Stop taking aspirin for primary prevention, task force says

By Judith Garber | October 14, 2021

Editor’s Note: On April 26, 2022, the US Preventive Services Task Force released their recommendation statement on aspirin for primary prevention. For adults age 40 to 59 years with a 10% or greater 10-year risk of cardiovascular disease, the USPSTF recommends that initiating aspirin for primary prevention be an individual decision made between patients and clinicians, giving this a “C” rating. For adults 60 and older, the USPSTF recommends against initiating low-dose aspirin use for the primary prevention of cardiovascular disease, giving this a “D” rating.

Does an aspirin a day keep the doctor away? It used to be the conventional wisdom that taking low-dose aspirin helped prevent a first heart attack or stroke. In fact, so many believe it is safe and effective that an estimated 6.6 million adults without heart disease take aspirin without a doctor’s recommendation. However, research over the past few years shows that that the evidence isn’t there to back up this practice.

A June 2020 review of published research on the topic (including three randomized trials published in 2019) found that taking aspirin reduced the relative risk of a serious cardiovascular event by 17%, but increased the risk of major gastrointestinal bleeding increased by 47% and brain bleeds by 34%. The absolute risk reduction for serious cardiovascular events was the same as the absolute risk increase in major bleeding (0.4%). This means that out of 1000 people taking aspirin for five years, four would avoid a serious heart attack but four others would experience major bleeding.

This new evidence got the attention of specialty societies. In early 2019, the American College of Cardiology and American Heart Association recommended that older adults not at high risk of heart attack or stroke refrain from taking daily aspirin.

Now, the US Preventive Task Force (USPSTF) has reversed their recommendation on the issue as well, in a draft guidance released this week. The USPSTF is an independent panel that issues recommendations on preventive services; their recommendations can impact what preventive services insurers will cover.

The new recommendation is as follows: For adults age 40-59 with a 10% or greater risk of heart disease, they do not recommend universal use of daily aspirin, instead suggesting that this be an individual decision made between patients and clinicians. For adults over 60, the USPSTF recommends against initiating low-dose aspirin to prevent a first heart attack or stroke, because the risk of bleeding is greater for older adults. For adults who have already had a heart attack or stroke, the USPSTF’s recommendation does not change. The proposed guideline change was met with approval by experts in the field, although some pointed out that this change should have come sooner.

One of the goals of the recommendation change is to encourage people without heart disease to rethink aspirin as a preventive measure. “[We want] to get people to talk with their clinicians instead of just buying a bottle off the shelf and saying, ‘I should be on aspirin,'” said USPSTF task force member Dr. Chien-Wen Tseng, in The Washington Post.

To eliminate medication overload, serious cultural, educational, and policy changes are needed. This action plan offers recommendations for policymakers, health care institutions, clinicians, and patients across five key categories to reduce harm from multiple medication use. Suggested Citation: Eliminating medication overload: A national action plan. Working Group on Medication Overload. Brookline, MA: The Lown Institute, 2020. DOI: https://doi.org/10.46241/LI.YLBW4885

Pharmaceutical marketing is a significant factor in the growing public health crisis of medication overload, which puts millions of older adults at risk of preventable harm and premature death. This issue brief provides recommendations to reduce pharmaceutical industry influence by limiting pharma sales rep visits to clinicians and direct-to-consumer advertising.

This issue brief provides recommendations for clinical practice guidelines and electronic health records that would give clinicians the information they need to appropriately prescribe and deprescribe.