Think Twice About Low-Dose Aspirin to Prevent Cardiovascular Disease

Should you recommend aspirin for PRIMARY prevention of CV disease?

No, not for most patients withOUT a prior MI or stroke.

This is a BIG change. It may take time for guidelines to catch up.

Mounting evidence suggests any CV benefit of using low-dose aspirin for primary prevention is offset by the risk of serious bleeding.

For example, aspirin's benefits are nearly a "wash" in patients with diabetes. Using aspirin for about 7 years may avoid a CV event in one in 90 patients...at the cost of life-threatening bleeding in one in 110.

And aspirin for primary prevention doesn't seem to decrease CV events in other patients...even those with multiple CV risks.

Ensure patients use aspirin 81 mg/day for SECONDARY prevention...such as in patients with a prior MI or stroke, peripheral artery disease, or angina. In these cases, CV benefits clearly outweigh bleeding risks.

But don't recommend low-dose aspirin for PRIMARY prevention in most patients...especially if bleeding risk is high due to a prior GI bleed, anticoagulant or chronic NSAID use, uncontrolled BP, etc.

Instead, focus on lifestyle changes...treat hypertension and dyslipidemia if appropriate...and emphasize smoking cessation if needed.

For primary-prevention patients already taking aspirin, use shared decision making to evaluate whether to stop it. Explain benefits and risks are usually a toss-up...bleeding risk increases with age...and aspirin is one more pill to take. Document your discussions.

Be ready for questions about "rebound" CV events after stopping aspirin. Keep in mind, this is a major concern in secondary prevention...especially with a coronary stent. But bleeding risk with aspirin for primary prevention likely outweighs any possible CV risk of stopping it.

And stay tuned...data are continuing to come out about aspirin for cancer prevention. We'll give you more on this in a future issue.

See our chart,Aspirin for Primary CV Prevention and More, for details of the new studies and to weigh benefits and risks of aspirin.

Key References

  • Lancet 2018;392(10152):1036-46
  • N Engl J Med Published online Aug 26, 2018; doi:10.1056/NEJMoa1804988
  • N Engl J Med Published online Sep 16, 2018; doi:10.1056/NEJMoa1805819
Prescriber's Letter Canada. Nov 2018, No. 341101



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