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The benefit-to-risk ratio of daily low-dose aspirin is high in individuals with known CVD disease; thus, continued use beyond age 70 years in most individuals is clinically logical. However, the analysis by Liu et al 2 also points out that a large percentage of individuals 70 years and older take daily aspirin in the absence of known CVD. The good news is that, generally, daily aspirin use is directly proportional to overall CVD risk, with individuals who have few risk factors for CVD being the least likely to take daily aspirin compared with those with known CVD disease being the most likely use aspirin.

The concern is that there is a considerable percentage of individuals at low risk for CVD who are taking aspirin therapy across all age groups. Many individuals included in this analysis may have higher risks for adverse events than for improved health outcomes. Dating back to the s, the use of aspirin for the primary prevention of acute coronary events has been considered and studied. In the past decade, aspirin use for primary prevention has been promoted by quality indicator developers, advocacy groups, and specialty societies.

Yet, despite ongoing study, until recently, data indicating a clear-cut benefit of low-dose aspirin for primary prevention have been lacking. For the age group older than 70 years, the USPSTF indicated that there was insufficient evidence to judge benefits vs risks. Three new studies examining daily aspirin use and primary prevention outcomes have been published since the USPSTF statement. The third study, the ASCEND A Study of Cardiovascular Events in Diabetes trial, 7 specifically enrolled individuals with type 1 or type 2 diabetes and showed a ificant reduction in cardiovascular events over a period of 7.

Major bleeding events, a well-known adverse event with aspirin therapy at any dose, also increased as expected. Tallying the of serious vascular events or revascularization procedures avoided and subtracting from them the of major bleeding events caused, the indicate that 0.

Despite the overall positive outcomes, the authors concluded that it was not clear that the benefits of aspirin therapy in people at low risk for CVD outweighed the harms. None of the 3 studies 5 - 7 demonstrated an improvement in mortality, either all cause or cardiovascular depending on the studywith one, the ASPREE Aspirin in Reducing Events in the Elderly study, 5 having higher all-cause mortality in the aspirin group. The increased deaths were primarily cancer related and downplayed by the authors, though examination of a large of demographic and risk indicates that randomization appeared to have worked well, making an anomaly such as this concerning.

This rate of aspirin use is poorly justified by current evidence and would seem likely to be causing more harm than good. That said, clinicians are left with a conundrum, because the USPSTF simulations indicate that the overall benefit from low-dose aspirin increases over time, particularly with respect to cancer prevention.

Furthermore, most individuals older than 70 years using daily aspirin are not newly initiating therapy but continuing therapy started at a younger age. Stopping a therapy on which an individual appears to be doing well can be a much harder decision for both patient and clinician than not starting the treatment in the first place. Despite the concern that stopping medication may lead to worse outcomes, low-dose aspirin therapy, like all medications used by older individuals, should be regularly reviewed, and the ongoing safety and need for use should be discussed.

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With the addition of 3 newer studies 5 - 7 that continue to question the efficacy of low-dose aspirin for primary prevention in older adults, this conversation has more immediacy. Only through careful, ongoing assessments can physicians make sure they are following what many consider to be the most important ethical tenet of clinical care— primum non nocere —first, do no harm. Published: June 21, Corresponding Author: Wilson D. Conflict of Interest Disclosures: None reported. Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

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Twitter Facebook. This Issue. Views 3, Citations 0. View Metrics. Invited Commentary. June 21, Wilson D. Pace, MD 1. Original Investigation. Elizabeth Y. Liu, BA; Mohammed E. Joseph, MD; Rita R. Back to top Article Information. Aspirin use among the adult U. Published Accessed April 4, Use of preventive aspirin among older US adults with and without diabetes. Use of low-dose aspirin as secondary prevention of atherosclerotic cardiovascular disease in US adults from the National Health Interview Survey, Aspirin use for the primary prevention of cardiovascular disease and colorectal cancer: U.

Preventive Services Task Force recommendation statement. Effect of aspirin on cardiovascular events and bleeding in the healthy elderly. 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. Effects of aspirin for primary prevention in persons with diabetes mellitus. Limit characters. Limit 25 characters. Conflicts of Interest Disclosure Identify all potential conflicts of interest that might be relevant to your comment.

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