Is aspirin indicated for primary prevention of cardiovascular events in a 65-year-old woman with pre-diabetes (impaired glucose regulation) and hypercholesterolemia (elevated cholesterol)?

From the Guidelines

Aspirin is not routinely indicated for primary prevention of cardiovascular events in a 65-year-old woman with pre-diabetes and hypercholesterolemia. According to the most recent guidelines, including those from 2024 1, the use of aspirin for primary prevention needs to be carefully considered, especially in older adults, due to the balance of risk and benefit. The potential bleeding risks of daily aspirin therapy likely outweigh the cardiovascular benefits for this patient.

Key Considerations

• The patient's age, pre-diabetes, and hypercholesterolemia are important factors, but current guidelines suggest a more cautious approach to aspirin use in primary prevention, especially as the patient is close to the age where the risk-benefit balance shifts further towards risk 1.
• Management should focus on lifestyle modifications, such as regular physical activity, a Mediterranean or DASH diet, weight management if needed, and appropriate medication for hypercholesterolemia, typically starting with a moderate-intensity statin.
• Blood pressure control and regular monitoring of glucose levels are also essential components of the patient's care.
• The patient should be assessed for overall cardiovascular risk using a validated risk calculator, and decisions about preventive therapies should be based on this comprehensive assessment rather than individual risk factors.

Aspirin Use in Similar Contexts

• For individuals with diabetes and at least one additional major risk factor who are not at increased risk of bleeding, aspirin therapy may be considered after a comprehensive discussion of benefits versus risks 1.
• However, for people over 70 years of age, the balance appears to have greater risk than benefit, making aspirin generally not recommended for primary prevention in this age group 1.

Conclusion on Aspirin Use

The decision to use aspirin for primary prevention should be made on a case-by-case basis, considering the individual's overall risk profile and potential for bleeding complications. Given the patient's profile, a thorough discussion of risks and benefits is necessary before considering aspirin therapy, but it would not be the first-line approach for primary prevention in this case, emphasizing the importance of other preventive measures and risk factor management.

From the Research

Aspirin for Primary Prevention in a 65-year-old Woman with Pre-diabetes and Hypercholesterolemia

• The use of aspirin for primary prevention of cardiovascular events in patients with diabetes is a topic of ongoing debate 2, 3, 4, 5, 6.
• Studies have shown that aspirin can reduce the risk of cardiovascular events in patients with diabetes, but this benefit is often counterbalanced by an increased risk of major bleeding 2, 4, 6.
• A meta-analysis of randomized controlled trials found that aspirin use in patients with diabetes reduced the composite endpoint of cardiovascular death, non-fatal myocardial infarction, and stroke, but increased the risk of major bleeding 4.
• Another meta-analysis found that aspirin use in patients with diabetes did not significantly reduce the risk of all-cause mortality, cardiovascular mortality, or bleeding events, but did reduce the risk of major adverse cardiovascular events (MACE) 5.
• The ASCEND trial, which studied the use of low-dose aspirin in persons with diabetes without prior cardiovascular disease, found that aspirin use led to a lower risk of cardiovascular events, but also increased the risk of major bleeding 2, 6.
• The ASPREE trial, which studied the use of low-dose aspirin in healthy elderly, found that aspirin use did not prolong disability-free survival and instead led to a higher rate of major hemorrhage 6.
• Based on these studies, it appears that the use of aspirin for primary prevention in patients with diabetes, including those with pre-diabetes and hypercholesterolemia, should be individualized and carefully considered, taking into account the patient's overall risk of cardiovascular events and bleeding 2, 3, 4, 5, 6.

Key Considerations

• The patient's age (65 years) and presence of pre-diabetes and hypercholesterolemia increase her risk of cardiovascular events 2, 3, 4, 5, 6.
• The patient's individual risk of bleeding should also be considered, as aspirin use can increase this risk 2, 4, 6.
• The use of aspirin for primary prevention in this patient population should be carefully weighed against the potential benefits and risks, and alternative strategies for reducing cardiovascular risk should also be considered 2, 3, 4, 5, 6.