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Ideas and Opinions |4 December 2018

More Evidence to Help Guide Decision Making About Aspirin for Primary Prevention

Michael Pignone, MD, MPH; Darren A. DeWalt, MD, MPH

Article, Author, and Disclosure Information
Author, Article, and Disclosure Information
This article was published at Annals.org on 27 November 2018.
  • Dell Medical School, University of Texas, Austin, Texas (M.P.)
    University of North Carolina School of Medicine, Chapel Hill, North Carolina (D.A.D.)

    Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-2637.

    Corresponding Author: Michael Pignone, MD, MPH, Department of Internal Medicine, Dell Medical School, DMS Health Discovery Building, Room 7.70, 1701 Trinity Street, Stop Z0900, Austin, TX 78712; e-mail, pignone@austin.utexas.edu.

    Current Author Addresses: Dr. Pignone: Department of Internal Medicine, Dell Medical School, DMS Health Discovery Building, Room 7.70, 1701 Trinity Street, Stop Z0900, Austin, TX 78712.

    Dr. DeWalt: UNC Chapel Hill, 5045 Old Clinic Building, CB 7110, Chapel Hill, NC 27516.

    Author Contributions: Conception and design: M. Pignone, D.A. DeWalt.

    Analysis and interpretation of the data: M. Pignone, D.A. DeWalt.

    Drafting of the article: M. Pignone, D.A. DeWalt.

    Critical revision of the article for important intellectual content: M. Pignone, D.A. DeWalt.

    Final approval of the article: M. Pignone, D.A. DeWalt.

    Administrative, technical, or logistic support: M. Pignone.

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Defining the role of aspirin in patients with no history of cardiovascular events (primary prevention) is challenging. Aspirin can have important benefits, including preventing cardiovascular events (1) and possibly reducing the incidence and mortality of some types of cancer (2). However, it can also have important harms, including increasing risk for gastrointestinal bleeding and possibly intracerebral hemorrhage (3). In 2016, the U.S. Preventive Services Task Force examined the body of evidence through a series of systematic reviews and issued a moderate-strength (“B”) recommendation for use of aspirin in “adults aged 50 to 59 years who have a 10% or greater 10-year [cardiovascular disease] risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years” (4).
Despite a relatively large number of trials, interpreting the evidence about aspirin for prevention is difficult because the benefits and downsides are closely balanced. Decision analytic and cost-effectiveness modeling find that aspirin's net health benefit may be good (with the potential for lower total costs) in middle-aged adults at increased cardiovascular risk, especially if aspirin also has a modest or greater effect on cancer mortality (5, 6).
Beyond the challenges in weighing benefits and harms, several important questions remain about the quality of evidence (bias and error) and the possibility that aspirin may work differently in various patient groups (effect modification). Of note, several trials...
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Pignone M, DeWalt DA. More Evidence to Help Guide Decision Making About Aspirin for Primary Prevention. Ann Intern Med. [Epub ahead of print 27 November 2018]169:804–805. doi: 10.7326/M18-2637

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Published: Ann Intern Med. 2018;169(11):804-805.

DOI: 10.7326/M18-2637

Published at www.annals.org on 27 November 2018

©
2018 American College of Physicians
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