Who Should Take Aspirin in Primary Prevention

Dr.Mohammed Al-Kebsi

Cardiac Center Educational Activity

Al-Thawra Teaching Hospital
Thursday, 16/02/2017
 Agenda

Define who is at moderate or high risk for CV events.

Review the last trials of Aspirin Use to Prevent CVDs.
Review the Final Recommendation Statement on
Aspirin Use to Prevent CVDs.
Discuss the harms and benefit of aspirin use.

The evidence does not support the "general" use

of Aspirin

Insufficient evidence to support use of ASA for primary prevention

Risk of bleeding CVD protection

first, do no harm
 50% of U.S. adults reported regular aspirin use. Among those
with a primary prevention indication, having discussed aspirin
with a provider was the strongest predictor of regular use.

84% said they used aspirin for heart attack prevention.

66% for stroke prevention
18% for cancer prevention

11% for prevention of Alzheimers disease

Most of the patients used aspirin as a result of a discussion with

a physician.

Cardiology practice

My doctor told me it would be okay.

I take it to help my heart.
Im not sure. I just thought it would be a good idea.
It makes my blood thinner circulate easily
An Aspirin a Day ... or Not?
In patients who are at high risk because they already
have occlusive vascular disease, long-term antiplatelet
therapy (eg, with aspirin) reduces the yearly risk of
serious vascular events (non-fatal myocardial infarction,
non-fatal stroke, or vascular death)
Against this benefi t, the
absolute increase in major gastrointestinal or other
major extracranial bleeds is an order of magnitude
smaller. Hence, for secondary prevention, the benefi ts
of antiplatelet therapy substantially exceed the risks.
 Coronary Heart Disease Risk Continuum
Three risk groups can be identified with a global risk
score: low, moderate, high

Low Risk Moderate Risk High Risk

(Per 1000 patients treated for 10
# of MIs Prevented

years)

10% 20%
10% 20%
20%
Risk of MI or CHD Death (10 year)

Benefits of intervention accrue to those at greatest

underlying risk
(Per 1000 patients treated for

Low Risk Moderate Risk High Risk

# of MIs Prevented

10 years)

10% 20%

10% 20%
20%
Risk of MI or CHD Death (10 year)
 Adverse event rate remains constant across underlying
risk strata

ASA should be indicated for all populations where benefits

outweigh the risks (including moderate risk)
Framingham ScorinRisk g:

Assessing CHD Risk in Men

Assessing CHD Risk in women
What about asp. In primary prevention

For primary prevention, the balance between the risk and

benefit caused by aspirin is substantially uncertain.

We need updated evidence for the efficacy and safety of low-

dose aspirin in primary prevention

What the trials says?

Serious vascular events in primary intervention Trials

What About ASA for 1 Prevention in diabetes?

Included: Six studies, n = 10,117 participants

De Berardis G et al. BMJ 2009;339:b4531

What About ASA for 1 Prevention in diabetes?

What About ASA for 1 Prevention in diabetes?

Aspirin for Diabetes (JPAD) Trial

JPAD supports the safety of using

low-dose aspirin in diabetics for primary prevention
What About ASA for 1 Prevention in diabetes?

Ongoing Trials
Ongoing Trials

Are we happy with the trials results?

Things are still somewhat confusing

This time we need updated guidelines for the efficacy and
safety of low-dose aspirin in primary prevention.

What the Guidelines says

ACCP 2012:
ages 50 and older without symptomatic (CVD) (2B)

CCA 2011:
Not recommended for routine use
May consider only in special circumstances where CHD
risk is high and bleeding risk is low
 ESC 2012:
Not recommended in patients without overt evidence of
cardiovascular or cerebrovascular disease

AHA 2011:

Routine use in healthy women under age 65 is not

recommended

Can be useful in women ages 65 and older if BP is

controlled and benefit outweighs risk of GI bleeding or
hemorrhagic stroke.

May be reasonable in women under age 65 for prevention

of ischemic stroke.

ADA 2015:

In those with diabetes at increased cardiovascular risk (10-

year risk >10%)
Includes most men >50 years of age or women >60 years of age
who have at least one additional major risk factor .

Aspirin is not recommended for primary prevention in low

risk patient
men <50 and women <60 years of age with no major additional
CVD risk factors (since potential adverse effects from bleeding
likely offset potential benefits)
 What the Guidelines says :

SOOOO CONCLUSION?
THE DATA ARE MIXED

BUT ONE MESSAGE IS CLEAR Based on the current available

evidence
 Take home message

The FDA recently issued a Consumer Update that does not

support aspirin for primary prevention and warns patients
about the risk of serious bleeding complications.
Current guidelines and trials for aspirin in differ from one
another, making it challenging for clinicians to determine
which patients would benefit.

One message is clear in the most current clinical guidelines,

that routine use of aspirin for primary prevention is not
recommended (esp. under age of 50).

Several ongoing trials may resolve this important clinical

dilemma.

What the Guidelines says:

The FDA recently issued a Consumer Update that does not

support aspirin for primary prevention and warns patients
about the risk of serious bleeding complications.

Current guidelines and trials for aspirin in differ from one

another, making it challenging for clinicians to determine
which patients would benefit.
 One message is clear in the most current clinical guidelines,
that routine use of aspirin for primary prevention is not
recommended (esp. under age of 50).

Several ongoing trials may resolve this important clinical

dilemma.

The FDA recently issued a Consumer Update that does not

support aspirin for primary prevention and warns patients
about the risk of serious bleeding complications.

Current guidelines and trials for aspirin in differ from one

another, making it challenging for clinicians to determine
which patients would benefit.

One message is clear in the most current clinical guidelines,

that routine use of aspirin for primary prevention is not
recommended (esp. under age of 50).

Several ongoing trials may resolve this important clinical

dilemma.

10-year risk of a heart attack of 15% is considered moderate,

while a 25% risk is considered high.

If our advice is to be followed, it will need to be a shared

decision made by both the patient and the doc

THANK YOU.