What are the current guidelines for aspirin therapy in patients with hypertension?

Aspirin Therapy in Hypertension: Current Guidelines

Low-dose aspirin (75-100 mg/day) is recommended only for hypertensive patients with high cardiovascular risk (≥20% 10-year risk or ≥5% cardiovascular mortality risk) and well-controlled blood pressure, as benefits outweigh bleeding risks only in these specific populations. 1

Patient Selection for Aspirin Therapy

Primary Prevention

• High-risk hypertensive patients (<80 years) who qualify for aspirin:

  • 10-year cardiovascular disease risk ≥20% or cardiovascular mortality risk ≥5% (based on SCORE model) 2
  • Blood pressure well-controlled (<140/90 mmHg) 1
  • No increased bleeding risk 2

• Not recommended for:

  • Patients with low to moderate cardiovascular risk 2
  • Patients with uncontrolled hypertension 1
  • Adults ≥60 years without established cardiovascular disease (per US Preventive Services Task Force) 3

Secondary Prevention

• Strongly recommended for all hypertensive patients with established cardiovascular disease 2
• Benefits clearly outweigh bleeding risks in this population 2

Risk Assessment

• Risk stratification using the SCORE risk chart is recommended for all hypertensive patients 2
• Consider additional risk factors:
  • Elevated serum creatinine (>1.3 mg/dl) - these patients show significantly greater reduction in cardiovascular events with aspirin 4
  • Diabetes mellitus - consider aspirin if cardiovascular risk is elevated 2
  • Age - benefits decrease and bleeding risks increase with advancing age 3

Dosage and Administration

• Optimal dose: 75-100 mg daily 1
• Long-term therapy is recommended for eligible patients 1
• Timing: No specific recommendation on timing of administration

Monitoring and Safety Considerations

• Regular monitoring for bleeding complications, particularly gastrointestinal bleeding 1
• Periodic reassessment of cardiovascular risk and bleeding risk 1
• Major bleeding risks increase by approximately 65% with aspirin use 4
• Non-fatal major bleeds may be twice as common with aspirin use compared to placebo 5

Special Populations

Diabetic Patients

• Aspirin recommended for diabetic hypertensive patients with established cardiovascular disease 2, 1
• For primary prevention in diabetics, consider aspirin if 10-year CVD risk is elevated 1

Elderly Patients

• Use with caution in patients >80 years due to increased bleeding risk 1
• Not recommended for initiating primary prevention in adults ≥60 years 3

Patients with Renal Dysfunction

• Patients with elevated serum creatinine (>1.3 mg/dl) show particularly favorable benefit-to-harm ratio with aspirin 4

Interaction with Antihypertensive Medications

• Low-dose aspirin (75 mg) does not interfere with the blood pressure-lowering effects of antihypertensive medications 6
• No negative interaction occurs between ACE inhibitors and low-dose aspirin 6
• Antihypertensive regimens do not need adjustment when adding aspirin 6

Emerging Approaches

• Coronary artery calcium (CAC) scoring may help identify patients most likely to benefit from aspirin therapy 7
• CAC ≥100 identifies subgroups where number needed to treat is lower than number needed to harm 7
• CAC = 0 identifies subgroups where harm likely exceeds benefit 7

Remember that the benefit-to-harm ratio of aspirin therapy is highly dependent on individual cardiovascular risk profile, and careful patient selection is critical to maximize benefits while minimizing bleeding complications.