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Daily Low-Dose Aspirin No Longer Recommended As Heart Attack Preventative For Older Adults

Discussion in 'Cardiology' started by Nada El Garhy, Mar 17, 2019.

  1. Nada El Garhy

    Nada El Garhy Golden Member

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    Daily low-dose aspirin no longer recommended as heart attack preventative for older adults

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    In this photo illustration, St. Joseph 81 mg asprin tablets are seen on April 12, 2016 in Miami, Florida. The U.S. Preventive Services Task Force has recommended that taking a low-dose asprin daily can help prevent both heart disease and colorectal cancer in adults ages 50 to 69.

    Studies: Low-dose aspirin risks may outweigh benefits

    If you're a healthy older adult looking for ways to reduce your risk of heart attack and stroke, don't turn to that age-old standby: daily low-dose aspirin. It's no longer recommended as a preventative for older adults who don't have a high risk or existing heart disease, according to guidelines announced Sunday by the American College of Cardiology and the American Heart Association.

    With daily low-dose aspirin use, risks may outweigh benefits for older adults

    "For the most part, we are now much better at treating risk factors such as hypertension, diabetes and especially high cholesterol," said North Carolina cardiologist Dr. Kevin Campbell, who wasn't involved in the new guidelines. "This makes the biggest difference, probably negating any previously perceived aspirin benefit in primary prevention."

    Doctors may consider aspirin for certain older high-risk patients, such as those who have trouble lowering their cholesterol or managing their blood sugars, as long as there is no increased risk for internal bleeding, the guidelines say. European guidelines recommend against the use of anti-clotting therapies such as aspirin at any age.

    "Clinicians should be very selective in prescribing aspirin for people without known cardiovascular disease," John Hopkins cardiologist Dr. Roger Blumenthal, who co-chaired the new guidelines, said in a statement. "It's much more important to optimize lifestyle habits and control blood pressure and cholesterol as opposed to recommending aspirin."


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    Using aspirin in younger age groups "is now a class 2b recommendation," Campbell said, "meaning that it is not necessarily the best course of action; there is much debate among experts, and the data is not definitive."
    However, personally, Campbell says, he "would advocate a healthy lifestyle, smoking cessation and risk-factor modification before even considering aspirin therapy in a patient without known cardiovascular disease."

    However, for anyone who has had a stroke, heart attack, open-heart surgery or stents inserted to open clogged arteries, aspirin can be life-saving.

    "Ultimately, we must individualize treatment for each patient, based on their individual situation," Campbell said.

    New research on aspirin

    Three recent studies found that taking a daily low-dose aspirin is, at best, a waste of money for healthy older adults. At worst, it may raise their risk of internal bleeding and early death.

    "Aspirin should be limited to people at the highest risk of cardiovascular disease and a very low risk of bleeding," Blumenthal said.

    Patients should work closely with their doctors to establish their risk for bleeding. That risk rises as one ages or develops kidney disease, heart disease, diabetes and high blood pressure. A history of ulcers or bleeding, especially in the gastrointestinal tract, or anemia is also a risk factor. Certain medications, such as nonsteroidal anti-inflammatory drugs, steroids, direct oral anticoagulants and warfarin, a blood thinner, can also increase the chance of bleeding.

    The guidelines stress that statins -- along with lifestyle changes such as a heart-healthy diet, regular exercise, weight loss and avoiding smoking or vaping tobacco -- should be used to prevent heart disease in anyone with LDL levels of more than 190 milligrams per deciliter. LDL stands for low-density lipoprotein and is the "bad" cholesterol that clogs arteries and leads to heart disease.

    Changing Type 2 diabetes recommendations

    Type 2 diabetes is a primary risk factor for cardiovascular disease, and the 2019 guidelines stress a diet, exercise and weight control plan as the first line of offense. Strive for at least 150 minutes a week of moderate-intensity exercise, such as brisk walking and swimming, the guidelines say. Then tack on another 75 minutes of high-intensity exercise, such as running and circuit training.

