The balance of benefits and harms no longer favour aspirin for primary prevention

There is strong evidence for using Aspirin in secondary prevention of vascular especially in myocardial information and stroke. However use of aspirin in primary prevention for CVD did not have such strong evidence.

Recent systematic reviews and meta-analysis has given a clear picture of when and where to use aspirin for primary prevention

  • As we have reported previously in this site there is clear evidence for Aspirin use in patients with Diabetes for primary prevention of CVD. Aspirin for Primary Prevention in Diabetes Mellitus
  • Aspirin’s treatment effect does not increase as ASCVD risk increases, as many hypothesize. There is no suggestion from these data that use of aspirin for higher-risk primary prevention patients is beneficial.  Meta-regression Analysis in Am J Medicine 2020
  • UPSTAF recommends that patient age, baseline cardiovascular disease risk, bleeding risk, and personal preference regarding aspirin use are key to decision making. (do not prescribe aspirin in patients over 70 years) – see next column
  • There is no evidence to support the use of low-dose aspirin or other NSAIDs of any class (celecoxib, rofecoxib or naproxen) for the prevention of dementia, but there was evidence of harm. Cochrane Database of Systematic Reviews 2020- see next column

 

Aspirin for Primary Atherosclerotic Cardiovascular Disease Prevention as Baseline Risk Increases: A Meta-Regression Analysis – 2020. American Journal of Medicine

Aspirin has long had a role in the primary prevention of atherosclerotic cardiovascular disease (ASCVD); however, recent randomized controlled trials (RCTs) have challenged this practice. Despite this, aspirin is still commonly recommended for high-risk primary prevention. We tested the hypothesis that aspirin is more efficacious for the primary prevention of ASCVD as the baseline risk increases.

Twelve RCTs were identified with 963,829 patient-years of follow-up. Aspirin was associated with a reduction in ASCVD (4.7 vs 5.3 events per 1000 patient-years; RR 0.86; 95% CI, 0.79-0.92). There was increased major bleeding among aspirin users (2.5 vs 1.8 events per 1000 patient-years; RR 1.41; 95% CI, 1.29-1.54). Regression analysis found no relationship between the log RR of ASCVD or major bleeding and rate of ASCVD in the control arm of each RCT

Conclusion

Aspirin is associated with a reduction in ASCVD when used for primary prevention; however, it is unlikely to be clinically significant given the increase in bleeding. More importantly, aspirin’s treatment effect does not increase as ASCVD risk increases, as many hypothesize. There is no suggestion from these data that use of aspirin for higher-risk primary prevention patients is beneficial.


Aspirin for primary prevention: USPSTF recommendations for CVD, colorectal cancer – 2016

Patient age, baseline cardiovascular disease risk, bleeding risk, and personal preference regarding aspirin use are key to decision making. A clinical decision tool can help.

  • Consider aspirin for patients 50 to 59 years of age who have a 10-year cardiovascular disease (CVD) risk of ≥ 10% and low bleeding risk. C
  • Discuss prophylactic aspirin (using a shared decision making model) with patients 60 to 69 years of age who have a 10-year CVD risk of ≥ 10% and low bleeding risk. C
  • Avoid using aspirin for primary prevention in patients ≥ 70 years of age B

A Strength of recommendation (SOR) A Good-quality patient-oriented evidence

B Inconsistent or limited-quality patient-oriented evidence

C Consensus, usual practice, opinion, disease-oriented evidence, case series


 

Aspirin and other non-steroidal anti-inflammatory drugs for the prevention of dementia – Cochrane Database 2020

Dementia is a worldwide concern. Its global prevalence is increasing. At present, there is no medication licensed to prevent or delay the onset of dementia. Inflammation has been suggested as a key factor in dementia pathogenesis. Therefore, medications with anti-inflammatory properties could be beneficial for dementia prevention.

To evaluate the effectiveness and adverse effects of aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) for the primary or secondary prevention of dementia.

Conclusion

There is no evidence to support the use of low-dose aspirin or other NSAIDs of any class (celecoxib, rofecoxib or naproxen) for the prevention of dementia, but there was evidence of harm. Although there were limitations in the available evidence, it seems unlikely that there is any need for further trials of low-dose aspirin for dementia prevention. If future studies of NSAIDs for dementia prevention are planned, they will need to be cognisant of the safety concerns arising from the existing studies.


 

 

There is strong evidence for using Aspirin in secondary prevention of vascular especially in myocardial information and stroke. However use of aspirin in primary prevention for CVD did not have such strong evidence.

Recent systematic reviews and meta-analysis has given a clear picture of when and where to use aspirin for primary prevention

As we have reported previously in this site there is clear evidence for Aspirin use in patients with Diabetes for primary prevention of CVD.