November 8, 2021.
We are writing to express our views on the U.S. Preventive Services Task Force’s (USPSTF) draft recommendation statement regarding low-dose aspirin use to prevent cardiovascular disease (CVD).
The National Center for Health Research (NCHR) is a nonprofit think tank that conducts, analyzes, and scrutinizes research on a range of health issues, with particular focus on which prevention strategies and treatments are most effective for which patients and consumers. We do not accept funding from companies that make products that are the subject of our work, so we have no conflicts of interest.
Based on the data, we strongly support the “C” grade recommendation for patients 40 to 59 years old with a 10% or more risk of developing CVD, as well as the “D” grade recommendation for patients 60 and older.
However, given that a “C” grade recommendation involves individual patient decisions, we urge the USPSTF to clearly note the various risk factors in their recommendation statement, in order to aid in patient decision-making. Although there is no clinical standard for calculating the risk of bleeding in patients taking low-dose aspirin, research has identified groups of patients with an increased risk: older age; male sex; diabetes patients; or history of GI issues, liver disease, alcohol disease, or peptic ulcer disease. Research has also noted that the risks for bleeding increase for patients taking antiplatelets, NSAIDs, steroids, and anticoagulants. The USPSTF has highlighted these risks, and we urge that these risk factors be made more prominent in the final draft of the recommendation for patients 40-59, such as adding a link to specific risk factors in the text box, since that would aid in individual patient decision-making. We also encourage the addition of information for patients who decide to start a low-dose regimen, such as noting the time-scale and adherence necessary, as well as the potential risks associated with discontinuation.
We urge the USPSTF to include a recommendation for those already taking low-dose aspirin, especially for the substantial number of adults who take daily low-dose aspirin without discussing it with a physician. Patients already taking aspirin, whether or not it has recently been discussed with their doctor, would benefit from knowing the risks of discontinuation. Research has found that, for long-term aspirin users, discontinuation may be associated with an increased risk of cardiovascular events.[2-5] The USPSTF should provide guidelines for safe tapering of use for those who are advised or who choose to do so. Given the large number of consumers who use daily aspirin in an effort to reduce CVD, we strongly encourage that the final recommendation statement provide clear advice for those already taking daily low-dose aspirin.
The National Center for Health Research can be reached at email@example.com or at (202) 223-4000.
- Guirguis-Blake JM, Evans CV, Perdue LA, Bean SI, Senger CA. Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: An Evidence Update for the U.S. Preventive Services Task Force. Evidence Synthesis No. 211. Rockville, MD: Agency for Healthcare Research and Quality; 2021. AHRQ publication no. 21-05283-EF-1.
- Baigent C, Blackwell L, Collins R, et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009;373:1849-60.
- De Berardis G, Lucisano G, D’Ettorre A, et al. Association of aspirin use with major bleeding in patients with and without diabetes. JAMA. 2012;307:2286-94.
- Selak V, Jackson R, Poppe K, et al. Predicting bleeding risk to guide aspirin use for the primary prevention of cardiovascular disease: a cohort study. Annals of Internal Medicine. 2019;170(6):357-368.
- de Groot NL, Hagenaars MP, Smeets HM, et al. Primary non-variceal upper gastrointestinal bleeding in NSAID and low-dose aspirin users: development and validation of risk scores for either medication in two large Dutch cohorts. Journal of Gastroenterology. 2014;49(2):245-253.