#347 USPSTF Update: Aspirin for Primary Prevention of CVD

July 27, 2022 | By Elena Gibson

Video

USPSTF Update with Dr. John Wong

Review the updated 2022 United States Preventive Task Force (USPSTF) guidelines on aspirin use to prevent cardiovascular disease (CVD) with Dr. John Wong. 

Episodes | Subscribe | Spotify | Swag! | Top Picks | Mailing List | thecurbsiders@gmail.com | Free CME!

Credits

• Producer & Writer: Elena Gibson MD
• Show Notes: Elena Gibson MD 
• Cover Art & Infographic: Elena Gibson MD 
• Hosts: Paul Williams MD, FACP; Elena Gibson MD  
• Showrunner: Matthew Watto MD, FACP
• Technical Production: PodPaste
• Guest: John Wong, MD 

Sponsor: Medmastery

Visit medmastery.com/curbsiders to receive a discount. 

USPSTF Aspirin for CVD Prevention Pearls

1. Aspirin for primary CVD prevention should be considered for adults 40-59 with a 10-year risk of CVD > 10% 
2. Aspirin should not be initiated for primary CVD prevention in adults >60 years old due to risk of bleeding. 
3. There is insufficient evidence to evaluate the benefit/risks of aspirin on CRC incidence or mortality 

USPSTF Update: Aspirin for CVD Prevention

Overall Recommendation

The 2022 USPSTF guidelines on aspirin use for primary CVD prevention recommend (USPSTF 2022):

• 40 to 59 years with a 10-year CVD risk  >10%: aspirin initiation for primary CVD prevention should be individualized with a risk vs. benefit discussion between the provider and patient
• 60 years or older: recommend against initiating aspirin for primary CVD prevention

**Applies to adults ages 40+ without a history of CVD or signs/symptoms of CVD

Benefits 

Daily low-dose aspirin use is associated with a small benefit in the reduction of cardiovascular events in adults 40 years or older who are at risk of CVD, and the benefits are greater for those with a higher 10-year CVD risk score (USPSTF 2022). Overall, the pooled analysis of 11 trials completed for this recommendation found a 12% reduction in nonfatal MI or CVA but no reduction in mortality from MI or CVA (USPSTF 2022). Early studies of aspirin use for primary CVD prevention identified a 45% reduction in the risk and mortality of MI or CVA (Physicians’ Health Study 1989). Dr. Wong describes results from three landmark trials published in 2018 on aspirin as primary CVD prevention as an example of the varying results reviewed: 

1. ASCEND: In patients with DM found a 12% reduction in the risk of a major CVD event and a 30% increase in the risk of a major bleeding event.The absolute risk reduction was 1.1% for a CVD event (NNT=91) and the absolute risk increase was 0.9% for a major bleeding event (NNH=112)
2. ARRIVE: In patients at moderate risk of CVD, there was no significant CVD benefit with aspirin use but gastrointestinal bleeding increased. 
3. ASPREE: In a healthy elderly population > 65-70 years, there was no significant CVD benefit, but there was a 30% increase in the risk of a major bleeding event. 

Harms

Aspirin use in adults has been shown to increase the risk of gastrointestinal bleeding, intracranial bleeding and hemorrhagic CVA (USPSTF 2022). This risk is particularly notable in individuals greater than 60 years old. The incidence of major bleeding risks was found to be higher in the general population than previously thought, making the therapeutic window for aspirin’s benefit as primary prevention more narrow (Selak 2018). 

What’s New?

The 2022 USPSTF update recommends considering aspirin initiation for primary CVD prevention at a younger age (40-59 years) for those with a ten-year CVD risk of  >10% compared to the 2016 recommendation (50-59 years). This recommendation was changed from a Grade B recommendation in 2016 to a grade C recommendation in 2022 . The evidence review included an evaluation of aspirin’s effects on CRC incidence and mortality, but there was not enough evidence to make a recommendation (USPSTF 2022).  

Links

1. USPSTF 2022 Recommendation : Aspirin Use to Prevent CVD

Goal

Listeners will review the updated 2022 USPSTF guidelines on aspirin use for cardiovascular disease prevention.

Learning objectives

After listening to this episode listeners will…  

1. Recognize the importance of primary CVD prevention
2. Identify when aspirin for CVD prevention is indicated based on age, ASCVD risk score and risk vs. benefit evaluation
3. Review the evidence used to make a recommendation for aspirin use in primary prevention of CVD 

Disclosures

Dr. Wong reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Gibson EG. Wong J. Williams PN.. “#347 USPSTF Update: Aspirin for Primary Prevention of CVD”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date, July 27 2021.