News| Volume 23, ISSUE 3, P1, April 2022

The Aspirin Controversy Continues Despite New Guidelines Regarding Aspirin Usage in Older Adults

      For many years, it was thought that an aspirin a day may keep the doctor away. This age-old sentiment has been put to the test in the past decade.
      In October 2021, the U.S. Preventive Services Task Force (USPSTF) released a draft of their recommendation regarding the role of aspirin in primary prevention against cardiovascular disease (CVD) in adults aged 60 and older (“Aspirin Use to Prevent Cardiovascular Disease: Preventive Medication,” The draft does not recommend initiating low-dose aspirin as primary prevention for CVD in older adults because the risk of harm outweighs the potential benefits. This recommendation mirrors the 2019 guidelines released by the American College of Cardiology and the American Heart Association based on high-quality evidence from several large trials (J Am Coll Cardiol 2019;74:1376–1414).
      Interestingly, the release of these new recommendations by the USPSTF is an update from their previous stance in 2016, which recommended considering aspirin initiation in adults aged 60–69 for primary prevention when their 10-year CVD risk is >10% and when they have a life expectancy of >10 years and are not at increased risk of bleeding (Ann Intern Med 2016;164:836–845). A 2019 meta-analysis of 15 randomized controlled trials comprising more than 165,000 participants found that aspirin, when used for primary prevention, did reduce the overall occurrence of nonfatal ischemic events (i.e., myocardial infarction, transient ischemic attack, and ischemic stroke), but it was associated with a higher risk of major bleeding, and there was no reduction in the all-cause death rates (J Am Coll Cardiol 2019;73:2915–2929).
      The controversy behind the guidelines lies in the question of what one should consider to be a meaningful outcome. Does the potential prevention of nonfatal CVD events (and possible prevention of functional decline, disability, and institutionalization) on a population level outweigh the potential risks of harm to an individual person?
      The USPSTF is a panel of experts in primary care who systematically review scientific and medical evidence to develop recommendations for or against medical preventive measures such as screenings, imaging studies, and medications to prevent unwanted diseases and illnesses. They assign letter grades (i.e., A through I) to each recommendation to describe the level of certainty seen in the available evidence that an intervention would be beneficial for a desired health outcome. Grades A and B are assigned when there is thought to be high certainty that the benefit of the intervention is substantial and the intervention is recommended. Grade C is assigned when there is no recommendation for or against the intervention. Grade D is assigned when the evidence points toward recommending against an intervention because the harm likely outweighs the benefits. Grade I denotates insignificant evidence to assess the balance of benefits and harms.
      In their most recent recommendation statement regarding aspirin for primary prevention in older adults, the USPSTF assigned the available evidence a grade D, indicating that the increased risk of adverse drug events with aspirin outweighs any potential reduction in nonfatal CVD events. The available evidence does not support the use of aspirin for primary CVD prevention, which means it should be a target for deprescribing in post-acute and long-term care.
      These new recommendations do not represent a change for most of us in clinical practice. Although there is established evidence that aspirin should be used in older adults for secondary prevention, most of us are aware of the limitations for aspirin usage in primary prevention, and we routinely assess the risks and benefits of each medication we prescribe in older adults. These new recommendations do, however, represent a change for many of our patients and caregivers who have recently heard about these guidelines on TV or through social media.
      We have witnessed patients who stop their aspirin because of misunderstandings about what constitutes primary and secondary prevention and a lack of understanding of harms versus benefits. One person with a recent history of ischemic stroke interpreted the updated guidelines to say that aspirin “is not needed for anyone and may cause severe bleeding.” These moments are opportunities to participate in shared decision-making between the clinician and patient, which is really the cornerstone of the practice of preventive medicine in older adults. Our preventive medicine algorithms often do not consider critical pieces of information in the heterogenous population of older adults across the PALTC continuum — such as functional status, cognitive limitations, and life expectancy — so we must rely heavily on discussions with our residents to determine the best next steps.
      In summary, the newest recommendations regarding low-dose aspirin initiation in older adults for primary prevention released by the USPSTF in October 2021 are based on a growing body of evidence that demonstrates a lack of benefit and an increased risk of harm with the use of aspirin for primary CVD prevention. Although the evidence has been available for years, many patients still routinely take aspirin for this purpose. Leaders in PALTC must continue to educate providers, patients, residents, and families about evidence-based medicine guidelines for best practice. We also must continue to exercise shared decision-making between the clinician and patient for deprescribing, particularly for those who don’t fit the usual preventive medicine algorithms.
      Dr. Sanford is an associate professor of internal medicine in the Division of Geriatrics at Saint Louis University. She serves in the medical director role at various facilities and also sees patients in the hospital and clinic settings.
      Dr. Little is an associate professor of geriatric medicine at Duke University. Her scholarly interests are interprofessional health education, deprescribing, and nonpharmacological management of dementia.

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