Publications of the Week (May 18, 2022)

Acetylsalicylic acid in the primary prevention of cardiovascular disease: To take or not to take?

Background: This is a 2022 update from the US Preventive Services Task Force (USPSTF) on the effectiveness of acetylsalicylic acid (ASA) for the primary prevention of cardiovascular disease (CVD) events (myocardial infarction and stroke), CVD mortality, and all-cause mortality. It took into account the harms (particularly bleeding) associated with ASA use.

Methods: The balance of benefits and harms from ASA use for the primary prevention of CVD was examined in subgroups, depending on age, sex, and CVD risk level.

The recommendations apply to individuals aged ≥40 years, without evidence of CVD, who are not at increased risk of bleeding (eg, no history of gastrointestinal ulcers, recent bleeding, or use of medications that increase the bleeding risk).

Results: The authors judged with moderate certainty that ASA use for the primary prevention of CVD events in adults aged 40 to 59 years who have a ≥10% 10-year CVD risk has a small net benefit.

Conclusions: The authors stressed the need for an individualized approach and issued careful conditional recommendations for the use of ASA in that group, that is, to selectively offer ASA to individual patients based on clinical judgment and patient preferences.

They also concluded that initiating ASA use for the primary prevention of CVD events in adults aged ≥60 years has no net benefit and recommend against this intervention (moderate or high certainty that the treatment has no net benefit or that the harms outweigh the benefits).

McMaster editors’ comment: Overall, the inclination to start ASA in primary prevention has decreased over the last few decades with greater awareness of an increased bleeding risk, especially in the elderly, and, possibly, because of the attenuated effects of ASA in patients with improved management of CVD risk factors, including hypertension and hyperlipidemia (see editorial).

The recommendations, editorial, and supplementary material are free to access. The tool for 10-year CVD risk calculation can be found here.