USPSTF concludes daily aspirin may hurt more than help, especially for older adults

For years, millions of Americans have been taking low-dose aspirin daily to reduce their chances heart attack and stroke. But now, as the evidence becomes even more conclusive, experts are doing an about-face. In April, U.S. Preventive Services Task Force (USPSTF) updated its 2016 guidelines no longer recommends routine use for primary CVD prevention. The new USPSTF recommend against initiating in adults 60 years older due lack information on risk/benefit However, approach is acceptable 40 59 old who ≥ 10% risk cardiovascular disease though payoff low, according USPSTF. “Rather than a ‘one-size-fits-all’ approach, has often used with past, recommendations important because they reflect that decision younger patients [age 40–59 years] should be individualized basis estimated after shared making,” said Michael Ernst, PharmD, FCCP, BCGP, BCPS, clinical professor department pharmacy practice science at University Iowa College Pharmacy. Overall, he said, health care providers much comprehensive integrated managing did past decades. “I think guideline reflects our understanding value prevention nuanced originally believed.” both significant timely, Ernst. It incorporates from several recent randomized trials, which become available since last update 2016. “A lot changed contemporary trends risks factor management some earlier trials were conducted had previously served foundation guidelines,” Ernst said. Aspirin now limited role based results 3 major studies published 2018—ASPREE (the Reducing Events Elderly), ASCEND (A Study Cardiovascular Diabetes), ARRIVE Assess Efficacy Safety Enteric-Coated Acetylsalicylic Acid Patients Moderate Risk Disease). Each trial demonstrated elevated bleeding without known CVD. harms determined outweigh benefits, particularly among aged 70 older. response, American Cardiology (ACC) Heart Association (AHA) released 2019 explicitly recommending reserved select high-risk not given routinely preventive measure years. USPSTF's guidance sets bar lower, age high, organizations all agree, history or those anticoagulants, steroids, anti-inflammatories. Tabled 1Clinician summary: prevent diseaseWhat does recommend?For greater 10-year risk:The intiate this group individual one.GRADE C: selectively offering providing service professional judgment patient preferences. There least moderate certainty net benefit small.For older:Do initiate CVD.GRADE D: service. high benefits.To whom recommendation apply?This applies 50 signs symptoms increased (e.g., gastrointestinal ulcers, bleeding, other medical conditions, medications increase risk).What's new?▪The ranges grades use.▪The currently considering persons age: instead years.▪Aspirin initiated making rather recommended group.▪There prevention.▪The unclear whether reduces colorectal cancer incidence mortality.How implement recommendation?▪Consider patient's age.▪For years: Estimate using estimator.▪In whose greater, decision-making, into account potential benefits use, well patients’ values preferences, inform about aspirin.▪For it would reasonable dose 81 mg/day.▪For older: Do CVD.Why topic important?CVD leading cause mortality U.S., accounting one four deaths. year, 60,500 first 610,000 experience stroke.What additional tools resources?▪The Million Hearts initiative provides improving preventing stroke millionhearts.hhs.gov▪CDC resources related professionals www.cdc.gov/heartdisease/index.htm▪The National Heart, Lung, Blood Institute coronary www.nhlbi.nih.gov/health-topics/coronary-heart-diseaseWhere read full statement?Visit website (www.uspreventiveservicestaskforce.org/uspstf) JAMA (jamanetwork.com/journals/jama/fullarticle/2791399) statement. This includes details rationale recommendation, including harms; supporting evidence; others.Note: recognizes decisions involve considerations alone. Clinicians understand but individualize specific situation. Adapted from: disease. JAMA. 2022;327(16)1577–1584. Open table tab Note: “Although categories differ, overall, aligns similarly ACC/AHA guideline, notion individualized,” was coauthor ASPREE papers. old, estimate estimator, if harms. stated might considered ages higher bleeding. “In guidelines, I there appreciation may offset aspirin, individuals low risk, anyone person ages—presumably accompanies age,” Pharmacists, like providers, will challenged educating public associated it, “baby dose.” comes decades being told beneficial. “Aspirin around many, many almost everyone personal it. successfully marketed simple cheap preventative your health. And it's universally prescription, ‘baby dose,’ unfortunately reinforces belief risk,” When updating medication histories, good idea ask along OTCs taking. “For purchasing so upon doctor by choice, create opportunities dialogue,” “Never assume also knows aspirin—facilitating conversation between need important.” although attention same way pharmacists can screen appear guideline. “There areas uncertainty still remain—particularly stop problems,” “Post-hoc analyses shed light short term discontinuing adults.” colon remains active area research. Just prior release estimates found one-third apparent indication. hopeful help adoption practice. “The informing couple translating actual challenging always say study don't apply me my patient,” He reminds just guidelines—a roadmap that's generally follow times. draws nuance estimator gauge how discussion balance,” “At end day, substitute reasoning [with] patient.”