Aspirin in the primary prevention of atherosclerosis: the skin of grief continues to shrink

Louis Meunier, Institute for Clinical Research, Montpellier

Despite significant advances represented by the use of high-potency statins and newer antiplatelet or anticoagulant therapies, low-dose aspirin remains an effective treatment for secondary prevention of cardiovascular disease and events (20% relative risk reduction). On the other hand, prescribing aspirin in primary prevention in people who have never had a cardiovascular accident has been a topic of debate for several years.

Thus, the recommendations of the USPSTF (US Preventive Services Task Force) in 2016 have already formulated a certain number of reservations regarding prescribing aspirin in primary prevention. Most striking were the following: lack of efficacy in subjects younger than 50 years of age or those aged 70 years or younger; Prescription is recommended between 50 and 59 years in people with a 10% risk of vascular accident in the next 10 years, with a life expectancy of at least 10 years and no risk of bleeding; Prescription is selective between 60 and 69 years old and is reserved for properly selected subjects. These recommendations, published in 2016, were based on a systematic review of 11 major clinical trials for primary prevention with doses of aspirin generally 100 mg/day. However, these trials were conducted at a time when control of plasma lipids and blood pressure was far from optimal and when tobacco consumption was widespread. It was therefore necessary in 2022 to update these recommendations. This was achieved by extending the analysis to 13 preventive trials, ie 161,680 subjects, with the idea of ​​​​a better assessment of the benefit/risk ratio of aspirin therapy. The most interesting results are obtained through the micro-simulation model produced from the experiments included in the systematic analysis. Benefits were judged on the basis of gains (or losses?) in life expectancy (expressed in years of life gained or [perdues ?] per 1,000 people) and on gains in good life expectancy, also expressed in net years gained with a good quality of life. The results were then reported by sex and age group according to whether aspirin therapy was started between 40-49 years, 50-59 years, 60-69 years, and 70-79 years. The results can be summarized as follows (table): • Aspirin use in men and women in the age group 40 to 59 years with a risk of cardiovascular disease 10% at maturity by 10 years extends life expectancy but nonetheless remains Very humble. Since results are expressed in years gained per 1,000 people, we converted at least two of them into patient days to make them more readable. Thus, for men aged 40-49 years, who have a 20% risk of developing cardiovascular disease in the next 10 years, the increase in life expectancy after initiation of aspirin therapy is only 19 days. For women ages 40 to 49, with a stroke risk equal to at least 10% in the next 10 years, that same gain is just 4 days. Gains in quality of life over years (earned?) or rather days gained are of the same magnitude. It must be thought that the authors of the article did not dare to turn 1000 sick years into sick days so as not to show so clearly the great humility of the results. • In the 60 to 69 age group, results have been conflicting, ranging from again very modest gains in quality or extension of life expectancy to a decrease depending on the level of risk when aspirin is started. In this age group, for the same life expectancy, the loss is observed in all cases even if it is very modest (on average 1-2 days per patient). • Finally, after the age of 70, a decrease in life expectancy is observed in terms of duration and quality of life, even if it remains very modest (a few days at most). • When considering the risk of bleeding, it increases under aspirin therapy, both with regard to gastrointestinal bleeding (+58%) and cerebral hemorrhage (+31%). Bleeding events usually occur soon after starting aspirin therapy. Insofar as the risk of bleeding doubles for every 10 years of age over 60 years of age, and to the extent that aspirin offers no benefit in terms of primary prevention at the cardiovascular level, it is quite certain that advanced age is a contraindication to initiating aspirin therapy. Brief table of the effect of aspirin in the primary prevention of cardiovascular disease. Gains or losses in life expectancy are very small in all cases, even when considered statistically significant. For example, the longest gain in life expectancy was 19 days, observed in men aged 40–49 years with a 20% risk of having a cardiovascular event in the next 10 years. GENERAL CONCLUSION The USPSTF 2022 recommendations are made in light of these very simple observations: • In people aged 40 to 59, aspirin can only be used for primary prevention in people at 10% risk of cardiovascular disease by age 10 Years . However, the advisability of starting this type of treatment is up to the discretion of the attending physician. However, this treatment is not recommended for people at risk of bleeding. • In persons 60 years of age or older, aspirin therapy should not be started as part of primary prevention. Ultimately, these 2022 recommendations are more restrictive than the 2016 recommendations; They leave little room for the use of aspirin in primary prevention. The USPSTF specifies that the decision to use aspirin in primary prevention should always be left to the discretion of health care professionals. Additionally, the Harvard University authors who wrote the editorial after the USPSTF study note that aspirin is still often used inappropriately in primary prevention. Posted by Practical Diabetology

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