Americans take aspirin for CVD prevention despite recommendations against it

Health care practitioners have their work cut out for them in discussing appropriate aspirin use with patients. New study findings published on July 22 in Annals of Internal Medicine found that aspirin is widely used for cardiovascular disease (CVD) prevention—despite recent changes in guidelines—and is not always taken with a physician’s recommendation.

In their examination of data from the 2017 National Health Interview Survey, the researchers found that of self-reported responses from more than 14,000 adults, nearly half of those aged 70 years and older without CVD said they used aspirin. In the overall patient sample, 22.8% reported doing so without their physician’s recommendation.

Christina Wee, MD, MPH, of Harvard Medical School and lead author of the study, said that given the recent change in guidelines and new evidence that the benefits of aspirin might be lower than previously thought, the researchers wanted to estimate how many Americans without preexisting heart disease were taking aspirin to prevent future heart disease. “[We] wanted to give health care providers a sense of how many of their patients they might need to talk to about the change in recommendations,” she said.

Earlier this year, the American College of Cardiology (ACC) and the American Heart Association (AHA) determined that low-dose aspirin for primary prevention of CVD should be reserved for select high-risk patients and not given routinely as a preventive measure to adults older than 70 years. The evidence, which was based on three major trials— ASPREE (the Aspirin in Reducing Events in the Elderly) trial, ASCEND (A Study of Cardiovascular Events in Diabetes), and ARRIVE (A Study to Assess the Efficacy and Safety of Enteric-Coated Acetylsalicylic Acid in Patients at Moderate Risk of Cardiovascular Disease)—found that the risk of bleeding outweighed the benefits for adults without known CVD.

In compiling the study results, Wee was surprised to discover that such a large proportion of older adults and those with a history of stomach ulcers who didn’t have preexisting heart disease or stroke were taking aspirin to prevent heart disease.

Of the nearly 30 million U.S. adults aged 40 and older taking aspirin to prevent CVD, about a quarter without CVD had a history of peptic ulcer disease.

It’s concerning, Wee noted, because older adults and those with stomach ulcers are at a higher risk of being harmed by aspirin, especially the risk of bleeding.

Michael Ernst, PharmD, FCCP, BCGP, BCPS, who was not involved with the study but was coauthor of the ASPREE papers, said that the findings seem to be consistent with what he’s seen in practice, especially with older adult patients.

“One of the biggest challenges to recruitment into the ASPREE study was the high prevalence of aspirin use among the eligible older adults we approached to participate,” said Ernst, who is clinical professor in the department of pharmacy practice and science at the University of Iowa College of Pharmacy. “[For] the U.S. participants, the rate of reported prior regular use of aspirin in this older age group approached 40%.”

Ernst said it’s important for pharmacists to ask patients taking aspirin for primary prevention whether they have discussed it with their provider.

He said educating patients about the potential risks of aspirin and possible adverse effects is necessary, too.

“Because it’s ‘low-dose’ and because it’s been around forever—and next to penicillin is probably the single most universally familiar drug to everyone—I believe the general public may underappreciate the potential risks of aspirin,” said Ernst.

Ernst clarified that patients should continue taking aspirin if they were told to do so by their doctors. Data still support the use of aspirin for patients who have had a CVD event. Depending on an individual’s comorbidities, the American Diabetes Association also recommends aspirin for primary prevention in patients with diabetes.

In general, clinicians should discuss with patients the risks versus benefits, according to the 2019 ACC/AHA guidelines.

For the full article, please visit www.pharmacytoday.org for the October 2019 issue of Pharmacy Today.