Please use the two patient cases below to answer the assessment question.
Patient 1
65-year-old African American male patient, non-smoker
PMH: hypertension, diabetes, chronic kidney disease, anemia
Medications: lisinopril 20 mg po daily, amlodipine 5 mg po daily, metformin 1000 mg po twice daily, canaglifozin 100 mg po daily, sevelamer 800 mg po three times daily
Vitals: BP: 126/78 mm Hg, P: 68 beats per minute, BMI 23 kg/m2
Labs: Creatinine 1.9 mg/dl (baseline), A1C: 6.5%, hemoglobin 10.7 g/dL, platelets 220k
Lipids (mg/dL): Total Cholesterol: 155, Triglycerides: 144, HDL-C: 39, LDL-C: 85
Patient 2
74-year-old white female patient, non-smoker
PMH: diabetes, hyperlipidemia, osteoarthritis
Medications: Glyburide 10 mg po daily, atorvastatin 20 mg po daily, ibuprofen 200 mg po three times daily
Vitals: BP 116/74 mm Hg, P: 72 beats per minute, BMI 27 kg/m2
Labs: Creatinine 1.1 mg/dl, A1c: 7.2%, hemoglobin 12.7 g/dL, platelets 195k
Lipids (mg/dL): Total Cholesterol: 155, Triglycerides: 88, HDL-C: 55, LDL-C: 82
The correct answer is: D. Neither patient 1 nor patient 2.
Previous ACC/AHA guidelines recommended aspirin for primary prevention in patients with an elevated ASCVD risk; however, recent primary prevention trials have shown less overall benefit for reducing CV events in this patient population. In these newer trials, aspirin for primary prevention has shown less benefit than previous trials in patients on contemporary ASCVD therapies such as statins and anti-hypertensive medications. The updated 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease provides a IIb (LOE A) recommendation that aspirin can be used for primary prevention in adults 40-70 years of age who are at higher ASCVD risk but not at an increased risk of bleeding. The guideline recommendations do not provide a specific ASCVD risk percentage or pooled-cohort equation threshold, but rather recommend evaluating the patient individually to look at comorbidities, ability to control risk factors (such as blood pressure, lipids and diabetes), family history of cardiovascular disease and/or coronary artery calcium scores. The updated guideline does not recommend routine aspirin use in patients over 70 years of age or in patients with risk factors for bleeding, such as kidney disease, previous history of bleeding, thrombocytopenia, coagulopathy and concurrent use of other medications that increase bleeding risk. Aspirin therapy for secondary prevention remains well established and widely recommended for this indication.
Patient 1 has an elevated ASCVD risk (27.7%), but his risk factors, such as blood pressure, blood sugar, lipids and non-smoking status, are well-controlled. Additionally, the patient would be at an elevated risk of bleeding with his chronic kidney disease and anemia (hemoglobin 10.7 g/dL). While this patient is at an increased risk of CV events, the new guidelines give a class III (harm) recommendation for using aspirin for primary prevention in any patient with risk factors for bleeding, of which multiple are present in patient 1.
Patient 2 is over 70 years old, and the risk of bleeding outweighs the primary prevention benefit in this population. Routine use of aspirin in these patients over 70 years is not recommended. There is insufficient evidence to recommend aspirin use in the population based on other ASCVD risk factors, such as the inability to achieve target glucose goals, which is seen in this patient. This patient also takes a non-steroidal anti-inflammatory drug (ibuprofen) for chronic osteoarthritis pain, which is a risk factor for bleeding.
References
- Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019. [Epub ahead of print]
- McNeil JJ, Wolfe R, Woods RL, et al. Effect of aspirin on cardiovascular events and bleeding in the healthy elderly. N Engl J Med 2018;379:1509-18.
- ASCEND Study Collaborative Group, Bowman L, Mafham M, et al. Effects of aspirin for primary prevention in persons with diabetes mellitus. N Engl J Med 2018;379:1529-39.
- Gaziano JM, Brotons C, Coppolecchia R, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet 2018;392:1036-46.
- Rothwell PM, Cook NR, Gaziano JM, et al. Effects of aspirin on risks of vascular events and cancer according to bodyweight and dose: analysis of individual patient data from randomised trials. Lancet 2018;392:387-99.
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