Low-dose acetylsalicylic acid for primary prevention of cardiovascular disease: Do not misinterpret the recommendations

Christine Truong

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Re: "Low-dose acetylsalicylic acid for primary prevention of cardiovascular disease" Truong, 61: 971-972
Jeff Nagge

Published on: 26 November 2015
Comment
Sara Asfour

Published on: 17 November 2015

Published on: (26 November 2015)
Page navigation anchor for Re: "Low-dose acetylsalicylic acid for primary prevention of cardiovascular disease" Truong, 61: 971-972
Re: "Low-dose acetylsalicylic acid for primary prevention of cardiovascular disease" Truong, 61: 971-972
Jeff Nagge, Clinical pharmacist
Other Contributors:
We read with interest the commentary "Low-dose acetylsalicylic acid (ASA) for primary prevention of cardiovascular disease: Do not misinterpret the recommendations"(1). While we agree with Ms. Truong's first suggestion that ASA should not routinely be recommended for the primary prevention of cardiovascular disease, we have different perspectives on the other two questions that she addresses.
When should we o...
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We read with interest the commentary "Low-dose acetylsalicylic acid (ASA) for primary prevention of cardiovascular disease: Do not misinterpret the recommendations"(1). While we agree with Ms. Truong's first suggestion that ASA should not routinely be recommended for the primary prevention of cardiovascular disease, we have different perspectives on the other two questions that she addresses.
When should we offer ASA for primary prevention?
Ms. Truong suggests that ASA should be offered when the benefits outweigh the risks, and suggests identifying "high risk" patients based upon the presence of various risk factors; for example, men older than 50 years. Our approach is to use cardiovascular risk calculators to estimate an individual's risk of a cardiovascular event to avoid arbitrarily categorizing individuals as high, moderate or low risk. An excellent website that has three such calculators is http://cvdcalculator.com. The calculator that we use the most is the ASCVD calculator, which calculates the 10-year risk of heart attack, stroke and cardiovascular death. The most recent Antiplatelet Trialists' Collaboration patient-level meta- analysis suggests that ASA reduces the risk of a first serious cardiovascular event by approximately 10%(2). In the example of a 50-year old man who is subjectively classified as high risk based upon gender and age alone, it is possible that his 10-year risk of heat attack, stroke or cardiovascular death is only 1% when using the ASCVD calculator. The use of ASA every day for ten years in this individual may lower that risk by about 0.1%, an amount likely considered unimportant by most clinicians and patients. By using risk calculators, and knowing the estimated risk reductions of various interventions, health-care professionals can dialogue with patients about specific benefits and harms of various interventions in the spirit of shared decision-making.
Should we stop ASA in patients who have been using it for primary prevention for many years?
Ms. Truong also highlighted a theoretical concern of provoking a hypercoagulable state when discontinuing ASA. To support this, she cited three sources: 1) a review article; 2) a retrospective case-control study in patients taking ASA for the secondary prevention of cardiovascular events; and, 3) a rapid response opinion to the second citation that did not provide any new information. In our own search of the literature, we could not find any credible information that suggested an increased risk of cardiovascular events in patients stopping ASA when it was being used for primary prevention. We believe this is very important to note, as we do not believe that clinicians should hesitate to stop ASA when there is no clear indication for use.
1. Truong C. Low-dose acetylsalicylic acid for primary prevention of cardiovascular disease: Do not misinterpret the recommendations. Canadian Family Physician 2015;61(11):971-972.
2. Baigent C, Blackwell L, Collins R et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual partici- pant data from randomised trials. Lancet 2009;373 (9678):1849-60.
Conflict of Interest:
None declared
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Competing Interests: None declared.
Published on: (17 November 2015)
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Comment
Sara Asfour, physician
Very well written article which presented good clinical questions.
It gives the exact situations when to offer the ASA for primary prevention which helps a lot in clinic. It also summarize good informations (evidence based) to give to patients when they ask questions about what they heard related to it.
It is also helpful to highlight the ongoing large studies (ARRIVE, ASCEND, ASPREE, ACCEPT-D) that we...
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Very well written article which presented good clinical questions.
It gives the exact situations when to offer the ASA for primary prevention which helps a lot in clinic. It also summarize good informations (evidence based) to give to patients when they ask questions about what they heard related to it.
It is also helpful to highlight the ongoing large studies (ARRIVE, ASCEND, ASPREE, ACCEPT-D) that we need to follow to still be updated.
Conflict of Interest:
None declared
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Competing Interests: None declared.