    First-line medication should include metformin, the guidelines say. If additional medications are needed, two new classes of medications are showing promise in reducing cardiovascular events in those with Type 2 diabetes: SGLT-2 inhibitors, which work to increase glucose and sodium removal via the kidneys; and GLP-1R agonists, which increase insulin and glucose production in the liver.

    New research on these two classes of diabetes medications shows that they can also cut the risk of heart attack, stroke and related deaths, the guidelines say.

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  2. Valery1957

    Valery1957 Well-Known Member

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    Meeting Coverage > ACC
    CV Primary Prevention Guidelines Updated
    Aspirin, diabetes, team-care recommendations revised
    • by Crystal Phend, Senior Associate Editor, MedPage TodayMarch 17, 2019

    • This article is a collaboration between MedPage Today® and:

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    NEW ORLEANS -- Aspirin got downgraded while heart-beneficial diabetes medications got a boost in updated primary prevention of atherosclerotic cardiovascular disease (ASCVD) guidelines.

    Other key additions to the American College of Cardiology (ACC)/American Heart Association guidelines were prominent endorsements of team-based care, shared-decision making, and considering social determinants of health.

    However, most sections largely pooled together existing recommendations on primary prevention from prior guidelines, such as 2017 and 2018 updates on cardiovascular risk assessment, cholesterol, and hypertension, writing committee co-chair Donna Arnett, PhD, MSPH, and colleagues noted.

    The document was released here at the ACC annual meeting and simultaneously published in the Journal of the American College of Cardiology and Circulation.

    "One really has to be comprehensive if you want to make an impact on ASCVD risk," said Amit Khera, MD, of UT Southwestern Medical Center in Dallas at an ACC press conference. "For busy clinicians, for people who are out there, this is a one-stop-shop, a central source for clinicians putting it all together...and hopefully that will help in the effectiveness of implementation."

    Aspirin Update

    Perhaps one of the most impactful changes, Khera said, would be changes to the aspirin recommendations.


    "Historically, we've always been trying to find this balance between lowering ASCVD risk, but aspirin always causes bleeding," he said. "In the past, in the right groups -- those at higher ASCVD risk -- it was felt that that balance favored taking aspirin in the right situation. Well, as of late, there have been some new studies involving data that suggest that balance has tipped the other way."

    "We've had three trials in last year (ARRIVE, ASCEND, and ASPREE) which really have shown us that the place for aspirin has diminished in terms of primary prevention, and that bleeding will be outweighing the benefit in our modern era with all of our recommended therapies," he added.

    The guidelines now recommend that prophylactic low-dose aspirin:

    • "Might be considered" for select patients, ages 40-70, at higher ASCVD risk but not at increased bleeding risk (IIb recommendation)
    • Should not routinely be used for adults age >70 (class III, a warning of harm)
    • Should not be given at any age among people at increased risk of bleeding (class III)


    "Generally no, occasionally yes," was how Khera summed up the recommendations. But he also cautioned against conflating these primary prevention recommendations to secondary prevention, for which aspirin still is recommended for use.

    Diabetes Update



    A 2018 consensus document from the ACC recommended considering addition of a glucose-lowering drug proven to have cardiovascular benefits for all type 2 diabetes patients with ASCVD.

    The new guideline suggests "it may be reasonable to initiate a sodium-glucose cotransporter 2 (SGLT-2) inhibitor or a glucagon-like peptide-1 receptor (GLP-1R) agonist to improve glycemic control and reduce CVD risk," in patients without established ASCVD as well. This got a IIb recommendation, although Khera noted that it's in the context of a comprehensive approach with nutrition, exercise, and first-line metformin.

    "Although most patients studied had established CVD at baseline, the reduction in heart failure has been shown to extend to primary prevention populations," the document noted.
     

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