Summary
JAMA Editor Howard Bauchner interviews Dr. Randall Stafford, a professor of medicine at Stanford, about his viewpoint on navigating the shifting landscape of low-dose aspirin for primary cardiovascular prevention. The discussion centers on three major 2018 clinical trials (ASPREE, ASCEND, ARRIVE) that showed aspirin's benefits for primary prevention are smaller than previously thought, while bleeding risks remain significant. Stafford presents a practical risk-stratification framework: consider aspirin initiation for patients with greater than 15% ten-year cardiovascular risk and lower bleeding risk, have shared discussions for intermediate risk (7.5-15%), and avoid initiation for low-risk patients (under 7.5%). He emphasizes that aspirin still has a place in primary prevention for the right patients but stresses shared decision-making rather than blanket recommendations.
Key Points
- Three 2018 clinical trials (ASPREE, ASCEND, ARRIVE) shifted the evidence on aspirin for primary prevention, showing smaller benefits than expected
- The ASPREE trial of 19,000 elderly participants found no significant cardiovascular benefit but 38% higher bleeding risk and 14% higher all-cause mortality in the aspirin group
- Meta-analysis shows aspirin reduces cardiovascular outcomes by about 11% but increases significant bleeding by about 40%
- Stafford's framework: consider initiation at >15% ten-year CVD risk, discuss benefits/harms at 7.5-15% risk, avoid initiation at <7.5% risk
- Aspirin may also reduce colorectal cancer risk, which should factor into the risk-benefit discussion
- Diabetes alone does not automatically warrant aspirin use; overall cardiovascular risk should guide the decision
- Shared decision-making between clinician and patient is essential rather than blanket prescribing or abandoning aspirin entirely
Key Moments
Balancing Benefits and Harms of Aspirin for Primary Prevention
Dr. Stafford explains the fundamental model of balancing aspirin's known benefits against its bleeding harms, noting the new studies have shifted the balance toward being more cautious.
"potential harms of aspirin, largely gastrointestinal bleeding and bleeding in the brain. And we know that there are potential benefits of aspirin, particularly the prevention of heart attacks and strokes, and that the issue is finding the right balance so that we are putting people on aspirin where their potential benefits will clearly offset their potential harms from aspirin"
ASPREE Trial Shows Increased Mortality in Elderly Aspirin Users
Stafford details the surprising ASPREE trial results showing 38% higher bleeding and 14% higher mortality in healthy elderly participants taking aspirin compared to placebo.
"And yet at the same time, there was clearly a very large risk of bleeding and bleeding mostly in the gastrointestinal tract. But that was 38% higher in the population that was taking aspirin. Now, what was particularly striking was that there was a increase in mortality in the group taking aspirin."
Risk Stratification Framework for Aspirin Decisions
Stafford presents his practical approach to aspirin prescribing based on 10-year cardiovascular risk thresholds, with consideration of colorectal cancer risk and bleeding risk.
"if somebody has a higher age and has those factors, and their risk of having a cardiovascular event, like a heart attack in the next 10 years, is greater than 15%, that's a person whose risk is high enough that it may make sense to consider aspirin"
Shared Decision-Making Is Essential for Aspirin Use
Stafford emphasizes that aspirin decisions should involve careful shared decision-making between provider and patient rather than blanket prescribing.
"I strongly feel that this is a clinical practice where the patient needs to be central to making the decision. So it shouldn't be me telling my patients take or don't take aspirin, but I think it really requires a careful discussion where there's a shared decision being made between the provider and the person in my office"
