Most aspirin use in middle-aged adults may be unnecessary under new assessment

Rochester General Hospital, the University of Texas Southwestern Medical Center, and Aga Khan University report that applying newer cardiovascular risk equations could sharply reduce the number of middle-aged adults considered candidates for aspirin to prevent heart disease.

Cardiologists and public health specialists weigh the balance between aspirin's potential benefit in lowering cardiovascular events and its known risk of major bleeding. Guidelines from the US Preventive Services Task Force recommend considering aspirin for adults aged 40 to 59 years who are not at high bleeding risk and have an estimated 10-year cardiovascular risk of at least 10%, as calculated with pooled cohort equations.

Investigators have developed the Predicting Risk of Cardiovascular Disease EVENTs (PREVENT) equations, which generate lower and better calibrated risk estimates than pooled cohort equations, but the implications for aspirin use have not been examined.

In the Research Letter, "Using the PREVENT Equations to Guide Aspirin Use for Primary Prevention of Cardiovascular Disease," published in JAMA Internal Medicine, researchers analyzed whether applying PREVENT alters eligibility for aspirin.

The team used 2015 to 2020 data from 3,158 participants in the National Health and Nutrition Examination Survey, representing an estimated 59.4 million US adults aged 40 to 59 years without cardiovascular disease.

Respondents with conditions associated with bleeding risk were excluded, such as severe kidney disease, elevated urine albumin, low platelet count, cancer, heart failure, or use of certain medications (steroids, antiplatelets, anticoagulants).

Eligibility was assessed by calculating 10-year cardiovascular risk using both pooled cohort equations and PREVENT.

Aspirin candidacy was defined as a risk of 10% or greater. Researchers also reported the proportion of adults already taking aspirin despite the calculated risk falling below this threshold.

Results showed that 8.3% of middle-aged adults, or about 4.9 million, qualified for aspirin under pooled cohort equations. Only 1.2%, or about 700,000, qualified under PREVENT. Among those meeting pooled cohort criteria, 85.9% did not meet the threshold with PREVENT. Of the estimated 7.6 million adults who reported aspirin use for prevention, nearly 97% did not meet PREVENT's eligibility threshold.

Authors conclude that PREVENT's adoption raises urgent questions about whether the same 10% cutoff applied to older calculators should be used. Establishing PREVENT-specific thresholds will likely require dedicated modeling studies to determine the net benefit of aspirin.

Researchers note that most adults self-reporting aspirin use during the study period did not meet the criteria by either calculator, pointing to a substantial opportunity to discontinue therapy where benefit is unlikely.

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