Aspirin for Primary Prevention: What’s a Clinician to Do?

Abstract

T he United States Preventive Services Task Force(USPSTF) 2009 recommendations regarding the use of aspirin for primary prevention of cardiovascular disease (CVD) were intended to provide concise evidence-based management strategies. 1 They endorsed the use of aspirin for primary prevention of myocardial infarction in men and for primary prevention of stroke in women when the benefits outweighed the potential harms. However, these guidelines were rapidly undermined by additional data, new reviews of previous trials, conflicting conclusions even among concurrent analyses, and varying thresholds for aspirin therapy among guidelines, professional societies, and other authoritative bodies. 2 In this issue of JGIM, Fiscella and colleagues reveal that, based on patient report, the USPSTF recommendations are followed in relatively few patients. 3 The authors analyzed National Health and Nutrition Examination Survey (NHANES) data from 2011 to 2012, 2 years after publication of the guidelines. Men between the ages of 45 and 79 years and women between 55 and 79 years, none of whom had known CVD, were included. To determine whether aspirin was merited by the published risk cutoffs, their 10-year risk for CVD was calculated based on Framingham equations, as the USPSTF intended. 1 Among those deemed eligible for aspirin therapy, only 34 % of men and 42 % of women reported that their physicians advised them to take it. 3 In contrast, 76 % of participants eligible for secondary prevention of CVD reported a physician recommendation for aspirin. Conversely, 24 % of men and 28 % of women who were not eligible for aspirin reported a physician recommendation to take it. USPSTF guidelinebased aspirin eligibility did not predict aspirin recommendation in multivariable logistic regression. Positive associations with older age, comorbidities such as diabetes mellitus, and access to healthcare suggest that traditional risk factors were employed for decision making, rather than the calculations and cutoffs recommended by the USPSTF.The study is limited, most notably by relying on self-report, and by the fact that the authors did not have access to whether