USA Guidelines for Aspirin

March 2018

The purpose of this document is to keep a working list of USA guidelines with information on aspirin.

Primary prevention of cardiovascular disease 

The U.S. Preventative Services Task Force (USPSTF) was created in 1984 and is an independent, volunteer panel of national experts in preventative and evidence-based medicine.  They use the following to grade their recommendations:

The USPSTF April 2016 recommends low-dose aspirin to prevent cardiovascular disease and colorectal cancer in the following groups:

Grade B Adults age 50 to 59 years with a 10 year CVD risk of greater than 10% who are not at increased risk for bleeding, have a life expectancy of at least 10 years and are willing to take low-dose aspirin for at least 10 years.

Grade C Adults age 60 to 69 years with a 10 year CVD risk of greater than 10% should consider their individual risks versus benefits of long term low dose aspirin. Those who are not at risk of bleeding, have a life expectancy of at least 10 years and are willing to take low-dose aspirin for at least 10 years are more likely to benefit.

“Persons who place a higher value on the potential benefits than the potential harms may choose to initiate low-dose aspirin.”

The USPSTF state that there is insufficient current evidence to assess the balance of benefits versus harms of initiating aspirin for primary prevention of CVD and CRC in adults younger than 50 years or 70 years or older. (Grade I).

https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/aspirin-to-prevent-cardiovascular-disease-and-cancer

USPSTF guidelines in development: CVD detection and prevention.

The USPSTF has recommendations on cardiovascular disease (CVD) risk and atrial fibrillation: screening with electrocardiology, cardiovascular disease: risk assessment using non-traditional risk factors and peripheral artery disease (PAD) in adults: screening with ankle brachial index at an evidence review and draft recommendation development stage. These draft guidelines focus on screening and risk assessment but this will help to identify more people who can benefit from preventative therapy. The cardiovascular screening guideline using non-traditional risk factors will include a review of treatment interventions aimed at preventing CVD events. The PAD screening review includes a section on treatment interventions in which it plans to explore antiplatelet therapy.

The American Heart Association (AHA) state (last update March 2017) that;

“Aspirin can help prevent heart attack.”

The AHA recommends;

People at high risk of heart disease should take low-dose aspirin (if told to by their healthcare provider) and that heart attack survivors regularly take low-dose aspirin.

They explain how aspirin helps prevent heart attack and stroke and provide questions for patients to ask their doctor about aspirin.  http://www.heart.org/HEARTORG/Conditions/HeartAttack/PreventionTreatmentofHeartAttack/Aspirin-and-Heart-Disease_UCM_321714_Article.jsp#.WD2DUbR4WhA

National Centre for Biotechnology Information (NCBI), National Library of Medicine (NLM), National Institute of Health (NIH) list an article in the Clinical Medicine and Research (Clin Med Res. 2014: 12(3-4):147-154) which states in its abstract:

“Aspirin therapy is well-accepted as an agent for the secondary prevention of cardiovascular events and current guidelines also define a role for aspirin in primary prevention. In this review, we describe the seminal trials of aspirin use in the context of current guidelines, discuss factors that may influence the effectiveness of aspirin therapy for cardiovascular disease prevention, and briefly examine patterns of use. The body of evidence supports a role for aspirin in both secondary and primary prevention of cardiovascular events in selected population groups, but practice patterns may be suboptimal. As a simple and inexpensive prophylactic measure for cardiovascular disease, aspirin use should be carefully considered in all at-risk adult patients, and further measures, including patient education, are necessary to ensure its proper use.”

They conclude that aspirin despite evidence-based guidelines for both primary prevention in CVD is not optimally used – there is both underuse and overuse. They advocate research to help optimise aspirin use in the groups most likely to benefit.

Launched in 2012, Million HeartsR  (https://millionhearts.hhs.gov/about-million-hearts/index.html) is a national initiative in the USA set up to prevent 1 million heart attacks and strokes by 2017. It is co-lead by The Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services Services on behalf of the U.S. Department of Health and Human Services.

Over the next 5 years until 2022 Million HeartsR  plans to build on its experience, expertise and partnerships and seeks commitment to preventing a million CVD events in five years by:

  • Optimizing care for the ABCS of heart health:
  • Aspirin when appropriate
  • Blood pressure control
  • Cholesterol management
  • Smoking cessation

And increase the use of cardiac rehabilitation and healthy living behaviours

The FDA on a consumer advice sheet (last update 30/12/2016) does not currently recommend the use of aspirin for the primary prevention of CVD;

“The FDA has reviewed the available data and does not believe the evidence supports the general use of aspirin for the primary prevention of a heart attack or stroke. In fact, there are serious risks associated with the use of aspirin, including increased risk of bleeding in the stomach and brain, in situations where the benefit of aspirin for primary prevention has not been established.”  https://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm390574.htm

Secondary prevention of cardiovascular disease

American Stroke Association recommends that to prevent another stroke occurring patients create a stroke prevention plan with their  doctor that may include discussing an aspirin regimen or other medications in addition to; managing high blood pressure, reducing blood sugar, eating better, stopping smoking, controlling cholesterol, being active and losing weight. They point out that aspirin is not appropriate for everyone. http://www.strokeassociation.org/STROKEORG/AboutStroke/PreventAnotherStroke/Prevent-Another-Stroke_UCM_496208_SubHomePage.jsp

Prevention of cardiovascular events in diabetics

The American Diabetes Association 2014 does advocate the use of aspirin for primary prevention of CVD for some people (Usually men over 50 and women over 60 years with other risk factors e.g. high BP and/or cholesterol) http://professional.diabetes.org/pel/taking-aspirin-protect-your-heart-english

Primary prevention of colorectal cancer/all GI cancers

The USPSTF recommends low-dose aspirin for the prevention of colorectal cancer in certain groups (see primary prevention of CVD above).

The National Cancer Institute has information on aspirin to reduce cancer risk that has been updated Feb 2017 (https://www.cancer.gov/about-cancer/causes-prevention/research/aspirin-cancer-risk). This is an update on a previous article April 2015 reviewing the evidence for aspirin and cancer prevention called “No easy answers about whether aspirin lowers cancer risk”. The 2017 information ‘Aspirin to reduce cancer risk’ supports the USPSTF 2016 recommendations.  The 2017 article describes consistent data for the use of aspirin to reduce the risk of colorectal cancer and supports the USPSTF guidance on using aspirin in population groups where the potential benefit is highest and risk lowest.  They describe how the ‘jury is still out’ on the role of aspirin in reducing the risk of other cancers. The article discusses how aspirins protective effects may depend as much on biological factors as it does on cancer type and reviews some of the current research on aspirins risks versus benefits.

The American Cancer Society has a September 2015 article discussing the research into aspirin and cancer prevention and the USPSTF (proposed) recommendations (Mendes 2015 Aspirin and Cancer Prevention: What the Research Really Shows). The article concludes;

“Neither the American Cancer Society, nor any other health organization, recommends taking aspirin solely to help prevent cancer. People who are wondering if they should take aspirin should talk to their health care provider, who knows their individual medical history and is aware of other medications they may be using, and can take this into account when weighing the overall risks and benefits of aspirin use for them.”