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Thursday, January 17, 2019

Whether Aspirin or Statin in Primary Prevention or Cardiovascular Disease (CVD

Posted by Dr Prahallad Panda on 8:16 PM Comments

Aspirin, chemically acetylsalicylic acid, has been a trusted pal of health-care providers for more than 100 years by now. Many beneficial effects, including benefits in certain heart diseases & colo-rectal cancer, came to light in the recent past, adding many feathers to its’ cap.
Aspirin has been a staple of primary prevention of cardiovascular disease (CVD) in at-risk populations based on recommendations by major organizations including the American Heart Association (AHA) together with the American College of Cardiology (ACC), US Preventive Services Task Force (USPSTF) and others. Accordingly, aspirin became one of the most commonly used medications for primary prevention of CVD, and it is estimated that 40% of US adults over 50 years of age use aspirin for this purpose.
The AHA Prevention Guidelines published in 1997 did not recommend aspirin use for primary prevention, citing the need for additional research. Major primary prevention studies completed from 1988 to 2001, including the British Doctors Study (BDS), US Physicians' Health Study (PHS), Thrombosis Prevention Trial (TPT), Hypertension Optimal Treatment (HOT) and low-dose aspirin trial of the Primary Prevention Project (PPP) trials, led the USPSTF and AHA to adopt recommendations for aspirin (75-100 mg/day, or 325 mg every other day) for primary prevention in 2002, particularly for high-risk individuals (5-year CVD risk ≥3%).
However, more recent studies did not demonstrate clear benefit of aspirin, including the Prevention of Progression of Arterial Disease and Diabetes (POPADAD), Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes (JPAD), Aspirin for Asymptomatic Atherosclerosis (AAA) and Japanese Primary Prevention Project (JPPP). In 2016, the USPSTF Guidelines were pared back, recommending aspirin for CVD and colorectal cancer prevention in adults aged 50 to 59 with a 10-year ASCVD risk of at least 10% without increased risk of bleeding and with life expectancy of at least 10 years (Grade B). Aspirin use in adults aged 60 to 69 who have the same risk requires an individualized approach based on a weaker recommendation (Grade C).
The recent contribution of the ARRIVE (Aspirin to Reduce Risk of Initial Vascular Events) , ASCEND (A Study of Cardiovascular Events in Diabetes) and ASPREE (Aspirin in Reducing Events in the Elderly) trials provides useful insight into the role of aspirin use for primary prevention in the modern era, when there is decrease in smoking, better control of cholesterol, lifestyle modification & increased use of statins.
It can be concluded that for primary prevention, in which risk is determined largely by age and the presence or absence of diabetes, the benefit–risk ratio for prophylactic aspirin in current practice is exceptionally small.
In contrast, for secondary prevention, in which risk is determined largely by the extent of atherosclerotic disease, the benefits of aspirin outweigh the risks of bleeding. Visit the NEJM here.
Therefore, beyond diet maintenance, exercise, and smoking cessation, the best strategy for the primary prevention of cardiovascular disease may simply be to replace aspirin with a statin.
Its’ use can be narrowed to the highest-risk populations, including individuals aged 40 to 70 years old without diabetes with 10-year ASCVD ≥20% or patients with diabetes with ASCVD ≥10%, provided they are not at high-risk of bleeding.See the ACC recommendation. 

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