Asparin Use counselling in Cardiovascular disease -Senior

Summary of Recommendation and Evidence

Population	Recommendation	Grade (What's This?)
Screening of both genders.	This screening is recommended for seniors.	B

IMPORTANCE

Cardiovascular Disease (CVD) and CRC are major causes of death among U.S. adults. In 2011, more than one-half of all deaths in the United States were caused by heart disease, cancer, or stroke.

RECOGNITION OF RISK STATUS

The primary risk factors for CVD include older age, male sex, race/ethnicity, abnormal lipid levels, high blood pressure, diabetes, and smoking. This recommendation applies to adults who are at increased CVD risk.

Risk factors for gastrointestinal (GI) bleeding with aspirin use include higher dose and longer duration of use, history of GI ulcers or upper GI pain, bleeding disorders, renal failure, severe liver disease, and thrombocytopenia. Other factors that increase risk for GI or intracranial bleeding with low-dose aspirin use include concurrent anticoagulation or nonsteroidal anti-inflammatory drug (NSAID) use, uncontrolled hypertension, male sex, and older age.

BENEFITS OF ASPIRIN USE

The USPSTF found adequate evidence that aspirin use to reduce risk for cardiovascular events (nonfatal MI and stroke) in adults aged 50 to 69 years who are at increased CVD risk is of moderate benefit. The magnitude of benefit varies by age and 10-year CVD risk.

The USPSTF found inadequate evidence that aspirin use reduces risk for CVD events in adults who are at increased CVD risk and are younger than 50 years or older than 69 years.

HARMS OF ASPIRIN USE

The USPSTF found adequate evidence that aspirin use in adults increases the risk for GI bleeding and hemorrhagic stroke. The USPSTF determined that the harms vary but are small in adults aged 59 years or younger and small to moderate in adults aged 60 to 69 years. The USPSTF found inadequate evidence to determine the harms of aspirin use in adults aged 70 years or older.

USPSTF ASSESSMENT

In adults aged 50 to 69 years who are at increased CVD risk, the benefits of aspirin use include prevention of MI and ischemic stroke and, with long-term use, reduced incidence of CRC. Aspirin use may also result in small to moderate harms, including GI bleeding and hemorrhagic stroke.

The USPSTF concludes that the evidence on aspirin use in adults younger than 50 years or older than 69 years is insufficient and the balance of benefits and harms cannot be determined.

PATIENT POPULATION UNDER CONSIDERATION

This recommendation applies to adults aged 40 years or older without known CVD (including history of MI or stroke) and without increased bleeding risk (for example, history of GI ulcers, recent bleeding, or use of medications that increase bleeding risk).

ASSESSMENT OF THE BALANCE OF BENEFITS AND HARMS

The magnitude of the health benefits of aspirin use depends on an individual's baseline CVD risk. The magnitude of harms depends on the presence of risk factors for bleeding.

Baseline CVD Risk: The magnitude of the cardiovascular risk reduction with aspirin use depends on an individual's initial risk for CVD events. Risk assessment for CVD should include ascertainment of the following risk factors: age, sex, race/ethnicity, total cholesterol level, high-density lipoprotein cholesterol level, systolic blood pressure, hypertension treatment, diabetes, and smoking.

GI and Intracranial Bleeding: Evidence shows that risk for GI bleeding, with and without aspirin use, increases with age. For this recommendation, the USPSTF considered older age and male sex to be important risk factors for GI bleeding.

Balance of Benefits and Harms: The USPSTF used a CVD microsimulation model to estimate cardiovascular event rates based on baseline risk factors and aspirin use. It used the AHA/ACC risk calculator to stratify findings of benefits and harms by 10-year CVD risk.

Overall, the USPSTF determined that the greatest net benefit to be gained is by adults aged 50 to 59 years whose 10-year CVD risk is 10% or greater. The USPSTF recommends that persons in this age and risk group start taking aspirin. Adults aged 60 to 69 years may also benefit from starting aspirin use, although the net benefit is smaller due to the increased risk for GI bleeding and decreased benefit in CRC prevention in this age group.

TREATMENT AND DOSAGE

The optimal dose of aspirin to prevent CVD events is not known. Primary prevention trials have demonstrated benefits with various regimens, including doses of 75 and 100 mg per day and 100 and 325 mg every other day. A dose of 75 mg per day seems as effective as higher doses. The risk for GI bleeding may increase with the dosage. A pragmatic approach consistent with the evidence is to prescribe 81 mg per day, which is the most commonly prescribed dose in the United States.

Although the optimal timing and frequency of discussions about aspirin therapy are unknown, a reasonable approach may be to assess CVD and bleeding risk factors starting at age 50 years and periodically thereafter, as well as when CVD and bleeding risk factors are first detected or change.

SUGGESTIONS FOR PRACTICE REGARDING THE I STATEMENTS

Potential Preventable Burden: Evidence from primary prevention trials on the benefits of initiating aspirin use in adults younger than 50 years is limited. The potential benefit is probably lower than in adults aged 50 to 69 years because the risk for CVD events is lower (only a small percentage of adults younger than 50 years have a 10-year CVD risk ≥ 10%). Adults younger than 50 years who have an increased 10-year CVD risk may gain significant benefit from aspirin use; how much benefit is uncertain.

Evidence on the benefits and harms of initiating aspirin use in older adults is limited. Many adults aged 70 years or older are at increased risk for CVD because of their age. They have a high incidence of MI and stroke; thus, the potential benefit of aspirin could be substantial.

Potential Harms: The relationship between older age and GI bleeding is well established; thus, the potential harms for adults older than 70 years are significant. The complexity of risk factors, medication use, and concomitant illness make it difficult to assess the balance of benefits and harms of initiating aspirin use in this age group. In addition, aspirin use in adults older than 70 years results in smaller reductions in the incidence of CRC compared with younger adults.

Current Practice: Nearly 40% of U.S. adults older than 50 years use aspirin for the primary or secondary prevention of CVD.5 A study of National Health and Nutrition Examination Survey data assessed how common aspirin use is for the primary prevention of CVD and whether physicians recommend it or patients start it on their own. Among patients who were eligible for aspirin therapy and were at increased CHD risk (> 10% 10-year risk), about 41% were told by a physician to take aspirin. Among patients aged 65 years or older who were told by a physician to take aspirin, 80% adhered to the recommendation.

USEFUL RESOURCES

The USPSTF has made other recommendations on CVD prevention, including smoking cessation and promoting a healthful diet and physical activity, as well as screening for carotid artery stenosis, CHD, high blood pressure, lipid disorders, obesity, diabetes, and peripheral artery disease.