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Wolff T, Miller T, Ko S. Aspirin for the Primary Prevention of Cardiovascular Events: An Update of the Evidence for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2009 Mar. (Evidence Syntheses, No. 68.)

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Aspirin for the Primary Prevention of Cardiovascular Events: An Update of the Evidence for the U.S. Preventive Services Task Force [Internet].

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1Introduction

Cardiovascular disease (CVD) is the leading cause of death in the U.S.; it is the underlying or contributing cause in approximately 58% of deaths. In 2003, 1 in 3 adults had some form of CVD. In adults ages 40 and older, the lifetime risk for CVD increases to 2 in 3 for men and more than 1 in 2 for women. Mortality data from 2003 showed that CVD was an underlying cause of death in 1 out of every 2.7 deaths, accounting for roughly 2.5 million deaths; the mortality rate from CVD was 308.8 per 100,000.(1)

The epidemiology of CVD events is different for men and women. Men have a higher risk for coronary heart disease and tend to have these events at a younger age than women. Men have a lifetime risk of 49% for a coronary heart disease event after the age of 40: for women the lifetime risk is 32%. The median age of first myocardial infarction is 65.8 years in men and 70.4 years for women. Women are more likely to die as a result of an myocardial infarction; 38% of women die within 1 year of a first myocardial infarction versus 25% of men. This is likely due in part to the older age in women at first myocardial infarction.(1, 2)

While incidence rates of stroke are higher in men than women, more women die of stroke than men because of their longer life expectancy. According to Framingham data the 10-year risk for initial ischemic stroke at age 55 is 1.8% for women and 2.4% for men; at age 65 the risk increases to 3.9% in women and 5.8% in men. The lifetime risk for ischemic stroke is greater in women than men between the ages of 55–75 (approximately 17–18% in women and 13–14% in men). After age 75 the risk decreases: 14% in women and 8% in men.

In 2002, the USPSTF strongly recommended that clinicians discuss aspirin with adults who are at increased risk for coronary heart disease.(3) The previous USPSTF recommendation on the prophylactic use of aspirin to prevent CVD was based on data from five RCTs that showed a 28% reduction in myocardial infarctions with aspirin use. Only two of the five studies included women. In 2005, data from the Women's Health Study provided important information about the benefit of aspirin in women. The Women's Health Study was a trial of 39,876 women randomized to aspirin or placebo and followed for 10 years for cardiovascular events.(4) With the availability of new data on benefits in women, the USPSTF decided to update its previous recommendation by re-evaluating the evidence for aspirin use in the primary prevention of CVD with a focus on sex-specific harms and benefits. This review updates the previous review and focuses on new evidence on the benefits and harms of aspirin for the primary prevention of CVD published since the 2002 USPSTF review and recommendation. (3)

Analytic Framework and Key Questions

In consultation with the USPSTF, we developed an analytic framework (Figure 1). From this analytic framework we developed the following key questions (KQ):

Figure 1. Analytic framework: aspirin to prevent cardiovascular events.

Figure

Figure 1. Analytic framework: aspirin to prevent cardiovascular events. CVD = cardiovascular disease; CHD = coronary heart disease; GI - gastrointestinal

KQ1a. Does aspirin use in women without known cardiovascular disease decrease coronary heart events, strokes, death from coronary heart events or strokes, or all-cause mortality?

KQ1b. Does aspirin use in men without known cardiovascular disease decrease coronary heart events, strokes, death from coronary heart events or strokes, or all-cause mortality?

KQ2a. Does aspirin use in women increase gastrointestinal bleeding or hemorrhagic strokes?

KQ2b. Does aspirin use in men increase gastrointestinal bleeding or hemorrhagic strokes?

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