MORE ON ASPIRIN AND CARDIOVASCULAR DISEASE

On March 22nd, I published a blog on aspirin for the primary and secondary prevention of cardiovascular disease. The message from the blog was that aspirin is of NO BENEFIT for the prevention of first-time cardiovascular events (primary prevention) such as coronary disease, heart attack, or stroke, in patients age 40-70 years. Additionally, it puts the user at higher risk of significant bleeding problems. The lack of benefit does not justify the risk of bleeding from aspirin.

For prevention of recurrent, or worsening, cardiovascular events (secondary prevention), aspirin has clearly been shown to be of benefit. Further information on this subject from two large scientific studies has recently come to light. This information is shared in what follows:

STUDY 1

THE ARRIVE TRIAL

Twelve thousand patients, mean age of 63 years, with a 15% risk of CVD in 10 years, were randomly assigned to groups that took aspirin or placebo for 5 years.

Results: There was no significant difference in primary cardiovascular events or deaths from any cause. There was, however, a significant increase in bleeding events in the aspirin group.

STUDY 2

THE ASCEND TRIAL

Fifteen thousand adult patients WITH Type 2 Diabetes and a 10% risk of CVD in 10 years were assigned to aspirin and placebo groups. The endpoint was a first cardiovascular event.

Results: The aspirin group had a SIGNIFICANTLY LOWER RATE OF CV EVENTS as well as more bleeding events. There was no difference between the groups in all causes of death.

Clearly, the presence of diabetes has a harmful effect. Diabetics have far worse hardening of the arteries, and higher rates of CVD at an earlier age than non-diabetics, and it seems aspirin is beneficial for primary prevention in these patients. The bleeding risk in this case does not outweigh the CV benefit.

RECOMMENDATIONS:

1. Low risk patients age 40-70 should not take daily aspirin for primary prevention
2. Patients over age 70 should not take daily aspirin for primary prevention
3. Diabetics of any age should take daily aspirin for primary prevention
4. Patients of any age should take daily aspirin for secondary prevention
5. Aspirin should be used with caution and avoided in patients with bleeding risk

“Do not prescribe aspirin for primary prevention of CVD in your elderly patients. Aspirin does not improve cardiovascular outcomes, and it significantly increases the risk of bleeding.”

Reference: Piggott C, Lyon C, Mounsey A. Aspirin, Yes, for at-risk elderly—but what about the healthy elderly? The J Fam Pract 2020 Apr;69(3):E16-E18.