Aging (Albany NY) | 2019
Aspirin for primary prevention in the elderly
Abstract
medications across the globe, not only for secondary prevention but also for primary prevention of cardiovascular disease (CVD), with nearly 36 million adults without prior CVD event taking aspirin in the US alone [1]. Since its approval for secondary prevention of CVD by the FDA in 1985, multiple randomized controlled trials have examined the role of aspirin in primary prevention. While early trials showed benefit of aspirin in reducing CV events, more recent trials have challenged these findings with even a signal towards net harm. This has resulted in change in the most recent U.S. Preventive Services Task Force recommendations towards a shared decision making especially with patients 60-70 years who are at CVD risk [2]. In 2018, 3 pivotal trials raised questions regarding benefits of aspirin in primary prevention, leading to a new update in the preventive care guidelines from the AHA/ACC [3]. The latest meta-analysis of 15 RCTs with a total of 165,502 participants conducted by us confirmed lack of mortality benefit of aspirin in primary prevention, and the observed benefit of aspirin in reducing non-fatal CVD events was negated by a higher rate of non-fatal bleeding events. Furthermore, incidence of cancer or cancer mortality did not seem to be reduced with aspirin over 6.5 years of follow-up [4]. The major advancements in healthcare have led to a dramatic increase in life expectancy over the past century with a substantial demographic shift toward aging of population. It has been shown that the risk of CVD doubles with each decade of life independent of traditional risk factors [5]. This has resulted in CVD being the principal cause of disability and death in the elderly; hence, primary interventions for such CVD have become a high priority. Aspirin use for secondary prevention in all populations has been widely accepted, as the benefits linked to reduction in myocardial infarction and stroke are likely to overweigh the risk of major bleeding. However, as shown in our meta-analysis the risk-benefit has not been favorable in primary prevention trials. Of note, while no major trial exclusively enrolled elderly population, except for the Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly (ASPREE) trial [6], subgroup analyses from major trials demonstrated minimal heterogeneity in CV outcomes based on age (< 65 vs > 65 years) [4,7,8]. Editorial