What are the recommendations for aspirin (acetylsalicylic acid) use in medically free individuals above 40 years old?

From the Guidelines

Aspirin is generally not recommended for routine use in healthy individuals over 40 years old solely for primary prevention of cardiovascular disease. For most medically free adults, the risks of daily aspirin therapy (primarily bleeding complications) may outweigh the potential benefits 1. However, some individuals at higher cardiovascular risk but without established disease might benefit from low-dose aspirin (typically 81 mg daily) after discussion with their healthcare provider. This includes people with multiple risk factors such as diabetes, hypertension, high cholesterol, smoking history, or strong family history of premature heart disease.

Key Considerations

• The decision to start aspirin should be individualized based on a person's specific cardiovascular risk profile and bleeding risk 1.
• For those who do take aspirin, it should be taken consistently at the same time each day, and patients should be aware of potential side effects including gastrointestinal irritation and bleeding.
• Aspirin works by inhibiting platelet aggregation, thereby reducing the formation of blood clots that can cause heart attacks and certain types of strokes. However, this same mechanism increases bleeding risk, which is why the risk-benefit assessment is crucial before starting therapy 1.

Recommendations

• The American Diabetes Association suggests low-dose aspirin therapy for primary prevention in patients with type 1 or 2 diabetes who have an increased CVD risk (>10% 10-year CVD risk) and are not at increased risk for bleeding 1.
• The American Heart Association and the American Stroke Association recommend the use of low-dose aspirin for cardiovascular prophylaxis in adults whose risk is sufficiently high for the benefits to outweigh the risks associated with treatment; they suggest that a 10-year CVD risk of 6% to 10% is sufficient 1.

From the Research

Aspirin Use in Medically Free Individuals Above 40 Years Old

• The use of aspirin for primary prevention of cardiovascular disease in medically free individuals above 40 years old is a topic of ongoing debate 2, 3, 4, 5, 6.
• The US Preventive Services Task Force (USPSTF) recommends that adults 40 years or older without signs or symptoms of cardiovascular disease who are not at increased risk for bleeding should discuss the benefits and harms of aspirin use with their clinician 3.
• 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 risk should be an individual one, taking into account the patient's preferences and risk factors 3.
• Aspirin use is not recommended for primary prevention of cardiovascular disease in adults 60 years or older, as the net benefit is small and the risk of bleeding is increased 3, 6.

Risk Stratification and Individualized Approach

• A differentiated and personalized approach to prescribing aspirin is recommended, taking into account the individual's 10-year cardiovascular risk and bleeding risk 2.
• The 10-year cardiovascular risk should be assessed in patients less than 70 years of age, and aspirin treatment should be considered only when the cardiovascular risk is very high and the bleeding risk is low 2.
• Primary care providers should make individual decisions about prescribing aspirin based on the benefit-risk ratio, rather than simply considering the patient's age 4.

Benefits and Harms of Aspirin Use

• Aspirin use has been shown to reduce the risk of cardiovascular events, but it also increases the risk of bleeding 2, 3, 5.
• The net benefit of aspirin use is small, and the decision to initiate aspirin use should be based on an individualized assessment of benefits and risks 3.
• Aspirin use should be considered only after implementation of therapeutic lifestyle changes and other drugs of proven benefit, such as statins 4.