The U.S. Preventive Services Task Force (USPSTF) on Tuesday finalized updated guidance advising against daily aspirin use to prevent an initial heart attack or stroke for certain populations—a reversal from the panel's 2016 recommendation.

Cheat sheets: Evidence-based medicine 101

Background

In 2016, USPSTF released a recommendation that patients over age 50, with a 10% or higher risk of cardiovascular disease in the next 10 years, should begin a daily regimen of low-dose aspirin—between 81 milligrams to 100 milligrams—to prevent heart disease, stroke, and colorectal cancer.

For individuals ages 60 to 69 years old, the 2016 guidelines recommended consulting with clinicians before starting a daily aspirin regimen, but said the decision to do so was, ultimately, an individual one.

However, two years ago, the American College of Cardiology (ACC)and American Heart Association (AHA) narrowed their recommendations, suggesting that aspirin should be prescribed more selectively to individuals ages 40 to 70 who have never had a heart attack or stroke. On aspirin, both organizations suggest following a "generally no, occasionally yes," guideline for primary prevention.

In October, USPSTF issued updated draft guidance that advised against the use of a low, daily dose of aspirin to prevent a first heart attack or stroke for certain populations—a reversal from the panel's 2016 recommendation.

USPSTF finalizes new daily aspirin recommendations

On Tuesday, USPSTF finalized the updated guidance, which was based on recent studies and analyses of the benefits and the risks of daily aspirin use.

According to a volunteer group of medical experts, adults 40 to 59 years of age who have a 10% higher risk of developing heart disease over a 10-year period, may have a "small net benefit," with a daily aspirin regimen.

For adults ages 60 and older who do not have cardiovascular disease or are not at high risk of developing it, USPSTF concluded there was "no benefit" to starting a daily aspirin regimen.

Notably, the guidelines do not apply to individuals who have already had a heart attack or stroke. In addition, the task force did not advise adults who are currently taking daily aspirin to stop the practice.

However, USPSTF did advise that patients should consider stopping a daily aspirin regimen around the age of 75 because of increased bleeding risk with age.

Commentary

In recent years, new evidence from several clinical trials has "cast doubt over the use of 'aspirin for all,'" said Carlos Santos-Gallego, a cardiologist at Mount Sinai Hospital.

According to John Wong, a physician at Tufts Medical Center and a member of USPSTF, whether a person chooses to take aspirin depends on their cardiovascular risk and should ultimately be decided with their doctor. While many people may take aspirin safely, it can potentially cause life-threatening bleeding in the stomach, intestines, and brain.

Since the panel's last guidance was released in 2016, the science has changed considerably. For instance, Salim Virani, a cardiologist at Baylor College of Medicine, noted that newer studies have not found a significant benefit with daily aspirin, in part because more people are taking other drugs, like statins.

"Aspirin's benefit has become marginal because we have these other therapies that reduce the risk of heart attacks or strokes, but the bleeding risk associated with aspirin therapy has persisted," Virani said.

Ultimately, to meet the 10% or greater risk threshold set by USPSTF, "you've got to have a lot of risk factors," said cardiologist Steven Nissen, chief academic officer of the Heart, Vascular & Thoracic Institute at the Cleveland Clinic. "Not very many people, even with these recommendations, are going to qualify."

For those wondering what to do about their current daily aspirin regimen, Demilade Adedinsewo, a cardiologist at the Mayo Clinic, said to simply ask their doctor. 

"This information should just basically make you have a conversation with your physician," Adedinsewo said. "This is not an all-blanket recommendation that everyone on aspirin should stop their aspirin." (Cueto, STAT News, 4/26; Aubrey/Stone, "Shots," NPR, 4/26)