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 heart attack 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 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.

Emphasize using aspirin 81 mg/day for SECONDARY prevention...such as in patients with a prior heart attack 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...adherence to BP meds and statins...and smoking cessation if needed.

If patients ask whether to stop aspirin for primary prevention, explain benefits and risks are usually a toss-up...and weigh preferences. Bleeding risk increases with age...and aspirin is one more pill to take.

Be ready for questions about "rebound" CV events after stopping aspirin. Explain 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 are continuing to come out about aspirin for cancer prevention. We'll give you the full scoop 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
Pharmacist's Letter. Nov 2018, No. 341101

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