Opining the Slow Demise of Aspirin for Cardiovascular Disease

Volume 14, Issue 4

Aspirin, once heralded as a wonder drug for reducing the risk of cardiovascular disease (CVD), has seen a steady erosion in status as a cornerstone CVD therapy for over a decade.

Perhaps one of the final nails in the coffin was hammered this week when the US Preventive Services Task Force (USPSTF) published its latest document recommending against aspirin use for most patients for the purpose of preventing CVD.

These guidelines, which more closely match those published by the American College of Cardiology/American Heart Association, suggest aspirin could be considered for adults aged 40-59 years who have a 10% ten-year risk of developing CVD. These new guidelines recommend against starting aspirin for primary prevention in patients aged 60 years or older. They go on to suggest considering stopping aspirin at age 75 in patients who choose to start when younger.

The attenuated benefit for aspirin in the contemporary era is likely the result of more effective therapies coming to market for common diseases that lead to CVD. Widespread use of statins for primary prevention, lower rates of smoking in the United States, more aggressive blood pressure guidelines, and new agents for diabetes have all likely contributed.

The movement against using aspirin for primary prevention is mirrored in other disease states where aspirin was once considered sacrosanct. Aspirin should still be used immediately when acute coronary syndrome or myocardial infarction is suspected, and it is still considered an essential component of dual antiplatelet therapy (DAPT).

However, the duration of use for this once considered life-long drug therapy continues to shorten. In patients who require blood thinners for atrial fibrillation as well as DAPT, the duration of aspirin use can be shorted to as little as 1 month.

Similarly, in the left ventricular assist device (LVAD) arena, aspirin use was empiric, and many patients with LVADs still take aspirin despite the growing evidence that it adds little benefit and increases the risk of bleeding. There is currently a large, randomized trial underway which will most likely show no benefit and hopefully end the widespread use of aspirin in patients with LVADs.

So, where will aspirin still be used? As noted above, patients suffering from acute coronary syndrome or acute myocardial infarction should still be treated with aspirin as part of DAPT for a period, usually 12 months, unless the patient is also on a blood thinner for atrial fibrillation. Heart transplant recipients should also still receive daily low-dose aspirin, given limited data shows lower rates of chronic rejection with the use of this agent.