From the Guidelines
Aspirin is generally not recommended for routine primary prevention of cardiovascular events in males over 60 years, as the potential harms of daily aspirin therapy often outweigh the potential cardiovascular benefits. For most men in this age group, the risk of gastrointestinal bleeding and hemorrhagic stroke associated with aspirin use is a significant concern. However, in select high-risk individuals with multiple cardiovascular risk factors and low bleeding risk, low-dose aspirin (typically 81 mg daily) might be considered after thorough discussion with a healthcare provider, as suggested by the American Diabetes Association and supported by studies such as 1.
This decision should be individualized based on comprehensive cardiovascular risk assessment, considering factors such as:
- Diabetes
- Hypertension
- Hyperlipidemia
- Smoking status
- Family history
The benefit-risk balance shifts more favorably toward aspirin use when the 10-year risk of cardiovascular disease is high (generally above 10%), as noted in studies like 1. Aspirin works by inhibiting platelet aggregation through irreversible inhibition of cyclooxygenase enzymes, thereby reducing thrombus formation, but this same mechanism increases bleeding risk. If aspirin is prescribed, it should be taken consistently, often with food to minimize gastrointestinal irritation, and patients should be monitored regularly for any signs of bleeding.
It's also important to consider that for patients over the age of 70 years (with or without diabetes), the balance appears to have greater risk than benefit, as indicated by 1. Thus, for primary prevention, the use of aspirin needs to be carefully considered and may generally not be recommended in older adults. Aspirin may be considered in the context of high cardiovascular risk with low bleeding risk, but generally not in older adults, emphasizing the need for personalized decision-making based on the latest evidence, such as that provided by 1.
From the Research
Aspirin Use for Primary Prevention of Cardiovascular Events in Males Over 60 Years
- The US Preventive Services Task Force (USPSTF) recommends against initiating low-dose aspirin use for the primary prevention of cardiovascular disease in adults 60 years or older 2.
- This recommendation is based on the finding that initiating aspirin use for the primary prevention of cardiovascular disease events in adults 60 years or older has no net benefit 2.
- A systematic review and meta-analysis found that aspirin use for primary prevention was associated with a lower risk of cardiovascular events, but also an increased risk of major bleeding events 3.
- The use of aspirin in individuals without cardiovascular disease was associated with a lower risk of cardiovascular events and an increased risk of major bleeding, with a number needed to treat of 265 and a number needed to harm of 210 3.
- A study found that the overall prevalence of US individuals who qualify for aspirin for primary prevention under the 2022 USPSTF guidelines is modest, with larger proportional eligibility among men, older age, and Black individuals 4.
- However, for males over 60 years, the USPSTF concludes with moderate certainty that initiating aspirin use for the primary prevention of cardiovascular disease events has no net benefit 2.
Considerations for Aspirin Use
- Factors associated with an increased risk of aspirin-related upper gastrointestinal complications include a prior history of ulcer or gastrointestinal bleeding, aspirin dose, and concomitant use with an NSAID, anticoagulant, or additional antiplatelet drug 5.
- Strategies to minimize the risk of developing upper gastrointestinal side effects in patients taking aspirin include the use of gastroprotective agents such as proton pump inhibitors and the eradication of Helicobacter pylori 5.
- The decision to initiate low-dose aspirin use for the primary prevention of cardiovascular disease in adults aged 40 to 59 years who have a 10% or greater 10-year cardiovascular disease risk should be an individual one, taking into account the potential benefits and harms 2.