From the Guidelines
Aspirin for primary prevention should be considered in individuals with diabetes who have an increased cardiovascular risk (>10% 10-year CVD risk) and are not at increased risk for bleeding, as stated in the most recent guidelines 1.
Key Considerations
- The decision to use aspirin should be individualized and made through shared decision-making between patient and provider, taking into account both cardiovascular risk factors and bleeding risk factors.
- Aspirin works by inhibiting platelet aggregation, thereby reducing the formation of blood clots that can cause heart attacks and strokes, but this same mechanism increases bleeding risk.
- The net benefit of aspirin tends to be greater in those at higher cardiovascular risk, while the potential harm increases with age and bleeding risk factors.
- Regular reassessment of the continued need for aspirin therapy is recommended as a patient's risk profile changes over time.
Recommendations
- Aspirin therapy for primary prevention may be considered in the context of high cardiovascular risk with low bleeding risk, but generally not in older adults, as stated in the guidelines 1.
- For patients with documented ASCVD, use of aspirin for secondary prevention has far greater benefit than risk; for this indication, aspirin is still recommended 1.
Important Factors to Consider
- Cardiovascular risk factors, such as diabetes, hypertension, hyperlipidemia, smoking, and family history.
- Bleeding risk factors, including history of GI bleeding, peptic ulcer disease, or use of other anticoagulants.
- Age, as the balance of benefits and risks may shift with increasing age, with older adults generally having a greater risk than benefit from aspirin therapy 1.
From the Research
Aspirin for Primary Prevention
Aspirin is considered for primary prevention of cardiovascular disease in certain individuals. The decision to use aspirin for primary prevention should be based on the individual's cardiovascular risk and the potential benefits and harms of aspirin therapy 2, 3, 4, 5, 6.
Eligibility Criteria
The 2022 US Preventive Services Task Force (USPSTF) guidelines recommend considering aspirin use for primary prevention in adults 40-59 years with a 10-year atherosclerotic cardiovascular disease (ASCVD) risk ≥10% and not at increased risk of bleeding 3. Approximately 7.2 million US individuals aged 40-59 years (10% of this population) are eligible for consideration of primary prevention aspirin, with men, older age, and Black individuals having higher proportions meeting aspirin use eligibility 3.
Benefits and Harms
Aspirin use reduces the risk of myocardial infarction in men and strokes in women, but increases the risk for serious bleeding events, primarily gastrointestinal bleeding events, in both men and women 5, 6. The net benefit of aspirin increases with increasing cardiovascular risk, and the decision to use aspirin chemoprevention should consider the patient's cardiovascular risk and relative utility for the different clinical outcomes prevented or caused by aspirin use 6.
Individualized Assessment
Clinicians should assess the risk of major adverse cardiovascular events (MACE) and base the decision on such stratification, considering the risk of bleeding and patient preferences 4. Aspirin should be considered for primary prevention patients at the highest risk of MACE who do not have a prohibitive risk of bleeding, and in the majority of cases after initiation of properly titrated statin therapy 4.