Should I start a 70-year-old African American patient with controlled diabetes (diabetes mellitus) and hypertension, who is already on a statin, and has plaque on the aorta, on aspirin (acetylsalicylic acid)?

Aspirin Therapy for a 70-Year-Old African American Patient with Aortic Plaque, Diabetes, and Hypertension

You should start low-dose aspirin (75-100 mg daily) for this 70-year-old African American patient with aortic plaque, controlled diabetes, and hypertension who is already on a statin, as he has multiple high-risk factors that place him at elevated cardiovascular risk. 1

Risk Assessment and Decision Algorithm

This patient has several factors that place him at high cardiovascular risk:

1. Age 70 years (advanced age)
2. African American ethnicity (higher cardiovascular risk)
3. Diabetes mellitus (even if controlled)
4. Hypertension
5. Aortic plaque (evidence of atherosclerosis)
6. Already on statin therapy (indicating recognized cardiovascular risk)

Step-by-Step Decision Process:

1. Calculate 10-year ASCVD risk: This patient's profile (age 70, African American, diabetes, hypertension, evidence of atherosclerosis) places him at >10% 10-year risk
2. Assess bleeding risk: No mentioned history of GI bleeding or other contraindications
3. Evaluate evidence of atherosclerosis: Presence of aortic plaque confirms atherosclerotic disease
4. Apply guideline recommendations: Multiple guidelines support aspirin use in this high-risk patient

Supporting Evidence for Aspirin Therapy

The European Society of Cardiology guidelines recommend aspirin for patients with hypertension who have an estimated 10-year risk of cardiovascular disease ≥20% or cardiovascular death ≥5%, provided they don't have increased bleeding risk 2. This patient meets these criteria with his multiple risk factors.

For patients with diabetes specifically, guidelines recommend aspirin for adults with diabetes whose 10-year risk of CHD events is >10% and who are not at increased risk of bleeding 2. This includes most men older than 50 years and women older than 60 years with at least one additional major risk factor (like hypertension), which applies to this patient.

The American Heart Association recommends low-dose aspirin (75-100 mg daily) for cardiovascular protection in high-risk patients, with optimal platelet inhibition while minimizing bleeding risk 1.

Dosing Recommendations

The optimal dosage is 75-100 mg daily of aspirin:

• The European Society of Cardiology recommends 75-100 mg daily 2
• The American Diabetes Association recommends 81-325 mg daily, with preference for the lower end of this range 2
• Recent evidence suggests that lower doses (75-100 mg) provide similar cardiovascular protection with less bleeding risk compared to higher doses 1

Monitoring and Precautions

• Monitor for bleeding complications at regular follow-up visits
• Assess for GI symptoms that might indicate bleeding
• Consider adding a proton pump inhibitor if the patient develops GI symptoms or has additional risk factors for bleeding
• Reassess cardiovascular risk and bleeding risk periodically

Important Considerations

1. Bleeding risk: The ASCEND trial showed that while aspirin prevented serious vascular events in persons with diabetes (rate ratio 0.88), it also increased major bleeding events (rate ratio 1.29) 3. However, for high-risk patients like this one with multiple risk factors and evidence of atherosclerosis, the benefits typically outweigh the risks.

2. Race considerations: African Americans have higher cardiovascular risk, making preventive therapy more favorable in the risk-benefit calculation.

3. Evidence of atherosclerosis: The presence of aortic plaque indicates established atherosclerotic disease, which strengthens the case for aspirin therapy.

4. Combination with statins: The patient is already on a statin, which is appropriate. The combination of statin and aspirin therapy has been shown to provide complementary cardiovascular protection in patients with diabetes 4.

By starting this patient on low-dose aspirin (75-100 mg daily) in addition to his current statin therapy, you will provide comprehensive cardiovascular protection aligned with current guidelines and evidence.