Aspirin for CV Primary Prevention and More
Full update June 2022
The FAQ below provides information to assist clinicians in estimating aspirin’s risk/benefit ratio in patients without CVD. Use for colorectal cancer prevention is also addressed. See our FAQ, The Truth About Aspirin, for information on aspirin formulations (e.g., Vazalore, Yosprala, Durlaza), when and how to take it, risk of side effects, myths, and misconceptions.
Question |
Answer/Pertinent Information |
Who might be a candidate for aspirin for primary prevention of CV events, per current guidelines? |
Note that no guideline recommends routine aspirin use for primary prevention of CV events. Use shared decision-making to individualize decisions based on CV risk vs bleeding risk in the following groups.1,2
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Why might recommendations differ among guidelines? |
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What new trials have influenced recent recommendations? |
Bottom line: aspirin does not likely provide net benefit for primary prevention patients ≥70 years of age, or patients without diabetes with an estimated 10-year event rate <20%, especially those with bleeding risks [Evidence Level A-1].5,6,8 |
Do patients with diabetes benefit from aspirin for primary prevention of CV disease? |
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Does aspirin risk differ in males vs females? |
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How do I decide whether to start/continue aspirin for primary prevention? |
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How/when do I stop aspirin? |
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How do I explain the more narrow indications for aspirin to patients? |
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Should aspirin be used for primary prevention in a patient with GI bleed risk? |
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What is the aspirin dose for primary prevention of CV disease? |
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Is aspirin effective for primary prevention of colon cancer? |
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Abbreviations: AAA = Aspirin for Asymptomatic Atherosclerosis; ACC = American College of Cardiology; ADA = American Diabetes Association; AHA = American Heart Association; ARRIVE = A Study to Assess the Efficacy and Safety of Enteric-Coated Acetylsalicylic Acid in Patients at Moderate Risk of Cardiovascular Disease; ASA = American Stroke Association; ASCB = ASymptomatic Carotid Bruit; ASCEND = A Study of Cardiovascular Events in Diabetes; ASPREE = Aspirin in Reducing Events in the Elderly; BP = blood pressure; CSC = Canadian Stroke Consortium; COX-2 = cyclo-oxygenase-2; CV = cardiovascular; CVD = cardiovascular disease; ESC = European Society of Cardiology; GI = gastrointestinal; JPAD = Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes; JPPP = Japanese Primary Prevention Project; MI = myocardial infarction; NSAID = nonsteroidal anti-inflammatory drug; POPADAD = Prevention of Progression of Arterial Disease and Diabetes; PPI = proton pump inhibitor; TIA = transient ischemic attack; USPSTF = United States Preventive Services Task Force.
Levels of Evidence
In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.
Level |
Definition |
Study Quality |
A |
Good-quality patient-oriented evidence.* |
|
B |
Inconsistent or limited-quality patient-oriented evidence.* |
|
C |
Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening. |
*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).
[Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56. https://www.aafp.org/afp/2004/0201/p548.pdf.]
References
- US Preventive Services Task Force, Davidson KW, Barry MJ, et al. Aspirin Use to Prevent Cardiovascular Disease: US Preventive Services Task Force Recommendation Statement. JAMA. 2022 Apr 26;327(16):1577-1584.
- Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019 Sep 10;140(11):e596-e646. Erratum in: Circulation. 2019 Sep 10;140(11):e649-e650. Erratum in: Circulation. 2020 Jan 28;141(4):e60. Erratum in: Circulation. 2020 Apr 21;141(16):e774.
- Diabetes Canada Clinical Practice Guidelines Expert Committee, Stone JA, Houlden RL, et al. Cardiovascular Protection in People With Diabetes. Can J Diabetes. 2018 Apr;42 Suppl 1:S162-S169. Erratum in: Can J Diabetes. 2019 Mar;43(2):154.
- American Diabetes Association Professional Practice Committee. 10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022 Jan 1;45(Suppl 1):S144-S174. Erratum in: Diabetes Care. 2022 Mar 07. doi: 10.2337/dc22-er05.
- Gaziano JM, Brotons C, Coppolecchia R, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet. 2018 Sep 22;392(10152):1036-1046.
- ASCEND Study Collaborative Group, Bowman L, Mafham M, et al. Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus. N Engl J Med. 2018 Oct 18;379(16):1529-1539.
- Mora S, Manson JE. Aspirin for Primary Prevention of Atherosclerotic Cardiovascular Disease: Advances in Diagnosis and Treatment. JAMA Intern Med. 2016 Aug 1;176(8):1195-204.
- McNeil JJ, Nelson MR, Woods RL, et al. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1519-1528.
- US Preventive Services Task Force. Final recommendation statement. Aspirin use to prevent cardiovascular disease: preventive medication. April 26, 2022. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/aspirin-to-prevent-cardiovascular-disease-preventive-medication#fullrecommendationstart. (Accessed May 5, 2022).
- Visseren FLJ, Mach F, Smulders YM, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021 Sep 7;42(34):3227-3337.
- Aspirin-Guide practical algorithm for shared decision making in the initiation of low-dose aspirin (ASA, 75 to 100 mg/d) in primary prevention of ASCVD. https://aspiringuideresources.s3.amazonaws.com/Aspirin_Guide_algorithm_2022.pdf. (Accessed May 6, 2022).
- Bhatt DL, Scheiman J, Abraham NS, et al. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. Circulation. 2008 Oct 28;118(18):1894-909. Erratum in: Circulation. 2010 Aug 24;122(8):e438.
- Seidu S, Kunutsor SK, Sesso HD, et al. Aspirin has potential benefits for primary prevention of cardiovascular outcomes in diabetes: updated literature-based and individual participant data meta-analyses of randomized controlled trials. Cardiovasc Diabetol. 2019 Jun 3;18(1):70. doi: 10.1186/s12933-019-0875-4.
- Dehmer SP, O'Keefe LR, Evans CV, et al. Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Updated Modeling Study for the US Preventive Services Task Force. JAMA. 2022 Apr 26;327(16):1598-1607.
- Guirguis-Blake JM, Evans CV, Perdue LA, et al. Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2022 Apr 26;327(16):1585-1597.
- Zheng SL, Roddick AJ. Association of Aspirin Use for Primary Prevention With Cardiovascular Events and Bleeding Events: A Systematic Review and Meta-analysis. JAMA. 2019 Jan 22;321(3):277-287. Erratum in: JAMA. 2019 Jun 11;321(22):2245.
- Nelson MR, Polekhina G, Woods RL, et al. Safety of Ceasing Aspirin Used Without a Clinical Indication After Age 70 Years: A Subgroup Analysis of the ASPREE Randomized Trial. Ann Intern Med. 2022 May;175(5):761-764.
- Lee J, Kim JK, Kim JH, et al. Recovery time of platelet function after aspirin withdrawal. Curr Ther Res Clin Exp. 2014 Mar 25;76:26-31.
- Wein T, Lindsay MP, Gladstone DJ, et al. Canadian Stroke Best Practice Recommendations, seventh edition: acetylsalicylic acid for prevention of vascular events. CMAJ. 2020 Mar 23;192(12):E302-E311.
- McNeil JJ, Wolfe R, Woods RL, et al. Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1509-1518.
Cite this document as follows: Clinical Resource, Aspirin for CV Primary Prevention. Pharmacist’s Letter/Prescriber’s Letter. June 2022. [380601]