High Rate of Inappropriate Use of Aspirin for Primary Prevention — Physician’s First Watch

Medical News |
January 13, 2015

High Rate of Inappropriate Use of Aspirin for Primary Prevention

By Larry Husten

Edited by Jaye Elizabeth Hefner, MD

A significant number of people are receiving aspirin inappropriately for primary prevention of cardiovascular disease, a Journal of the American College of Cardiology study finds. Although once broadly recommended, aspirin for primary prevention is now advised only for people who have a moderate-to-high 10-year risk (6% or greater).

Using registry data from nearly 70,000 primary prevention patients receiving aspirin, researchers calculated that 11.6% had a 10-year risk below 6%. Women were more likely than men to receive aspirin inappropriately. Inappropriate use varied significantly among practices, ranging from 7.2% in the lower quartile to 13.6% in the upper quartile. People who received aspirin inappropriately were 16 years younger, on average, than those who received aspirin appropriately.

An editorialist writes that "the benefit of aspirin may be overshadowed by the bleeding hazard," especially since bleeding risk is strongly correlated to ischemic risk. Because statins and other drugs will have already produced a substantial risk reduction in many patients, he speculates, "aspirin's benefit is almost completed eliminated (theoretically)."

Reader Comments (7)

E. Lerner, BSN

So if asa is used for preventative cancer reasons, is non enteric coated still a better recommendation?

MICHAEL NANCY AMSDEN Physician, Emergency Medicine, retired

In all my years I do not think I have seem someone bleed from one 81 ASA a day only. It is better to think of decreasing clots, strokes and PE.

H ROBERT SILVESTEIN Physician, Cardiology, Preverntive Medicine Center

The current aspirin recommendations are guesswork at best. A carefully considered "risk vs benefit" discussion with patients re the use of any medication, including aspirin, is essential. Personally, I am a "believer" in the use of uncoated low-dose aspirin @ 81 mg BID but would not argue strongly with those who choose any of the different approaches. To be perfectly frank, while "guidelines" are helpful and interesting, it is essential that they be put forth with greater gentility & humility than is currently done. Most guidelines have a "regal" and commanding tone to them that put practicing physicians on the defensive and at legal risk if they disagree. On another blog, ophthalmologist Ed Petrus stated that low-dose aspirin results in a 44% decreased 1st AMI risk in patients with controlled hypertension, 25% decrease 2nd AMI risk, 23% less likely to die from an AMI, 25% reduction in heart disease in patient's with PAD, 36% reduction in AMI in diabetics, 30% stroke risk reduction, 50% Alzheimer's risk reduction, 45% Parkinson's risk reduction. 10 years of ASA Rx -> reduced breast/lung/colorectal/prostate/esophageal cancer, & Hodgkin's lymphoma. 65% of enteric coated aspirin do not provide anti-clotting benefits. Impressive & persuasive to me. HRS, MD, FACC

William DeMedio MD Physician, Family Medicine/General Practice

The risk of aspirin may be "theoretically higher" in these 11.6% of patients. However the actual mortality rate for premature cardiovascular disease and GI bleeds had actually fallen greatly over 30 years. I once admitted on average 1-2 GI bleeds per week. Today that number is 1-2 every 3 months. Likewise the number of young widows and widowers I had to call due to cardiovascular mortality death has dropped greatly.

I will continue to recommend aspirin to anyone I perceive to benefit from it.

Tom Simpson, PharmD, MBA, CGP Other Healthcare Professional, Geriatrics, Pharmacy Consultant Services, Inc.

Patients should take a chewable baby aspirin (with other meds) at bedtime. Timing and dosage form are important. If no other meds are taken at bedtime, it can be taken with dinner. However, chewing the aspirin and swallowing with 120+ml water, etc. virtually eliminates GI toxicity. "Safety"/enteric coated aspirin are the worst. They do one of two things - (a) pass through the GI tract unabsorbed (not uncommon), or (b) dissolve all at once in one spot in the GI tract, leading to a much greater chance of bleeding than the chewable form. They should be avoided. "Baby aspirin" is useful to prevent recurrent heart attacks, TIA's/strokes (I had 5 in 24 hours when hospitalized for 5 days and not given it, with no prior history of ever having one), and prevention of various GI cancers (which never seems to get mentioned despite good evidence).

Hoogheem, Other, Unspecified, Retired

Still active with clients....

Robert Hennessy MD Physician, Family Medicine/General Practice

Typical Cardiology viewpoint! Nothing outside of the heart matters! The benefits of low dose aspirin for primary prevention of cancer(s) is so firmly established that it amazes me that anyone is still debating the cardiovascular blah blah blah!!!

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