{"id":1382,"date":"2009-12-16T16:10:25","date_gmt":"2009-12-16T21:10:25","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/to-recommend-aspirin-or-not-to-recommend-aspirin-that-is-the-question\/"},"modified":"2011-07-19T17:45:31","modified_gmt":"2011-07-19T21:45:31","slug":"to-recommend-aspirin-or-not-to-recommend-aspirin-that-is-the-question","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2009\/12\/16\/to-recommend-aspirin-or-not-to-recommend-aspirin-that-is-the-question\/","title":{"rendered":"To Recommend Aspirin or Not to Recommend Aspirin, That Is the Question"},"content":{"rendered":"

The debate over the use of aspirin in primary prevention of cardiovascular events among adults with no known cardiovascular disease continues to grow. In March, the United States Preventive Services Task Force assigned Class A recommendations <\/a>to encourage:<\/p>\n

Men 45-79 to use aspirin when potential MI benefit outweighs potential GI harm
\n Women 55-79 to use aspirin when potential stroke benefit outweighs potential GI harm <\/p>\n

 
\nNo controversy yet. As before, physicians are being told that aspirin is a \u201cmust use\u201d drug among patients at moderate risk of either MI or stroke.
\n 
\nHowever, since the USPSTF recommendation, several studies have presented data that contradict this Class A recommendation, including a meta-analysis from the Oxford Antithrombotic Treatment Trialists (ATT) <\/a>published in the Lancet<\/em>.
\n 
\nThis analysis is particularly interesting because previous meta-analyses only made use of summary-level data. However, through a collaborative agreement established among principal investigators of the large trials of aspirin for primary prevention, subject-level data (n=95,000) was made available for this paper. This agreement allowed for reliable comparisons of both the benefits and risks of aspirin in important groups, such as older adults, adults with diabetes, and others at increased risk of coronary heart disease. I recently collaborated on a research paper <\/a>published in Archives of Internal Medicine<\/em> that advocated for the availability of subject-level data for meta-analysis for purposes such as this.
\n 
\nThe Oxford ATT found that aspirin was not associated with a reduced rate of vascular death but was associated with a 12% relative risk reduction per year in the primary prevention of serious vascular events. However, the absolute event rates per year were low (0\u00b751% for aspirin recipients vs. 0\u00b757% for controls), and the absolute risk reduction was reported as 0.07% (NNT>1000 for 1 year of treatment). This reduction was due mainly to fewer non-fatal myocardial infarctions. Complicating matters, aspirin was also associated with more major gastrointestinal and extra-cranial bleeds, with an absolute harm increase of 0.03% per year.
\n 
\nWithin the pre-specified sub-group analyses, there was no significant heterogeneity in their findings: the risk reduction in primary prevention of serious vascular events was similar regardless of patient age, sex, BMI, past medical history of diabetes, hypertension, hyperlipidemia, or predicted 5-year CHD risk.
\n 
\nPerhaps we will have a better understanding when the results of ASPREE<\/a>, ACCEPT-D<\/a>, and ASCEND<\/a> are available. We can only hope that the principal investigators enter into the same collaborative agreement and share subject-level data for meta-analysis.
\n 
\nNevertheless, given this more precise examination of existing data, I cannot see how aspirin can remain a \u201cmust-use\u201d drug for primary prevention of cardiovascular events among patients at moderate risk of either MI or stroke since there is minimal net effect on serious vascular events and no effect on mortality.
\n 
\nDo you agree? And what will you suggest to your primary care colleagues, like me, who are making decisions as to whether to recommend aspirin among large groups of patients with no known cardiovascular disease?<\/p>\n","protected":false},"excerpt":{"rendered":"

The debate over the use of aspirin in primary prevention of cardiovascular events among adults with no known cardiovascular disease continues to grow. In March, the United States Preventive Services Task Force assigned Class A recommendations to encourage: Men 45-79 to use aspirin when potential MI benefit outweighs potential GI harm Women 55-79 to use […]<\/p>\n","protected":false},"author":277,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-1382","post","type-post","status-publish","format-standard","hentry","category-general"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/1382","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/277"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=1382"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/1382\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=1382"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=1382"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=1382"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}