*For medical professionals only
“img class=”responsive ” sizes=”(min-width: 320px) 320px, 100vw” src=”https://mmbiz.qpic.cn/mmbiz_png/x5F5KAyDKw19I4VvcibrfNia7lD1fial5KribXqZxjxMxtoc3ichKKz6ib3w5kJias8QNRBYGn80MM0AxEgOvRLibqE2uw/640″ width=”6400″ >Recently, the U.S. Preventive Medicine Task Force (USPSTF) recommended (but did not strongly recommend) consideration of aspirin for certain high-risk middle-aged adults.
The main recommendations are as follows:
For middle-aged adults (ages 40-59) with a 10-year cardiovascular risk ≥10% years), the net benefit of aspirin is small, but it can be considered in middle-aged adults with low bleeding risk (grade C recommendation).
Aspirin is not recommended for the elderly (age ≥ 60 years) (Class D recommendation).
Background
The potential value of aspirin for primary prevention of cardiovascular disease emerges for the first time In a 1989 recommendation of the United States Pharmacopoeia Commission.
Since 1989, the USPSTF guidelines have gone through several iterations on aspirin recommendations, strength of recommendations, target age groups, and balancing cardiovascular benefits and bleeding risks methods are different.
In 2009, the USPSTF expanded and strengthened its recommendations for aspirin, and in 2016, the USPSTF weakened those recommendations.
The 2022 update further weakens the recommendation for routine use of aspirin, reflecting the results of 3 randomized trials published in 2018 (ASPREE, ASCEND, and ARRIVE trials, Older patients with intermediate and high risk primarily involved in cardiovascular risk).
USPSTF’s grading system has changed over time.
In 1996, Class C was defined as “not recommended or objected”. In 2002, Class A was defined as “strongly recommended”.
Since 2009, the definitions are as follows:
Class A: USPSTF recommendation; high certainty with substantial net benefit.
Class B: USPSTF recommendation; very certain net benefit is moderate, or moderate – fairly certain net benefit is moderate.
Grade C: The USPSTF recommends selective recommendations to individual patients based on professional judgment and patient preference; at least moderately certain, with small net benefit.
Class D: USPSTF recommends against; moderate or high certainty of no net benefit, or the risks outweigh the benefits.
Class I: The USPSTF believes that the current evidence is insufficient to assess the balance of benefits and risks.
Comments
For 13 years, the USPSTF has strongly recommended aspirin for adults with cardiovascular disease Primary prevention medication, transitioning to a weaker recommendation, only recommended for selective use in patients at high risk of cardiovascular disease and low risk of bleeding (after detailed shared decision-making discussions).
One of the reasons for this shift is due to:
other prevention strategies (i.e. antihypertensive drugs, statins and smoking cessation), the absolute baseline risk of cardiovascular disease decreased, leading to a narrowing of the window of opportunity for aspirin benefit, while the risk of bleeding remained unchanged.
In a concurrent review in JAMA, Dr. Brett discusses other points:
First of all, this USPSTF advisory statement only covers aspirin;
does not directly address the issue of discontinuing aspirin therapy in patients 60 years of age and older , nor does it address the issue of discontinuation in long-term aspirin patients in their 60s or 70s.
The second problem is that this USPSTF advisory statement relies heavily on the risk stratification of the ACC/AHA cardiovascular risk assessment.
Risk assessments appear objective but are in fact imprecise, presenting significant challenges for clinicians and patients to have productive shared decision discussions.
Source:
1.Aspirin use to prevent cardiovascular disease. JAMA 2022 Apr 26 ; 327:1577.
2.Aspirin use to prevent cardiovascular disease and colorectal cancer: Updated evidence report and systematic review for the US Preventive Services Task Force. JAMA 2022 Apr 26;
3.Should patients take aspirin for primary cardiovascular prevention? Updated recommendations from the US Preventive Services Task Force. JAMA 2022 Apr 26; 327:1552.
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