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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

Evidence Syntheses, No. 68

, MD, MPH, , DrPH, and , MD, MPH.

Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 540 Gaither Road, Rockville, Maryland 20850
Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 09-05129-EF-1

Structured Abstract

Background:

Coronary heart disease and cerebrovascular disease are leading causes of death in the United States. In 2002, the U.S. Preventive Services Task Force (USPSTF) strongly recommended that clinicians discuss aspirin with adults who are at increase risk for coronary heart disease.

Purpose:

To determine the benefits and harms of taking aspirin for the primary prevention of myocardial infarctions, strokes, and death.

Data Sources:

MEDLINE and Cochrane Library (search dates 1 January 2001 to 28 August 2008), recent systematic reviews, reference lists of retrieved articles, and suggestions from experts.

Study Selection:

English-language, randomized, controlled trials (RCTs), case-control, meta-analysis, and systematic reviews of aspirin versus control for the primary prevention of cardiovascular disease were selected to answer the following questions: Does aspirin in adults without known cardiovascular disease decrease coronary heart events, strokes, death from coronary heart events or stroke, or all-cause mortality? Does aspirin increase gastrointestinal bleeding or hemorrhagic strokes?

Data Extraction:

All studies were reviewed, abstracted, and rated for quality by using predefined USPSTF criteria.

Data Synthesis:

New evidence from one good quality RCT, one good quality meta-analysis, and 2 fair quality sub-analyses of RCTs demonstrates that aspirin use in patients without known cardiovascular disease (CVD) reduces the number of CVD events. Men in these studies experienced a reduction in the number of myocardial infarctions and women experienced a reduction in the number of ischemic strokes. Aspirin does not appear to affect CVD mortality or all-cause mortality in either men or women. The use of aspirin for primary prevention increases the risk for major bleeding events, primarily GIBs, in both men and women. Men have an increased risk for hemorrhagic strokes with aspirin use. A new RCT and meta-analysis suggest that the risk for hemorrhagic strokes in women is not statistically significantly increased.

Limitations:

There is limited new evidence on aspirin for the primary prevention of CVD. The dose of aspirin used in the RCTs varied preventing the estimation of the most appropriate dose for primary prevention. Several of the RCTs were performed in health professionals potentially limiting generalizability.

Conclusions:

Aspirin reduces the risk of myocardial infarctions in men and strokes in women. The risk of serious bleeding is increased with aspirin use.

A version of this report was published in Annals of Internal Medicine on March 17, 2009.

Suggested AHRQ Citation:

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. Evidence Synthesis No. 68. AHRQ Publication No. 09-05129-EF-1. Rockville, Maryland: Agency for Healthcare Research and Quality, March 2009.

This report is based on research conducted by staff of the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD. The investigators involved have declared no conflicts of interest with objectively conducting this research. The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.

This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

Bookshelf ID: NBK35203PMID: 20722166
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