US Task Force's new aspirin recommendations: What clinicians need to know

Tuesday, the U.S. Preventive Services Task Force (USPSTF) unveiled new draft recommendations regarding the use of low-dose aspirin as a preventive measure against cardiovascular diseases such as heart attacks or stroke.



The guidance—which is open to public comment until Nov. 8—has two major components:



  • A recommendation that adults aged 40 to 59 years who have no history of cardiovascular disease (CVD) but have 10% or greater 10-year risk of CVD should be considered on a case-by-case basis before beginning preventive low-dose aspirin use


  • A recommendation against beginning low-dose aspirin use for primary prevention of CVD in those aged 60 years or older


The independent panel’s draft recommendations reflect new clinical evidence published since its prior guidance from 2016. These international studies weighed the net benefit of CVD event prevalence against increased risk of “potentially serious harms, such as internal bleeding,” USPSTF member John Wong, M.D., said in a statement.



The task force, cardiology professional organizations and individual clinical experts all stressed that both pieces of the new guidance only address patients who have no history of CVD and are not already taking daily aspirin. They said that patients who have established CVD, have a stent in an artery or have prosthetic heart valves should continue using prescribed aspirin.



Above all, the experts underscored that any changes in prescribed medications should be guided by the patient’s healthcare provider.



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“It’s important that people who are 40 to 59 years old and don’t have a history of heart disease have a conversation with their clinician to decide together if starting to take aspirin is right for them,” Wong said.



The American Heart Association (AHA) said in a statement that the new USPSTF guidance follows their own recommendations for primary prevention of CVD published in 2019. Because aspirin’s overall CVD protection benefit “is small” and frequently offset by the bleeding risk, “we continue to urge clinicians to be very selective when prescribing aspirin,” AHA President Donald M. Lloyd-Jones, M.D., said in a statement.



Demilade A. Adedinsewo, a cardiologist at Mayo Clinic in Jacksonville, Florida, who is not affiliated with USPSTF, said in an email that the new recommendations likely will have a much larger impact in primary care practice than it will among cardiovascular specialists. Further, she pointed out that statins “are also much more effective for cardiovascular disease prevention and are currently favored for primary prevention for patients who meet criteria for use,” she said.



C. Noel Bairey Merz, M.D., director of the Barbra Streisand Women’s Heart Center and professor of cardiology at Cedars-Sinai Medical Center, who also is not affiliated with USPSTF, affirmed that the updated guidance’s caution surrounding preventive aspirin use reflects the cardiology field’s broader discussions in recent years.



However, she noted that treatments and lifestyle changes outside of aspirin are not always viable options for some older patients. Aspirin or not, hammering out an appropriate CVD prevention strategy still requires clinicians to weigh treatment-related health risks alongside the patient’s concerns, behaviors and other restrictions, she said.



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“Most patients and physicians would agree that [heart attack or stroke] causes serious morbidity while [bleeding] dominantly does not,” Merz said in an email statement. “Additionally, not all seniors can or want to take statins, or carefully manage their blood pressure, or quit smoking. Thus, shared decision making between the physician and patient can personalize approaches to prevention.”



Patient-physician conversations will be particularly important in the coming days. As news of USPSTF’s recommendations spread among the general public, Merz said that providers should be ready to field new questions or unconsulted treatment changes.



“Unfortunately, these updated guidances typically result in established cardiovascular patients stopping their aspirin, and/or calling their physician’s offices asking for guidance,” she said.



Merz also cautioned that the recent study data USPSTF’s recommendations are based on reflect outcomes among patients living in wealthy westernized countries—and, more specifically, countries like Australia and the U.K., where national healthcare systems greatly differ from the U.S.



Going forward, she said she would like to see more published research and recommendations on preventive aspirin use across these unaddressed populations.



“Because the new trials were conducted … with safety net socialized healthcare systems which have higher quality of healthcare and lower rates of adverse health outcomes, we should address aspirin utility in the U.S., particularly in middle and low [socioeconomic status] populations that do not have access to quality healthcare other than emergency care,” she said.