October 14, 2021

Should you take a daily aspirin? New draft guidance could change the answer.

Daily Briefing

    The U.S. Preventive Services Task Force (USPSTF) on Tuesday issued draft guidance that—in a reversal from the panel's 2016 guidance—advises against the use of a low, daily dose of aspirin to prevent a first heart attack or stroke for certain populations.

    The guidance was posted online for public comment through Nov. 8. At that point, the panel will assess feedback and make a final decision regarding the recommendation.

    Slide deck: Cardiovascular market trends for 2021

    Background

    In 2016, USPSTF released a recommendation that patients over age 50, with a 10% or higher risk of cardiovascular disease in the next 10 years, should begin a daily regimen of low-dose aspirin—between 81 milligrams to 100 milligrams—to prevent heart disease, stroke, and colorectal cancer. The 2016 guidance also suggested that taking a low, daily dose of aspirin could help prevent colorectal cancer.

    For individuals ages 60 to 69 years old, the 2016 guidelines recommended consulting with clinicians before starting a daily aspirin regimen, but said the decision to do so was, ultimately, an individual one.

    However, two years ago, the American College of Cardiology (ACC) and American Heart Association (AHA) narrowed their recommendations, suggesting that aspirin should be prescribed more selectively to individuals ages 40 to 70 who have never had a heart attack or stroke. On aspirin, both organizations suggest following a "generally no, occasionally yes," guideline for primary prevention, the Times reports.

    New USPSTF draft recommendation shifts precedent

    If finalized, the panel's draft recommendation for older adults would deviate from the 2016 guidelines for preventing a first heart attack and stroke—and be in line with more recent guidelines from other medical groups.

    Specifically, the draft guidance recommends that adults ages 40 to 59 years old who have at least a 10% risk of a cardiovascular event over the next ten years—but who have not previously had a heart attack or stroke—should consult with their doctor to determine if they should start taking low-dose aspirin as a preventative measure, although the panel concluded that such dosage may confer a small benefit.

    However, for people ages 60 and older, the draft guidance strongly discouraged the use of low-dose aspirin to prevent a cardiovascular event, citing new research indicating there's no net benefit to doing so given the increased risk of a bleeding event, including a gastrointestinal bleed or a brain bleed.

    "When we looked at the literature, most of it suggested the net balance is not favorable for most people—there was more bleeding than heart attacks prevented," said Amit Khera, a co-author of ACC and AHA's guidelines. "And this isn't nose bleeds, this can be bleeding in the brain."

    The panel cited additional research showing that even though the use of low-dose aspirin may help lower the risk of a first cardiovascular event for some people, it does not lower the number of deaths from heart disease or other causes. Moreover, since people now can better control high blood pressure and other risk factors, "there is less room for aspirin now to make a difference," Donald Lloyd-Jones, AHA president, said.

    However, experts recommend that individuals who are already taking a daily dose of low-dose aspirin talk to their doctor before making any changes. According to Chien-Wen Tseng, the research director of family medicine and community health at the University of Hawaii and a national task force member, the task force doesn't "recommend anyone stop without talking to a clinician, and definitely not if they have already had a heart attack or stroke."

    Notably, the guidance also reverses the endorsement that aspirin can help prevent colorectal cancer, citing new research indicating aspirin use was linked to a near-doubling of colorectal cancer fatalities over the course of a five-year follow-up period.

    If approved, these updated guidelines could affect tens of millions of adults at high risk for cardiovascular disease—the leading cause of death in the United States, according to the Times.

    "There's no longer a blanket statement that everybody who's at increased risk for heart disease, even though they never had a heart attack, should be on aspirin," Tseng said. "We need to be smarter at matching primary prevention to the people who will benefit the most and have the least risk of harms." (Johnson, Modern Healthcare, 10/12; Knutson, Axios, 10/12; Rabin, New York Times, 10/13; Tanner, STAT News, 10/12)

    What health systems need to know about CV services in 2021

    The year 2020 held the promise of a blank slate for health care leaders, but by early March, that promise dissipated. In a year when the public and political spotlight was already focused squarely on health care, the Covid-19 pandemic fueled the health care market’s evolution.

    Read our new executive briefing to learn the four major trends impacting CV service lines across the next year.

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