5MinuteConsult Journal Club
It’s OK To Stop Aspirin for Primary Prevention in Older Populations
Ann Intern Med.. doi:10.7326/M21-3823
The original ASPREE (Aspirin in Reducing Events in the Elderly) trial in the US, Europe and Australia found taking 100 mg of enteric coated aspirin for primary prevention of CVD did not improve disability-free survival, CVD events or cancer. In this post hoc analysis of ASPREE trial, researchers compared those who took aspirin at least 2 days a week versus placebo and found no difference in all-cause mortality, dementia, or disability over 5 years. The only group found to benefit from aspirin were those who took aspirin for at least 5 years prior to the study (which lasted another 4.9 years); but that benefit was in a very small subset which limited its’ clinical significance. The data did suggest a slight trend aspirin use may lower some CV events, but did not help the big outcomes of disability, all-cause mortality or cancer.
~5 years of aspirin supplementation in those 70 and older did not lower disability-free survival, CVD events or cancer.
This data, coupled with the April 26, 2022 USPSTF recommendation “D-There is moderate to high certainty that the service has no net benefit or the harms outweigh the benefit; Discourage its use” (https://uspreventiveservicestaskforce.org/uspstf/recommendation/aspirin-to-prevent-cardiovascular-disease-preventive-medication) gives a clear message. Using aspirin for primary prevention of cardiovascular disease, dementia, cancer and all-cause mortality is not beneficial, especially in those over age 70 years.
Additionally, this trial may have over-estimated aspirin’s benefit, as it used 100 mg, whereas in the US we use 81 mg. If perspective helps, we are the ONLY country to recommend aspirin for primary prevention, as Europe and Asia do not.
The question remains, what to do with those currently on aspirin? Offer this information using shared decision making. Let the patient decide. Our job is foremost to do no harm. Reserve aspirin for those post CV events.
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