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Aspirin Use Discourged / 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease
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"Prophylactic aspirin in primary-prevention adults >70 years of age is potentially harmful......for adults <40 years of age, there is insufficient evidence to judge the risk–benefit ratio of routine
aspirin for the primary prevention of ASCVD"
Prophylactic aspirin in primary-prevention adults >70 years of age is potentially harmful and, given
the higher risk of bleeding in this age group, difficult to justify for routine use (S4.6-9). In addition,
for adults <40 years of age, there is insufficient evidence to judge the risk–benefit ratio of routine
aspirin for the primary prevention of ASCVD. However, one caveat is that, although routine use is
not recommended in these settings, there is also insufficient evidence to comment on whether
there may be select circumstances in which physicians might discuss prophylactic aspirin with adults
<40 years of age or >70 years of age in the context of other known ASCVD risk factors (e.g., strong
family history of premature MI, inability to achieve lipid or BP or glucose targets, or significant
elevation in coronary artery calcium score). As inferred from the first recommendation, there is also
no justification for the routine administration of low-dose aspirin for the primary prevention of
ASCVD among adults at low estimated ASCVD risk. For example, in the recent ARRIVE (A
Randomized Trial of Induction Versus Expectant Management) trial, observed average 10-year
ASCVD risk was <10%, and the overall benefits of prophylactic aspirin by intention-to-treat were
Negligible
The accumulated trial and observational data to date support avoiding prophylactic aspirin in the
setting of known risk factors for increased bleeding outcomes (S4.6-10). A nonexhaustive list of
conditions associated with increased bleeding risk includes: a history of previous gastrointestinal
bleeding or peptic ulcer disease or bleeding at other sites, age >70 years, thrombocytopenia,
coagulopathy, CKD, and concurrent use of other medications that increase bleeding risk, such as
nonsteroidal anti-inflammatory drugs, steroids, direct oral anticoagulants, and warfarin (S4.6-10).
Conclusion
Most ASCVD events are avoidable through primordial prevention (i.e., the prevention of risk factor
development) and control of traditional cardiovascular risk factors. Tobacco avoidance is critically
important for ASCVD prevention, and all adults should strive to engage in regular brisk physical activity
most days of the week and adhere to a healthy dietary pattern to help lower future ASCVD risk. A diet
high in fruits, vegetables, and whole grains is best. Fish, legumes, and poultry are the preferred sources
of protein. Minimizing the consumption of trans fats, added sugars (including sugar-sweetened
beverages), red meats, sodium, and saturated fats is also important. Clinicians should work in
partnership with patients to assess their readiness for sustained lifestyle improvements, identify
potential barriers to change, and encourage them to try to achieve measurable goals and continue to
monitor their progress (S6-1). Finally, social determinants of ASCVD risk—and their impact on the
patient's ability to prevent or treat risk factors—must be taken into account. Clinicians need to consider
patients'
2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease
Top 10 Take-Home Messages for the Primary Prevention of
Cardiovascular Disease
1. The most important way to prevent atherosclerotic vascular disease, heart failure, and atrial
fibrillation is to promote a healthy lifestyle throughout life.
2. A team-based care approach is an effective strategy for the prevention of cardiovascular disease.
Clinicians should evaluate the social determinants of health that affect individuals to inform
treatment decisions.
3. Adults who are 40 to 75 years of age and are being evaluated for cardiovascular disease prevention
should undergo 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimation and have a
clinician–patient risk discussion before starting on pharmacological therapy, such as
antihypertensive therapy, a statin, or aspirin. In addition, assessing for other risk-enhancing factors
can help guide decisions about preventive interventions in select individuals, as can coronary artery
calcium scanning.
4. All adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts,
whole grains, lean vegetable or animal protein, and fish and minimizes the intake of trans fats,
processed meats, refined carbohydrates, and sweetened beverages. For adults with overweight and
obesity, counseling and caloric restriction are recommended for achieving and maintaining weight
loss.
