Clinical Question

Should primary care clinicians recommend low-dose aspirin for the primary prevention of cardiovascular disease (CVD) in adults 60 years or older?

Bottom Line

In this updated review, the U.S. Preventive Services Task Force (USPSTF) recommends against initiating low-dose aspirin (81 mg daily) for the primary prevention of CVD in adults 60 years or older (D recommendation). The USPSTF recommends shared decision-making regarding the initiation of low-dose aspirin for the primary prevention of CVD in adults 40 to 59 years of age with a 10% or greater risk of CVD and without an increased risk of bleeding (C recommendation). Risk factors for bleeding include older age, history of peptic ulcer disease, alcoholism, liver disease, long-term nonsteroidal anti-inflammatory drug or steroid use, and anticoagulant therapy. (Level of Evidence = 1a)

Synopsis

The USPSTF found adequate evidence that low-dose aspirin used for the primary prevention of CVD reduces the risk of major cardiovascular events. There is no high-quality evidence, however, that low-dose aspirin reduces the risk of cardiovascular mortality or all-cause mortality. Evidence remains uncertain for a benefit of reducing the risk of colorectal cancer. Potential harms include a significant risk of major bleeding events, with increasing risk proportional to increasing age. New recommendations (which replace the 2016 guidelines) include considering aspirin for high-risk individuals at 40 years of age instead of 50 and no longer recommending aspirin for primary prevention in adults 60 years or older. For patients already taking aspirin or choosing to start taking aspirin, the USPSTF recommends stopping aspirin at approximately 75 years of age. The American Heart Association recommends shared decision-making regarding the use of aspirin for the primary prevention of CVD in high-risk adults 40 to 70 years of age who do not have an increased risk of bleeding. A previous Top 20 POEM (https://www.aafp.org/pubs/afp/content/top-poems/2020.html) found that there was no net cardiovascular benefit and no effect on cancer incidence or mortality in four of the most recent large trials performed in an era of better cardiovascular risk factor management and screening for colorectal cancer.