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Stratification by CVD risk equations does not inform the use of aspirin for primary prevention in older adults
Enayet K Chowdhury1,2, Michael E Ernst3,4, Mark R Nelson5
1School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
Insights
Low-dose aspirin does not offer a net clinical benefit for primary prevention of cardiovascular disease (CVD) in older adults. Current CVD risk scores fail to identify subgroups who would benefit from aspirin therapy.
Area of Science:
- Cardiology
- Preventive Medicine
- Geriatrics
Background:
- Cardiovascular disease (CVD) remains a leading cause of mortality in older adults.
- Aspirin is commonly considered for primary prevention of CVD, but its net benefit in older populations is debated.
- Risk stratification tools are crucial for guiding preventive strategies.
Purpose of the Study:
- To evaluate if established CVD risk equations can identify older adults who may benefit from low-dose aspirin for primary prevention.
- To assess the balance between aspirin's benefits (CVD reduction) and risks (major hemorrhage) based on predicted CVD risk.
Main Methods:
- Utilized Framingham (FRS), ASCVD, and SCORE2-OP risk equations to predict 10-year CVD risk in older individuals.
- Categorized participants into low (T1), intermediate (T2), and high (T3) risk tertiles based on predicted risk.
- Analyzed rates of CVD events and major hemorrhagic events according to each risk equation's definitions.
Main Results:
- CVD event rates increased across risk tertiles (T1 to T3) for all equations.
- Aspirin showed a significant reduction in CVD risk for the highest risk tertile (T3) by FRS and ASCVD (28% and 25% respectively).
- However, aspirin increased major bleeding events in T1 and some T2 groups, and the CVD risk reduction in T3 was offset by increased bleeding risk (32% for FRS, 15% for ASCVD).
Conclusions:
- Current CVD risk scores do not identify specific subgroups of older individuals without prior cardiovascular events who would experience an overall net clinical benefit from low-dose aspirin.
- The potential benefits of aspirin for CVD prevention in older adults are counterbalanced by an increased risk of major hemorrhage.
- Further research may be needed to refine risk prediction models for aspirin use in primary prevention.
Purpose:
We aimed to determine whether commonly recommended CVD risk equations would inform a risk-benefit discussion on the role for aspirin as a primary prevention strategy for CVD in older persons. We assessed aspirin's effect on CVD and major haemorrhage on the basis of baseline levels of CVD risk using risk scores pertaining to the older age groups.
Methods:
We used a) the Framingham (FRS), b) the Atherosclerotic Cardiovascular Disease (ASCVD), and c) the European SCORE2-OP equations to calculate 10-year predicted CVD risk. Participants were classified into predicted risk tertiles (T): lower (T1), intermediate (T2) and higher (T3) risk. We identified CVD and major haemorrhagic events utilising each risk equation's definition of CVD.
Results:
The CVD event rate increased from T1 to T3 using all risk equations. For participants with greatest CVD risk (T3) according to FRS and ASCVD, aspirin versus placebo was associated with a proportional 28% (95% CI: 54 to 95%) and 25% (95% CI: 57 to 97%) reduction in CVD risk respectively. However, there was no significant effect of aspirin for individuals with low (T1) or moderate (T2) risk, nor according to the SCORE2-OP tertiles.Rates of major haemorrhagic events were highest in all T3 groups. Aspirin was associated with a significant increase in bleeding events versus placebo in all T1 groups and FRS and SCORE2-OP T2 groups. The reduction in CVD events in FRS and ASCVD T3 groups was offset by a 32% and 15% increased risk of bleeding respectively.
Conclusion:
In older persons with no prior cardiovascular events, current CVD risk scores do not identify any subgroups with overall net clinical benefit from low dose aspirin.
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