Can I start an 85-year-old female patient with new onset Left Bundle Branch Block (LBBB) and vascular dementia and Alzheimer's disease on aspirin (acetylsalicylic acid) for primary prevention of stroke and cardiovascular events?

Aspirin for Primary Prevention in an 85-Year-Old Female with New Onset LBBB and Dementia

Aspirin is not recommended for primary prevention of stroke or cardiovascular events in this 85-year-old female patient with new onset LBBB, vascular dementia, and Alzheimer's disease. 1

Rationale Against Aspirin Use in This Patient

• The 2024 American Heart Association/American Stroke Association guidelines explicitly state that "in individuals ≥70 years of age with at least 1 additional cardiovascular risk factor, the use of aspirin is not beneficial to prevent a first stroke" (Class 3: No Benefit, Level of Evidence A) 1
• Advanced age (85 years) is itself a vascular risk factor, and evidence from the ASPREE trial (Aspirin in Reducing Events in the Elderly) showed no reduction in stroke with aspirin therapy in patients ≥70 years of age 1
• The patient's advanced age and cognitive impairment (vascular dementia and Alzheimer's disease) place her at increased risk for adverse events, including bleeding complications 1
• A prespecified secondary analysis of ASPREE found a small increase in intracranial bleeding with aspirin use (0.7% absolute increase) in elderly patients 1

Evidence from Clinical Trials and Guidelines

• The ASPREE trial enrolled patients ≥70 years of age (median age 74) and found no reduction in the primary endpoint (fatal coronary heart disease, nonfatal MI, fatal or nonfatal stroke, or hospitalization for heart failure) with aspirin 100 mg/day compared to placebo over a median follow-up of 4.7 years 1
• A subanalysis of the Japanese Primary Prevention of Atherosclerosis With Aspirin for Diabetes (JPAD) trial focused on stroke also found no reduction in stroke associated with aspirin use among Japanese patients with a mean age of 71 years 1
• The 2022 US Preventive Services Task Force recommends against initiating low-dose aspirin use for primary prevention of cardiovascular disease in adults 60 years or older (D recommendation) 2
• Recent primary prevention trials have shown either no benefit or modest benefit on combined ischemic endpoints, without impact on hard cardiovascular events such as myocardial infarction or stroke, accompanied by an increased risk of bleeding 3

Special Considerations for This Patient

• The presence of vascular dementia suggests the patient already has cerebrovascular disease, but this would be considered for secondary rather than primary prevention 1
• New onset LBBB may indicate underlying cardiac disease, but this alone is not an indication for aspirin in primary prevention at this age 1
• The patient's cognitive impairment (vascular dementia and Alzheimer's disease) may increase the risk of medication non-adherence and complications 1
• The risk of bleeding complications, particularly intracranial hemorrhage, is especially concerning in a patient with possible cerebrovascular disease 1

Alternative Approaches for Cardiovascular Risk Reduction

• Focus on optimal management of modifiable cardiovascular risk factors such as hypertension, diabetes, and hyperlipidemia, if present 1
• Consider other preventive strategies that have demonstrated benefit in the elderly without increasing bleeding risk 1
• Evaluate for specific conditions that might warrant targeted therapies (e.g., atrial fibrillation requiring anticoagulation) 1
• If the patient has established coronary artery disease (not mentioned in the case), different recommendations would apply 1

Conclusion

Based on the most recent evidence and guidelines, aspirin should not be initiated for primary prevention of stroke or cardiovascular events in this 85-year-old female patient with new onset LBBB, vascular dementia, and Alzheimer's disease. The potential harms, particularly bleeding risk, outweigh any potential cardiovascular benefits in this age group.