From 2011 to 2018, researchers performed a cross-sectional study of data collected from the National Health and Nutrition Examination Survey of 7103 US adults aged 60 years and older with and without diabetes to determine the prevalence of self-reported aspirin use for the prevention of cardiovascular disease (CVD) among this population.  The results of the study were published in JAMA Network Open.1

Aspirin use was found to be more prevalent among older adults with diabetes (61.7%) compared with older adults without diabetes (42.2%). Among individuals with diabetes, 56.6% of women were less inclined to use aspirin for the primary prevention of CVD compared with 54% of men with diabetes who typically took aspirin for this purpose.

Individuals with diabetes who were at high risk for CVD did not demonstrate an increased likelihood of taking aspirin as a primary CVD prevention measure compared with individuals with diabetes who were at low risk for CVD. Older age was not significantly correlated with aspirin use among individuals with diabetes; however, age older than 80 years was significantly correlated with an increased probability of aspirin use among individuals without diabetes.1 


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The investigators of this study questioned the safety of long-term aspirin use among the older adult population for whom the risk of bleeding is already high, considering paradigm shifts across several professional organizations regarding this prophylactic measure. The study’s results encouraged the need for continuous health care provider monitoring and individualized risk-benefit analysis of long-term aspirin use to prevent CVD in this patient population.1

The researchers calculated that an estimated 9.9 million US adults older than 70 years who take aspirin for primary CVD prevention might not benefit from continued long-term aspirin use because doing so may cause more harm than good. The authors pointed out the lack of clarity regarding long-term primary CVD-preventive aspirin use for older adults.1

The American Heart Association (AHA) and the American Diabetes Association (ADA) recommended that aspirin use for primary CVD prevention is acceptable for individuals with diabetes who have a 10% 10-year risk of CVD without an increased risk of bleeding. The ADA does not recommend aspirin use for those with a low risk of CVD. The US Preventive Services Task Force recommended the practice of individual provider judgment when determining the necessity of aspirin use for primary CVD prevention among individuals aged 60 to 69 years who are at high risk for CVD development in 10 years. No recommendations guided decision-making for individuals older than 70 years.1

Three separate randomized clinical trials in 2018 demonstrated an increased risk of adverse bleeding events and variable benefits of aspirin use among older adults with and without diabetes.2-5 These studies showed a heightened risk of all-cause mortality and risk of hemorrhage, and no was benefit derived from aspirin use for primary prevention of CVD compared with placebo in older adults.4-5 One study did find that CVD-preventive aspirin use among individuals older than 40 years who had diabetes significantly reduced the risk of serious vascular events despite a higher bleeding risk.2 Because of conflicting evidence supporting the efficacy of aspirin use for the primary prevention of CVD, it is important for providers to carefully analyze the risk vs benefit of this prophylactic intervention for individuals on a case-by-case basis. 

One limitation of this study1 included the potential misclassification of participants who were prediabetic and taking medications to control glucose who may have self-reported that they had a diagnosis of diabetes. It was also difficult to distinguish if patients were using aspirin for CVD prevention or cancer prevention, as it may be prophylactically recommended by physicians for both conditions. The final limitation was that this study used a cross-sectional design; therefore, it was hard to make generalizable conclusions based on observations performed at a specific moment in time.

References

  1. Liu EY, Al-Sofiani ME, Yeh H-C, Echouffo-Tcheugui JB, Joseph JJ, Kalyani RR. Use of preventive aspirin among older US adults with and without diabetes.  JAMA Network Open. Published online June 21, 2021. doi:10.1001/jamanetworkopen.2021. 12210
  2. Bowman L, Mafham M, Wallendszus K, et al; ASCEND Study Collaborative Group. Effects of aspirin for primary prevention in persons with diabetes mellitus. N Engl J Med. 2018;379(16):1529-1539. doi:10.1056/NEJMoa1804988
  3. Gaziano JM, Brotons C, Coppolecchia R, et al; ARRIVE Executive Committee. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet. 2018;392(10152):1036-1046. doi:10.1016/S0140-6736(18)31924-X
  4. McNeil JJ, Nelson MR, Woods RL, et al; ASPREE Investigator Group. Effect of aspirin on all-cause mortality in the healthy elderly. N Engl J Med. 2018;379(16):1519-1528. doi:10.1056/NEJMoa1803955
  5. McNeil JJ, Wolfe R, Woods RL, et al; ASPREE Investigator Group. Effect of aspirin on cardiovascular events and bleeding in the healthy elderly. N Engl J Med. 2018;379(16):1509-1518. doi:10.1056/NEJMoa1805819