choose to take aspirin. Other patients do not have strong general preferences for taking (or not taking) drugs purely for prevention and are not interested in long-term discussion. Such patients often ask a trusted clinician to decide for them. But for other patients, personalized decision-making involves detailed discussion and the expectation that clinicians can predict with certainty whether a particular patient will receive a net benefit from aspirin. However, this goal is deceptive and clinicians should not pretend otherwise. For these patients, the best approach is for clinicians to be aware of primary aspirin prevention data.
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