https://immattersacp.org/weekly/archives/2019/03/26/1.htm

New guideline recommends low-dose aspirin for many fewer patients

Changes to the American College of Cardiology/American Heart Association guideline include no longer routinely giving low-dose aspirin for primary prevention to adults older than age 70 years or to younger patients who are not at high risk.


Low-dose aspirin should be considered for primary prevention only in adults with the highest risk for atherosclerotic cardiovascular disease (ASCVD) and lowest risk for bleeding, according to an updated guideline.

Low-dose aspirin (75 to 100 mg orally daily) might be considered for the primary prevention of ASCVD among select adults 40 to 70 years of age who are at higher ASCVD risk but not at increased bleeding risk, according to the 2019 American College of Cardiology/American Heart Association Guideline on the Primary Prevention of Cardiovascular Disease. It should not be routinely given for the primary prevention of ASCVD among adults older than age 70 years. Low-dose aspirin should not be administered for the primary prevention of ASCVD in adults of any age who are at increased risk of bleeding.

The guideline, which was published by the Journal of the American College of Cardiology and Circulation on March 17, also offered a top 10 list of messages for primary prevention of ASCVD, including promoting a healthy lifestyle and team-based care. An executive summary was also published in both journals (JACC) (Circulation).

Other recommendations include the following:

  • Adults who are 40 to 75 years of age and undergoing evaluation for cardiovascular disease prevention should have 10-year ASCVD risk estimation, then discuss with a physician before starting on antihypertensive therapy, a statin, or aspirin.
  • For diabetic adults, metformin is the first-line therapy, followed by a sodium-glucose cotransporter 2 inhibitor or a glucagon-like peptide-1 receptor agonist.
  • All adults should be assessed at every health care visit for tobacco use, and those who use tobacco should be strongly advised to quit and then helped to do so.
  • Statin therapy is first-line treatment for primary prevention of ASCVD in patients with elevated low-density LDL levels (≥190 mg/dL), those with diabetes who are 40 to 75 years of age, and those determined to be at sufficient ASCVD risk after a clinician-patient risk discussion.
  • Nonpharmacological interventions are recommended for all adults with elevated blood pressure or hypertension. For those requiring pharmacological therapy, the target blood pressure should generally be below 130/80 mm Hg.

An accompanying editorial in Circulation highlighted key aspects of the guideline.

“Each one of these guidelines provides a superb summary of evidence-based care, but for busy practitioners, the number of guidelines and updates can be overwhelming,” the editorial stated. “… Paramount is a patient-centered treatment paradigm that emphasizes team-based care, shared decision-making, and evaluation of social determinants of health.”