The author of this article: Liu Meilin, Hu Mengliang, Department of Elderly Medicine, Peking University First Hospital
aspirin
Low-dose aspirin is the basic drug for the prevention and treatment of cardiovascular disease (CVD), and adverse reactions such as aspirin-related bleeding have also attracted widespread attention in recent years.
Low-dose aspirin is an essential agent for the prevention and treatment of cardiovascular disease (CVD). In recent years, adverse reactions such as aspirin-related bleeding have aroused widespread concern.
The U.S. Preventive Services Task Force (USPSTF) assessed the cardiovascular protective effects of aspirin for primary prevention of CVD and its impact on longevity through a latest systematic evidence review and decision analysis. In addition, the working group further assessed evidence for the incidence and mortality of colorectal cancer (CRC) in populations where aspirin is used for primary and secondary prevention of CVD.
The USPSTF included three new trials and three new cohort studies published since 2016, using a micro-simulation model to stratify by age, sex, and CVD risk, as well as bleeding risk assessments, the benefits and harms of aspirin for primary prevention of CVD and CRC.
Before the final version of the results is released, the relevant drafts and suggestions are now in the online consultation period. The team of Professor Liu Meilin of the Department of Aging of Peking University First Hospital interpreted the draft report for the first time and shared it with colleagues.
Professor Liu Meilin
Aspirin and longevity
The draft modelling report shows that the net benefit of low-dose aspirin, as measured by quality-adjusted life years (QALYs), varied by age, sex, and 10-year ASCVD risk level.
10 years of age 40 to 59 years of age ≥5% of men and women aged 60 to 69 years, 10 years of ≥ of men and women with a risk of 10 years of CVD may have a lifetime benefit from primary prevention with low-dose aspirin, and the net lifetime benefit after taking aspirin is 2.3 to 66.2 QALYs per 1000 people.
5% of men aged 40 to 49 years of age ≥ 10 years of CVD and 10% of women ≥, and 7.5% of men aged 50 to 59 years of age with a 10-year risk of CVD ≥ and 15% of women ≥ increased by 0.4 to 52.4 life years per 1000 people.
For men and women aged 60 to 69 years with a 10-year CVD risk ≥ 10%, there was a net benefit from QALYs and no longer life.
QALYs, on the other hand, do not have a net benefit or extend life expectancy for individuals aged 70 to 79 years.
Aspirin with
Primary prevention of cardiovascular disease
Aspirin benefits reported by the USPSTF include a reduction in nonfatal myocardial infarction and a nonfatal ischemic stroke, with hazards including an increase in nonfatal major gastrointestinal bleeding and intracranial hemorrhage.
There is substantial evidence that aspirin used for primary prevention of CVD reduces the risk of myocardial infarction and stroke, but does not reduce cardiovascular or all-cause mortality.
For adults aged ≥40 years without a history of CVD but at increased risk of CVD, low-dose aspirin had a small benefit in reducing the risk of cardiovascular events (nonfatal myocardial infarction and stroke), with an increased benefit with an increased risk of CVD over 10 years, with a greater lifetime benefit of aspirin when started at a young age.
The USPSTF believes that aspirin use in adults increases the risk of gastrointestinal bleeding, intracranial hemorrhage, and hemorrhagic stroke, increasing in the older population.
Low-dose aspirin for primary prevention of cardiovascular disease reduces the risk of nonfatal myocardial infarction and stroke in men and women aged 40 to 59 years with a 10-year risk of CVD ≥10%, with a potentially lifetime benefit increasing with a 10-year increased risk of CVD.
There was no significant reduction in the risk of aspirin CVD use in people aged 60 to 69 years.
Taking aspirin is not beneficial in 20% of patients aged 70 to 79 years with a 10-year risk of ASCVD ≤.
In a 2016 decision-making analysis, it was thought that aspirin increased non-fatal and fatal major gastrointestinal bleeding.
Update tips for 2021
Due to the very low number of fatal gastrointestinal haemorrhages observed in the aspirin primary prevention trial, a review of the updated systemic evidence cannot be directly assessed. The risk of gastrointestinal bleeding, intracranial hemorrhage, and hemorrhagic stroke increases with age, regardless of aspirin use.
