For years physicians have recommended daily low-dose aspirin to prevent heart attacks and strokes and 25% of American adults heed that advice, according to a study published in July in the Annals of Internal Medicine. That would be fairly good news if recommendations hadn’t changed. But they have—and in some very significant ways. As many individuals may not think to discuss their aspirin use with their primary-care provider, pharmacists can serve an important role in educating their customers about the latest recommendations.
“Although prior American Heart Association and American College of Cardiology (AHA/ACC) guidelines recommended aspirin only in persons without elevated bleeding risk, the 2019 guidelines now explicitly recommend against aspirin use among those over the age of 70 who do not have existing heart disease or stroke," said senior author Christina C. Wee, MD, MPH, a general internist and researcher at Beth Israel Deaconess Medical Center in Boston and associate professor of Medicine at Harvard Medical School.
The new guidelines do not encourage daily aspirin use for primary cardiovascular disease (CVD) prevention in younger adults either.
“Clinicians should be very selective in prescribing aspirin for people without known cardiovascular disease,” said Roger Blumenthal, MD, co-chair of the AHA/ACC panel that issued the new guidelines and director of the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease in Baltimore. “Aspirin should be limited to people at the highest risk of cardiovascular disease and a very low risk of bleeding.”
What drove the big change? New research indicates that daily aspirin provides little benefit to most people and can actively harm older adults, the group most likely to have made taking the medication part of their regular routine. The AIM study determined that about half of adults over age 70 years without a history of heart disease or stroke take aspirin once a day.
The ASPREE trio of studies published last fall in the New England Journal of Medicine found that in older adults, daily low-dose aspirin did not extend disability-free survival or reduce the risk of cardiovascular events. Instead, it significantly increased the risk of bleeding and major hemorrhage by 38% and was also associated with an increase in all-cause mortality.
The randomized, controlled trial included 19,114 Australian and American adults with an average age of 74 years and tracked their outcomes for a median of 4.7 years. The study terminated early “after a determination was made that there would be no benefit with continued aspirin use,” the authors noted.
Two other major studies, both with more than 13,000 participants, found no benefit for daily aspirin for individuals initially assessed as at high risk of CVD who did not have diabetes (ARRIVE) and limited benefit among those with diabetes (ASCEND). Low-dose aspirin doubled the risk of gastrointestinal bleeding in the high-risk population and increased the risk 29% among patients with diabetes.
These studies do not change the recommendations for aspirin use in individuals who have previously experienced heart attack or stroke or who are otherwise known to have CVD. The guidelines continue to strongly recommend aspirin for these patients.
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