Is aspirin (acetylsalicylic acid) indicated for primary prevention of cardiovascular events in an elderly female patient with diabetes (diabetes mellitus) and hypercholesterolemia?

From the Guidelines

Aspirin is generally not recommended for primary prevention of cardiovascular events in elderly female patients with diabetes and hypercholesterolemia. According to the most recent guidelines, for people over the age of 70 years (with or without diabetes), the balance appears to have greater risk than benefit 1. The risk of gastrointestinal bleeding and hemorrhagic stroke with aspirin therapy is significantly higher in older adults, which outweighs the potential cardiovascular benefits.

Management should focus on optimal control of diabetes with appropriate medications (such as metformin, SGLT2 inhibitors, or GLP-1 receptor agonists), cholesterol management with statins (such as atorvastatin 20-80mg daily or rosuvastatin 10-40mg daily), blood pressure control, smoking cessation if applicable, and lifestyle modifications including regular physical activity and a heart-healthy diet.

Some key points to consider in the management of elderly female patients with diabetes and hypercholesterolemia include:

• Optimal control of diabetes and cholesterol levels to reduce cardiovascular risk
• Blood pressure control to reduce the risk of cardiovascular events
• Lifestyle modifications, such as regular physical activity and a heart-healthy diet, to reduce cardiovascular risk
• Avoidance of aspirin for primary prevention due to the increased risk of bleeding

If aspirin is considered in specific high-risk cases, a lower dose (75-100mg daily) might be used, but this decision should be individualized after carefully weighing cardiovascular risk against bleeding risk 1. The shift away from routine aspirin use reflects evolving evidence showing that for many patients without established cardiovascular disease, the harms of daily aspirin may exceed the benefits, particularly as age increases 1.

From the FDA Drug Label

Warnings Stomach bleeding warning: This product contains an NSAID, which may cause severe stomach bleeding The chance is higher if you are age 60 or older The FDA drug label does not answer the question.

From the Research

Aspirin Indication for Primary Prevention of Cardiovascular Events

• The use of aspirin for primary prevention of cardiovascular events in an elderly female patient with diabetes and hypercholesterolemia is a complex decision that requires careful consideration of the patient's individual risk factors and health status 2.
• Studies have shown that aspirin has a net clinical benefit when used for secondary prevention of cardiovascular disease in people with and without diabetes, but the evidence for primary prevention is inconsistent 2.
• The ASCEND trial documented a cardiovascular benefit of aspirin for primary prevention in adults with diabetes, but also suggested that the increased risk of bleeding may outweigh the cardiovascular benefit 2.
• A multifactorial approach that focuses on managing cardiovascular risk factors such as hypertension, dyslipidemia, dysglycemia, and smoking is recommended in all patients, especially those with diabetes 2.
• The decision to initiate aspirin for primary prevention of cardiovascular events must be considered carefully on an individual basis to balance the cardiovascular benefit and bleeding risk in all patients, especially those with diabetes 2.

Considerations for Elderly Female Patients

• Elderly female patients with hypercholesterolemia are at increased risk of cardiovascular disease, and the management of dyslipidemia is critical for the prevention of cardiovascular events 3, 4, 5.
• Women remain underscreened and undertreated for dyslipidemia compared to men, and recent lipid trials have shown different efficacies of therapies such as ezetimibe, inclisiran, and bempedoic acid with a greater relative benefit for women 5.
• The pathophysiology of dyslipidemia varies between men and women and across a woman's lifetime, and best practices for management of women with dyslipidemia include early screening with lifestyle intervention and pharmacotherapy with statin and non-statin agents to achieve guideline-directed LDL-C thresholds 5.

Management of Cardiovascular Risk Factors

• Managing cardiovascular risk factors such as hypertension, dyslipidemia, dysglycemia, and smoking is critical for the prevention of cardiovascular events in patients with diabetes and hypercholesterolemia 2, 6.
• Statins are the most widely prescribed drugs for lowering low-density lipoprotein cholesterol (LDL-C) and reducing cardiovascular morbidity and mortality, but they can have side effects such as statin-associated muscle symptoms (SAMS) and new-onset type 2 diabetes (NOD) 6.
• Metformin and exercise training may be useful in counteracting statin-associated side effects and improving cardiovascular outcomes in patients with diabetes and hypercholesterolemia 6.