Update on Aspirin: Recommendations, Depression, and Nonobstructive Coronary Artery Disease

Aspirin (ASA) is commonly employed for its antiplatelet, analgesic, and antipyretic effects. The benefit of ASA for secondary cardiovascular disease prevention has been well established but has recently come under review with recommendation for changes.

Depression is one of the most important causes of poor quality of life, especially in older adults. Could ASA be beneficial or detrimental later in life? Finally, in nonobstructive coronary artery disease (CAD), what is the role of ASA to reduce major cardiovascular events?

The United States Preventive Services Task Force (USPSTF) recently released a final recommendation set of statements on the use of ASA to prevent cardiovascular disease.¹ For persons between 40-59 years of age with ≥ 10% 10-year risk of cardiovascular disease but without cardiovascular disease, the recommendation is a Grade C, meaning selective provision of ASA to individuals based on professional judgment and patient preferences in individuals not already taking ASA. The USPSTF considers ASA to have a small benefit in these persons.

For persons at least 60 years of age, the USPSTF recommends against starting ASA for cardiovascular secondary prevention (Grade D). The dose recommendation is 81 mg, independent of person’s body mass index. The one-size-fits-all recommendation has come under scrutiny and is under investigation.^2-3 

Depression is a leading cause of disability, as it is associated with multiple comorbidities and impairs the person affected, especially older adults.⁴ In a review of published meta-analyses and systematic reviews, 25 publications of relatively low quality, 2 meta-analyses, and 3 qualitative systematic reviews indicated sleep disturbances, hearing problems, poor vision, and cardiac disease were associated with depression in individuals over 80 years of age who received ASA. The review involved 1,199,927 participants.⁵

The association of ASA with these factors for depression may be more attributable to the agent’s use in an octogenarian than the drug itself. This study should not cause a clinician to recommend discontinuing the drug in persons who are tolerating ASA.

Aspirin and statin use were analyzed in a cohort study of 6386 participants who underwent CT angiography in the Coronary CT Angiography Evaluation for Clinical Outcomes (CONFIRM) Registry. In patients without discernible plaque or with nonobstructive CAD, the baseline use of a statin, but not aspirin, was associated with improved clinical morbidity and mortality outcomes.⁶ However, neither therapy improved clinical outcomes in participants with no detectable plaque.

We have all grown up learning that aspirin was a stronghold of cardiovascular drug therapy. These guidelines and studies suggest that paradigm is changing. However, before ASA is discarded, we probably need to understand whether dosing is important to the outcomes of this historical drug.

References:

1. US Preventive Services Task Force. Aspirin use to prevent cardiovascular disease: US Preventive Services Task Force recommendation statement. JAMA. 2022;327(16):1577-1584. doi:10.1001/jama.2022.4983
2. Baigent C, Blackwell L, Collins R, et al. Aspirin in the primary and secondary prevention of vascular disease: Collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009;373(9678):1849-1860. doi:10.1016/S0140-6736(09)60503-1 
3. Rothwell PM, Cook NR, Gaziano JM, et al. Effects of aspirin on risks of vascular events and cancer according to bodyweight and dose: analysis of individual patient data from randomised trials. Lancet. 2018;392(10145):387-399. doi:10.1016/S0140-6736(18)3133-4
4. Alexopoulos GS. Depression in the elderly. Lancet. 2005;365(9475):1961-1970. doi:10.1016/S0140-6736(05)66665-2
5. Wu Q, Feng J, Pan CW. Risk factors for depression in the elderly: An umbrella review of published meta-analyses and systematic reviews. J Affect Disord. 2022:307:37-45. doi:10.1016.j.jad.2022.03.062
6. Indraratna P, Naoum C, Zekry SB, et al. Aspirin and statin therapy for nonobstructive coronary artery disease: Five-year outcomes from the CONFIRM registry. Radiol Cardiothorac Imaging. 2022:4(2):e210225. doi:10.1148/ryct.210225