Cardiovascular Disease Prevention

Risk Assessment and Management

• The American College of Cardiology recommends calculating 10-year ASCVD risk using a validated calculator, considering factors such as age, sex, diabetes, cholesterol levels, blood pressure, family history, and smoking status, to determine high risk, defined as ≥10% 10-year risk, before considering aspirin therapy 1, 2, 3
• Aspirin therapy is most beneficial in high-risk patients for secondary prevention, with a benefit-risk ratio that is most favorable in this population, and is recommended for patients with established cardiovascular disease, with either aspirin (75-100 mg daily) or clopidogrel (75 mg daily) being recommended 4, 3
• The decision to use aspirin for primary prevention should be based on a calculation of 10-year ASCVD risk and an assessment of bleeding risk factors, including age >70 years, history of GI bleeding/ulcers, concurrent anticoagulant or NSAID use, uncontrolled hypertension, renal disease, anemia, thrombocytopenia, coagulopathy, and chronic kidney disease 1, 2, 5, 3

Aspirin Therapy Recommendations

• The American College of Chest Physicians (ACCP) suggests low-dose aspirin (75-100 mg daily) for primary prevention in persons aged 50 years or older without symptomatic cardiovascular disease (Grade 2B recommendation) 4
• Aspirin is generally not recommended for primary prevention in adults aged 60 years or older due to increased bleeding risks outweighing cardiovascular benefits, and is contraindicated in patients under 21 years due to the risk of Reye syndrome 6, 7, 2
• The American College of Cardiology recommends against routine primary prevention of cardiovascular disease with aspirin in most individuals, particularly those aged 60 years or older, due to bleeding risks outweighing cardiovascular benefits, but may be considered in select individuals with a 10% or greater 10-year ASCVD risk and no increased bleeding risk 6
• Aspirin should not be initiated for primary prevention of cardiovascular disease regardless of cardiovascular risk, as stated by the 2019 ACC/AHA guidelines with a Class III: Harm recommendation and Level B-R evidence, but may be considered in patients with diabetes who are over 50 years old with at least one additional major risk factor and are not at increased bleeding risk 6, 7

Aspirin Dosing and Monitoring

• The American College of Cardiology recommends using the lowest effective dose (75-100 mg daily) of aspirin if deemed appropriate, with the most common low-dose tablet being 81 mg in the US, and 75-162 mg daily being the recommended dose for primary prevention 1, 6, 7, 8, 9, 10
• Initial loading dose of 160-325 mg, followed by 75-150 mg daily is recommended for acute MI, and 75-150 mg daily is as effective as higher doses for long-term secondary prevention 1, 3
• Patients should be monitored for signs of bleeding and cardiovascular events while on aspirin therapy, and aspirin therapy should be adjusted or discontinued based on patient response and risk factors 1, 3

Bleeding Risk Assessment

• The American Heart Association suggests evaluating for bleeding risk factors, including age >70 years, history of GI bleeding/ulcers, concurrent anticoagulant or NSAID use, uncontrolled hypertension, renal disease, anemia, thrombocytopenia, coagulopathy, and chronic kidney disease, before recommending aspirin 1, 2, 5
• Active peptic ulcer disease, history of aspirin allergy, severe liver disease, and bleeding disorders are contraindications for aspirin therapy, and relative contraindications include history of GI bleeding/ulcers, age >70 years, concurrent anticoagulant or NSAID use, and uncontrolled hypertension 1, 3, 5

Guideline Recommendations

Efficacy and Safety of Aspirin Therapy

• Aspirin therapy has a modest reduction in non-fatal myocardial infarction, limited impact on stroke in primary prevention, and no significant reduction in vascular mortality in primary prevention 1
• Aspirin therapy increases major bleeding risk by 29-48%, with major GI bleeding occurring in 2-4 per 1,000 middle-aged individuals and 4-12 per 1,000 older individuals over 5 years, and hemorrhagic stroke risk increasing by 0-2 per 1,000 persons over 5 years 1, 3
• Aspirin reduces risk of coronary heart disease by 28% in patients with established cardiovascular disease, and reduces risk of serious vascular events by approximately 25% in patients with prior occlusive vascular events 1, 3
• Aspirin reduces risk of cardiovascular events by 21% in patients with established cardiovascular disease, and reduces nonfatal MI by 26% in patients with established cardiovascular disease 1, 3
• Aspirin reduces stroke by 25% in patients with established cardiovascular disease, and reduces all-cause mortality by 13% in patients with established cardiovascular disease 1, 3