Recent findings from Rochester General Hospital, the University of Texas Southwestern Medical Center, and Aga Khan University indicate that utilizing newer cardiovascular risk equations could significantly reduce the number of middle-aged adults deemed eligible for aspirin as a preventive measure against heart disease. This research has sparked discussions among cardiologists and public health specialists regarding the balance between the potential benefits of aspirin in reducing cardiovascular events and its associated risks, particularly the threat of major bleeding.
The US Preventive Services Task Force currently recommends considering aspirin for adults aged 40 to 59 who are not at elevated risk of bleeding and have a projected 10-year cardiovascular risk of at least 10%. This risk is typically assessed using pooled cohort equations. However, a new set of equations, known as the Predicting Risk of Cardiovascular Disease EVENTs (PREVENT), have been developed to provide more accurate risk estimates compared to the traditional pooled cohort equations. Despite this advancement, the implications of using PREVENT for aspirin eligibility have not yet been thoroughly investigated.
In the research letter titled Using the PREVENT Equations to Guide Aspirin Use for Primary Prevention of Cardiovascular Disease, published in JAMA Internal Medicine, researchers analyzed the impact of applying the PREVENT equations on aspirin eligibility. The study utilized data from the National Health and Nutrition Examination Survey (NHANES) collected between 2015 and 2020, involving 3,158 participants who represent approximately 59.4 million adults in the US aged 40 to 59 years without existing cardiovascular disease.
To ensure accuracy, respondents with conditions that increase bleeding risk were excluded, including severe kidney disease, elevated urine albumin, low platelet counts, cancer, heart failure, and those taking specific medications such as steroids, antiplatelets, or anticoagulants. Eligibility for aspirin was determined by calculating the 10-year cardiovascular risk using both pooled cohort equations and PREVENT, with candidacy defined as a risk of 10% or higher.
The results revealed that only 8.3% of middle-aged adults, approximately 4.9 million individuals, qualified for aspirin under the pooled cohort equations. In stark contrast, just 1.2%—about 700,000 individuals—met the criteria under the PREVENT equations. Among those who qualified based on pooled cohort criteria, an overwhelming 85.9% did not meet the threshold when evaluated using PREVENT. Furthermore, of the estimated 7.6 million adults who reported using aspirin for prevention, nearly 97% did not satisfy the eligibility requirements set by the PREVENT equations.
The authors of the study emphasize that the adoption of the PREVENT equations raises critical questions regarding the applicability of the same 10% cutoff used in older calculators. Establishing PREVENT-specific eligibility thresholds will likely necessitate dedicated modeling studies to assess the net benefits of aspirin therapy. The findings also suggest a significant opportunity to reconsider the necessity of aspirin therapy for many adults, as the majority of those self-reporting its use during the study period did not meet the criteria from either risk calculation tool.
In conclusion, this new research sheds light on the potential for cardiovascular risk assessment to reshape guidelines regarding aspirin use in primary prevention of heart disease, ultimately leading to more personalized and effective healthcare strategies for middle-aged adults.