5. Adults should engage in at least 150 minutes per week of accumulated moderate-intensity physical
activity or 75 minutes per week of vigorous-intensity physical activity.
6. For adults with type 2 diabetes mellitus, lifestyle changes, such as improving dietary habits and
achieving exercise recommendations, are crucial. If medication is indicated, metformin is first-line
therapy, followed by consideration of a sodium-glucose cotransporter 2 inhibitor or a glucagon-like
peptide-1 receptor agonist.
7. All adults should be assessed at every healthcare visit for tobacco use, and those who use tobacco
should be assisted and strongly advised to quit.
8. Aspirin should be used infrequently in the routine primary prevention of ASCVD because of lack of
net benefit.
9. Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated lowdensity
lipoprotein cholesterol levels (≥190 mg/dL), those with diabetes mellitus, who are 40 to 75
years of age, and those determined to be at sufficient ASCVD risk after a clinician–patient risk
discussion.
10. Nonpharmacological interventions are recommended for all adults with elevated blood pressure or
hypertension. For those requiring pharmacological therapy, the target blood pressure should
generally be <130/80 mm Hg.
Synopsis
For decades, aspirin has been widely administered for ASCVD prevention. By irreversibly inhibiting
platelet function, aspirin reduces risk of atherothrombosis but also increases risk of bleeding,
particularly in the gastrointestinal tract (S4.6-11). Aspirin is well established for secondary prevention of
ASCVD (S4.6-12) and is widely recommended for this indication (S4.6-13). However, in primary
prevention, aspirin use is more controversial. Because persons without prior ASCVD are inherently less
likely to have future ASCVD events than are those with a prior history, it is more challenging for
clinicians and patients to balance benefits and harms of prophylactic aspirin for primary prevention. This
uncertainty is reflected in international guidelines, where, for example, aspirin is not recommended in
European guidelines for primary ASCVD prevention (S4.6-13) but is recommended in prior U.S.
guidelines for selected primary prevention for adults who have elevated risk of ASCVD based on
traditional risk factors (S4.6-14, S4.6-15). Adding to this controversy are more recently conducted
primary-prevention trials that, in contrast to older trials (S4.6-12), have shown less overall benefit of
prophylactic aspirin alongside coadministration of contemporary ASCVD preventive treatments, such as
evidence-based hypertension and cholesterol therapies (S4.6-5–S4.6-9, S4.6-16, S4.6-17).
2. Prophylactic aspirin in primary-prevention adults >70 years of age is potentially harmful and, given
the higher risk of bleeding in this age group, difficult to justify for routine use (S4.6-9). In addition,
for adults <40 years of age, there is insufficient evidence to judge the risk–benefit ratio of routine
aspirin for the primary prevention of ASCVD. However, one caveat is that, although routine use is
not recommended in these settings, there is also insufficient evidence to comment on whether
there may be select circumstances in which physicians might discuss prophylactic aspirin with adults
<40 years of age or >70 years of age in the context of other known ASCVD risk factors (e.g., strong
family history of premature MI, inability to achieve lipid or BP or glucose targets, or significant
elevation in coronary artery calcium score). As inferred from the first recommendation, there is also
no justification for the routine administration of low-dose aspirin for the primary prevention of
ASCVD among adults at low estimated ASCVD risk. For example, in the recent ARRIVE (A
Randomized Trial of Induction Versus Expectant Management) trial, observed average 10-year
ASCVD risk was <10%, and the overall benefits of prophylactic aspirin by intention-to-treat were
negligible
3. The accumulated trial and observational data to date support avoiding prophylactic aspirin in the
setting of known risk factors for increased bleeding outcomes (S4.6-10). A nonexhaustive list of
conditions associated with increased bleeding risk includes: a history of previous gastrointestinal
bleeding or peptic ulcer disease or bleeding at other sites, age >70 years, thrombocytopenia,
coagulopathy, CKD, and concurrent use of other medications that increase bleeding risk, such as
nonsteroidal anti-inflammatory drugs, steroids, direct oral anticoagulants, and warfarin (S4.6-10).
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