Daily aspirin for primary CVD prevention increased risk for major GI bleeding in healthy older adults
While aspirin is not recommended for primary prevention of cardiovascular disease (CVD) in most adults ages 70 years and older, more research is needed to assess its role in select high-risk populations of older adults, an ACP Journal Club commentary said.
The ASPirin in Reducing Events in the Elderly (ASPREE) trial randomized 19,114 healthy, community-dwelling older adults to receive either daily aspirin (100 mg/d) for primary prevention of cardiovascular disease (CVD) or placebo. In a recent secondary analysis of the trial, researchers found that daily aspirin increased risk for major GI bleeding by about 60% overall in older adults. The absolute five-year risk of bleeding was 0.25% (95% CI, 0.16% to 0.37%) for a 70-year-old not taking aspirin and up to 5.03% (95% CI, 2.56% to 8.73%) for an 80-year-old taking aspirin with additional risk factors.
The study was published online on Aug. 3, 2020, by Gut. The following commentary by Calvin Hirsch, MD, FACP, appeared in the ACP Journal Club section of the January Annals of Internal Medicine.
The analysis of the ASPREE trial by Mahady and colleagues shows that, in adults aged ≥70 years, 100 mg of daily aspirin for primary prevention of CVD was associated with a 61% increased risk for clinically important GI bleeding at 5 years, compared with placebo. The absolute risk for GI bleeding increased 2.4-fold between the ages of 70 and 80 years, regardless of whether the participant was receiving aspirin. Population-based research has shown that risk for major bleeding associated with aspirin remains <1% per year until around age 70 years, after which it increases exponentially. The ASPREE trial found that among older adults, aspirin is no better than placebo for preventing CVD or a composite endpoint of death, disability, or dementia.
Aspirin is not recommended for primary prevention of CVD in most adults aged ≥70 years due to the overall lack of efficacy and increased risk for GI bleeding. However, subpopulations of older adults who have a high risk for CV events may show a net benefit from primary prevention with aspirin. A meta-analysis of 10 randomized trials of mostly middle-aged adults with diabetes found that aspirin was associated with a 10% reduction of major adverse CV events (relative risk, 0.90 [95% CI, 0.81 to 0.99]). In a small, open-label trial, patients with chronic kidney disease who were randomly assigned to primary prevention with aspirin (mean age, 67 y) had reduced risk for a composite CV endpoint, compared with usual care, over a mean follow-up of 65 months. More research is needed to assess the role of primary CVD prevention with aspirin in select high-risk populations of older adults.