Perspective from Raj Khandwalla, MD
Disclosures: Brett and Guirguis-Blake report no relevant financial disclosures. Please see the full recommendation statement and evidence review for all other authors' relevant financial disclosures.
April 26, 2022
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USPSTF finalizes recommendations on initiating aspirin for primary CVD prevention

Perspective from Raj Khandwalla, MD
Disclosures: Brett and Guirguis-Blake report no relevant financial disclosures. Please see the full recommendation statement and evidence review for all other authors' relevant financial disclosures.
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The U.S. Preventive Services Task Force has published a final recommendation that advises against the initiation of low-dose aspirin for primary CVD prevention in adults aged 60 years or older, a D-grade recommendation.

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

Photo of aspirin pills
The USPSTF advises against the initiation of low-dose aspirin for primary CVD prevention in adults aged 60 years or older. Source: Adobe Stock.

These recommendations align with the USPSTF’s draft recommendations that were released in October 2021. They are an update to the task force’s 2016 recommendations, which supported the initiation of aspirin for primary prevention in adults aged 50 to 59 years at risk for CVD and stated that aspirin should be considered in adults aged 60 to 69 years with a 10% or greater 10-year CVD risk.

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. Guirguis-Blake, MD, a 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 decrease in major CVD events (OR = 0.9; 95% CI, 0.85-0.95), although it did not significantly reduce CVD mortality or all-cause mortality. The researchers also reported that low-dose aspirin was linked to a significant increase in major bleeding (OR = 1.44; 95% CI, 1.32-1.57).

During its review, the USPSTF also investigated the effect of aspirin use on colorectal cancer in primary CVD prevention populations, as previous research has linked it to a reduction in colorectal cancer-specific mortality. However, the task force said the evidence is unclear whether aspirin reduces the risk for colorectal cancer incidence or mortality.

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

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

In a statement about the USPSTF recommendations, Donald M. Lloyd-Jones, MD, ScM, FAHA, president of the American Heart Association (AHA), said the new guidance does not apply to patients who are already taking low-dose aspirin because they had a myocardial infarction, stroke or stenting or a history of atrial fibrillation. He urged these patients to continue taking aspirin as directed by their physician.

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

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

“The USPSTF authors acknowledge that in several external validation studies the calculator overpredicts cardiovascular risk, and they appropriately remind clinicians that cardiovascular risk prediction is ‘imprecise and imperfect at the individual level,’” he wrote. “This source of uncertainty is in obvious tension with the guideline’s specific use of the 10% threshold for cardiovascular risk and presents a challenge in individualizing decisions to initiate aspirin use. Plugging data into the ACC/AHA calculator and generating a specific percent probability creates a sense of precision for clinicians and patients that is misleading, although alluring in its apparent objectivity.”

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