New Guidelines for Aspirin to Prevent Cardiovascular Disease

Atherosclerotic Cardiovascular Disease (ASCVD) remains the leading cause of morbidity and mortality worldwide. The American College of Cardiology (ACC) and the American Heart Association (AHA) have recently updated guidelines for the use of aspirin for primary prevention of cardiovascular disease.

Aspirin, in low doses, irreversibly inhibits cyclooxygenase-1 (COX-1) via acetylation. This results in inhibition of platelet generation of thromboxane A2, developing in an antithrombotic effect.  While aspirin may prevent a cardiovascular event, there is an increased risk of bleeding. Because of this, it’s important to consider the risks and benefits that come with aspirin use.  Previous United States Preventative Task Force (2016 USPTF) guidelines recommended aspirin for primary prevention in ages 50-69 with an ASCVD risk ≥10%. In light of three randomized control trials released in 2018 (ASCEND, ARRIVE, and ASPREE), new ACC/AHA guidelines provide the following recommendations:

  • Low-dose aspirin (75-100 mg orally daily) may be considered for the primary prevention of ASCVD among select adults 40 to 70 years of age who are at higher ASCVD risk but not at increased bleeding risk.

  • Low-dose aspirin (75-100 mg orally daily) should not be administered on a routine basis for the primary prevention of ASCVD among adults >70 years of age.

  • Low-dose aspirin (75-100 mg orally daily) should not be administered for the primary prevention of ASCVD among adults of any age who are at increased risk of bleeding.

Nickname and Date Trial Target Methods Outcome
ARRIVE: August 2018 Use of aspirin to reduce risk of initial vascular events in patients with moderate risk of cardiovascular disease Age >55/60 (men/women); No diabetes + ≥3 cardiovascular risk factors; ASA 100mg vs placebo No difference in cardiovascular outcomes; increase in gastrointestinal bleeding
ASPREE: October 2018 Use of aspirin to reduce events in the elderly Age >70; No history of previous cardiovascular events; ASA 100mg vs placebo No difference in disability-free survival; increased major bleeding, increased mortality
ASCEND: September 2018 Effects of aspirin in primary prevention in people with diabetes Age >40; Diabetes mellitus + no history of cardiovascular disease; ASA 100mg vs placebo Decreased serious vascular events by 1.1%; increased major bleeding by 0.9%


Aspirin is not the only way we can help our patients prevent cardiovascular disease. As shown in the following graphic, lifestyle modifications are the backbone of decreasing cardiovascular risk. In addition, medications with proven cardiovascular benefits should be considered for appropriate patient populations.

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By Shelly Stephenson
Lipscomb University Pharm.D. Candidate 2019

References:
Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Circulation. 2019; CIR0000000000000678.

Gaziano JM, Brotons C, Coppolecchia R, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet. 2018;392(10152):1036-1046.

 McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on Disability-free Survival in the Healthy Elderly. N Engl J Med 2018;379:1499-1508.