The USPSTF report cautions that bleeding-related risk factors, including men, a history of diabetes and gastrointestinal disorders (e.g., peptic ulcer disease), liver disease, smoking, and high blood pressure, as well as the use of nonsteroidal anti-inflammatory drugs, steroids, and anticoagulants, should be considered when deciding whether to start or continue aspirin therapy.
Aspirin and colorectal cancer
The USPSTF report highlights the effects of aspirin on CRC morbidity or mortality with less research. There is also insufficient evidence on the effect of low-dose aspirin on CRC morbidity and mortality in CVD primary prevention trials.
The outcome of CRC incidence varies greatly depending on the timing of follow-up, with aspirin not affecting CRC incidence until 10 years after initiation, and several long-term studies suggest that aspirin administration for more than 10 years can reduce CRC incidence.
Due to the relatively low number of deaths from CRC in the study, the effect of aspirin on CRC mortality could not be accurately assessed. The benefit of aspirin for overall cancer incidence and mortality was not statistically significant.
2021 USPSTF Update Recommendations
The USPSTF recommends that aspirin should be preceded by a risk assessment and consideration of patient preferences, and that the benefits of starting aspirin are greater in individuals at higher> risk of CVD events (e.g., 15% or 20% > 10-year CVD risk).
The decision to start using aspirin should require a joint decision between the clinician and the patient after fully communicating the potential benefits and harms, and individuals who value the potential benefits may choose to start using low-dose aspirin.
In individuals who took aspirin, if no bleeding events occurred, the net benefit continued to increase over time. As the risk of bleeding increases with age and the net benefit decreases, modelling data suggest that discontinuation of aspirin may be reasonable around age 75 years.
UsPSTF decision analysis shows that in order to accurately estimate whether aspirin is used for primary prevention of CVD, especially in the context of decreased smoking prevalence, increased statin use, and more aggressive management of hypertension, there is a need to establish more precise, more personalized, real-world estimation models (e.g., age, sex, race/ethnicity, economy, comorbidities) to determine whether primary aspirin prevention has different benefits or harms in a particular population.
In addition, future research should also focus on further exploring the effects of aspirin on the incidence of CRC and the risk of death, and establish a comprehensive risk assessment model.
Table 2021 USPSTF Update Recommendations
(Click to view a larger image)
The 2021 recommendation will replace the 2016 USPSTF recommendation on the use of aspirin for the prevention of CVD and CRC.
The 2016 USPSTF recommends that adults aged 50 to 59 years and 60 to 69 years ≥ 10 years of CVD, no increased risk of bleeding, a life expectancy of at least 10 years, and adults willing to take low-dose aspirin daily for at least 10 years should start using low-dose aspirin.
Evidence prior to 2016 is insufficient to assess the pros and cons of primary prevention of CVD and CRC in adults under 50 years of age or adults aged 70 years and older with aspirin.
The 2021 USPSTF changes its recommended age range and grade for aspirin use.
Recommends that adults aged 40 to 59 years with a 10-year risk of ≥ CVD should decide whether to start low-dose aspirin for primary prevention of CVD, depending on individual circumstances;
Initiation of low-dose aspirin for primary prevention of CVD ≥ adults aged 60 years is not recommended.
Based on an analysis of new evidence in populations for primary prevention of CVD, as well as long-term follow-up data from the Women's Health Study (WHS) and new trial evidence, the USPSTF considers low-dose aspirin to reduce CRC morbidity or mortality.
In summary
Although the risk of CVD increases with age, the risk of gastrointestinal bleeding, intracranial hemorrhage, and hemorrhagic stroke also increases with age.
Given the increased risk of bleeding from aspirin use in older populations, a variety of risk factors and net benefits should be taken into account when deciding whether to start or continue aspirin therapy.
The USPSTF considers aspirin not to be used for primary prevention in people with unclear net benefit and a high risk of bleeding.
References: https://www.uspreventiveservicestaskforce.org/uspstf/announcements/public-comment-draft-recommendation-statement-draft-evidence-review-and-draft-modeling-report-aspirin-use-prevent-cardiovascular
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