Assessing Aspirin: 8 Questions on Primary CVD Prevention

October 24, 2018
Aparna Sajja, MD
Aparna Sajja, MD

,
Seth Martin, MD, MHS
Seth Martin, MD, MHS

Dr. Martin is an assistant professor at the Ciccarone Center for the Prevention of Heart Disease at the Johns Hopkins University School of Medicine.

To Rx or not to Rx aspirin - is one of our 8 questions based on new research that highlights costs vs benefits of aspirin therapy.

The simple little white pill has made medical and consumer headline news for weeks. Find out what you know about the history, the study outcomes, the recommendations, and patient selection for aspirin use in primary prevention of cardiovascular disease with our 8-question quiz.

Question 1.

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Answer: A. True. Based on major studies completed since the 1980s, the American Heart Association (AHA) and US Preventive Services Task Force (USPSTF) adopted recommendations for the use of aspirin in primary prevention of cardiovascular disease (CVD), particularly for high-risk individuals (5-year CVD risk ≥3%). Aspirin has since been a commonly used medication, with an estimated 40% of US adults aged >50 years using aspirin for primary prevention of coronary events.

Question 2.

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Answer: A. The JUPITER Trial. The major primary prevention studies completed between 1988 and 2001 included the US Physicians’ Health Study, Thrombosis Prevention Trial (TPT), Hypertension Optimal Treatment (HOT), British Doctors Study, and the low-dose aspirin trial of the Primary Prevention Project (PPP) trials. The  JUPITER trial (option A) looked at statin use, not aspirin.

Question 3.

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Answer: B. False. Currently, the USPSTF (2016) recommends aspirin use as primary prevention in adults aged 50-59 with a 10-year ASCVD risk of at least 10% and (1) without increased risk of bleeding or (2) life expectancy of at least 10 years (Grade B). For adults aged 60-69 with the same risk, a more individualized approach is suggested (weaker recommendation, Grade C).

Question 4.

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Answer: C. Ischemic stroke. Aspirin is the only antiplatelet agent that has been established as effective in the early treatment of acute ischemic stroke. The primary risk associated with aspirin use is bleeding (options A, B, D, E), a result of its antithrombotic effect.

Question 5.

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Answer A. True. In the ARRIVE trial, 100 mg of aspirin daily in an intermediate-risk population did not lead to a reduction in adverse CV events. The consensus from the study was use of aspirin in such patients should be individualized.

 

Question 6.

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Answer: A. 54-year-old man with diabetes and 10-yr ASCVD risk >10%. With diabetes and estimated ASCVD risk >10%, he is in a group that has realized a net benefit from daily low-dose aspirin. In the ASCEND trial, among individuals with diabetes and no prior history of cardiovascular disease, aspirin led to a 12% relative reduction in major adverse CV events vs placebo.

Options B and C: Patients older than age 70 years have not been shown to benefit from aspirin for reduction in major adverse CV events in the primary prevention setting. In fact, the ASPREE trial showed a significant increase in major bleeding and an increase in all-cause mortality in this population.

Question 7.

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Answer: C. 65-year-old woman with multiple CV risk factors and ASCVD risk >20%. With estimated ASCVD risk >20%, she is in an aspirin benefit group.

Options A and B. These patients are not clearly in groups likely to derive CV benefit from aspirin and are at increased risk for bleeding.

Question 8.

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Answer: A. 75-100 mg daily or every other day. Low-dose aspirin (75 to 100 mg) taken every day or every other day is recommended for primary prevention. In the United State, 81 mg daily is often used. While recent studies (ASPREE, ARRIVE, ASCEND) used 100 mg of daily aspirin, the 2005 Women’s Health Study used the lowest absolute dose (100 mg every other day) to show CV benefit. It is possible that even lower doses may be effective in reducing CVD risk while minimizing bleeding events.

Source: Meyer J, Arps K, Blumenthal RS, Martin SS. New data on aspirin use in the era of more widespread statin use. American College of Cardiology Web site. https://www.acc.org/latest-in-cardiology/articles/2018/09/28/08/08/new-data-on-aspirin-use-in-the-era-of-more-widespread-statin-use Accessed October 22, 2108.