Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer

Abstract

ImportanceThe US Preventive Services Task Force (USPSTF) is updating its 2016 recommendation on the use of aspirin for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC).ObjectiveTo provide updated model-based estimates of the net balance in benefits and harms from routine use of low-dose aspirin for primary prevention.Design, Setting, and ParticipantsMicrosimulation modeling was used to estimate long-term benefits and harms for hypothetical US cohorts of men and women aged 40 to 79 years with up to 20% 10-year risk for an atherosclerotic CVD event and without prior history of CVD or elevated bleeding risks.ExposuresLow-dose (≤100 mg/d) aspirin for lifetime use, unless contraindicated by a bleeding event, and with stopping ages in 5-year intervals from age 65 to 85 years.Main Outcomes and MeasuresPrimary outcomes were lifetime net benefits measured in quality-adjusted life-years (QALYs) and life-years. Benefits included reduced nonfatal myocardial infarction and ischemic stroke. Harms included increased nonfatal major gastrointestinal bleeding and intracranial hemorrhage. Reduced CRC incidence was considered in sensitivity analysis.ResultsEstimated lifetime net QALYs were positive for both men and women at 5% or greater 10-year CVD risk when starting between ages 40 and 59 years and at 10% or greater 10-year CVD risk when starting between ages 60 and 69 years. These estimates ranged from 2.3 (95% CI, −2.7 to 7.4) to 66.2 (95% CI, 58.2 to 74.1) QALYs per 1000 persons. Lifetime net life-years were positive for men at 5% or greater and women at 10% or greater 10-year CVD risk starting aspirin at ages 40 to 49 years and for men at 7.5% or greater and women at 15% or greater 10-year CVD risk at ages 50 to 59 years. These estimates ranged from 0.4 (95% CI, −6.1 to 6.9) to 52.4 (95% CI, 43.9 to 60.9) life-years per 1000 persons. Lifetime net life-years were negative in most cases for persons starting aspirin between ages 60 and 79 years, as were lifetime net QALYs for persons aged 70 to 79 years. Stopping aspirin between ages 65 and 85 years generally showed little advantage compared with lifetime use. Sensitivity analyses showed lifetime net benefits may be higher if aspirin reduced CRC incidence or CVD mortality and lower if aspirin increased fatal major gastrointestinal bleeding or reduced quality of life with routine use.Conclusions and RelevanceThis microsimulation study suggested that several population groups may benefit from taking aspirin for the primary prevention of CVD, primarily in persons starting at younger ages with higher 10-year CVD risk.

Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer

“…Nonfatal and fatal events were analyzed separately as secondary outcomes. Results for the secondary outcomes of nonfatal MI and nonfatal ischemic stroke, which appear in the companion decision analysis, are reported here; results for other secondary outcomes are available in the full report…”

“…This systematic review updated the body of evidence on the CVD and CRC benefits and harms of aspirin in primary CVD prevention populations. This review was used in conjunction with a decision analysis to update USPSTF recommendations.…”

Aspirin for the Primary Prevention of Atherosclerotic Cardiovascular Disease in Women

“…As with previous USPSTF recommendations, the new recommendations used a simulation model to estimate lifetime net benefit, measured by quality-adjusted life-years (QALYs) and net lifeyears gained from taking aspirin. 5 One difference is that the current model, compared with previous models, did not assume benefit for reduction in colorectal cancers. Despite this difference, the equation in the simulations model still estimated a lifetime net benefit measured by QALYs for both women and men aged 40 to 59 years with predicted 10-year ASCVD risk of at least 5% and benefit for individuals aged 60 to 69 years with predicted 10-year ASCVD risk of at least 10%.…”

“…As with previous USPSTF recommendations, the new recommendations used a simulation model to estimate lifetime net benefit, measured by quality-adjusted life-years (QALYs) and net life-years gained from taking aspirin . One difference is that the current model, compared with previous models, did not assume benefit for reduction in colorectal cancers.…”

Should Patients Take Aspirin for Primary Cardiovascular Prevention?

“…Those estimates, briefly described above, are detailed in the separate Evidence Review (in Table 2) but not in the Recommendation Statement. Instead, the Recommendation Statement includes a table (Table 2 in the article) derived from a decision analytic model, showing net benefits of aspirin therapy expressed as life-years and quality-adjusted life-years (QALYs) gained per 1000 persons, according to age, sex, and 10-year risk. This expression of net benefit has the advantage of collapsing cardiovascular and bleeding outcomes into a single quality-of-life metric.…”