Core Concepts
Aspirin's effectiveness in preventing heart attacks and strokes has declined, leading to a shift in clinical recommendations, and new drug classes like P2Y12 inhibitors may provide safer alternatives for some patients.
Abstract
The article discusses the changing landscape around the use of aspirin for the primary prevention of cardiovascular disease (CVD). It highlights how a series of recent studies (ASCEND, ARRIVE, and ASPREE) have shown a significant decline in the purported benefits of aspirin, while its potential harms, such as increased risk of gastrointestinal and intracranial bleeding, have become more pronounced.
The article explains that the decline in aspirin's effectiveness is attributed to other "primary care interventions" that have helped reduce CVD risk, such as reduced smoking rates, improved diet and physical activity, and better management of hypertension. Additionally, the introduction of new drug classes, like statins for high cholesterol and P2Y12 inhibitors for acute coronary syndrome, have also contributed to the changing landscape.
The article discusses the updated guidelines from the US Preventive Services Task Force (USPSTF), which have downgraded the recommendation for low-dose aspirin use in primary prevention, stating that the decision should be an individual one based on professional judgment and patient preferences. The American College of Cardiology and American Heart Association have also dialed down their previous strong recommendations on low-dose aspirin for primary prevention.
The article highlights that while aspirin may still be beneficial for some high-risk patients, clinicians should focus on other evidence-based interventions, such as smoking cessation, screening for hypertension, and behavioral modifications like weight management and lipid control. The article also emphasizes the importance of considering family history and the potential role of newer drug classes, like P2Y12 inhibitors, in primary prevention, although more research is needed in this area.
Stats
A landmark study in 1988 reported a 44% drop in heart attacks among US male physicians aged 40-84 years who took aspirin.
In 2017, nearly a quarter of Americans over age 40 who did not have cardiovascular disease (CVD) took aspirin, and over 20% were doing so without a physician's recommendation.
The recent studies (ASCEND, ARRIVE, and ASPREE) showed that aspirin decreased the risk for myocardial infarction by only 11% among study subjects, while its potential harms were much more pronounced, with a 58% increase in the risk for gastrointestinal bleeding and a 31% increased risk for intracranial bleeding.
Quotes
"The calculus for taking aspirin appeared to have changed dramatically: The drug decreased the risk for myocardial infarction by only 11% among study subjects, while its potential harms were much more pronounced."
"They have shown a better bleeding profile, especially clopidogrel compared to aspirin."
"Is there a magic age? I don't think there is," said Douglas Lloyd-Jones.