2019 Chinese Expert Consensus Statement on Aspirin Application in Primary Prevention of Cardiovascular Disease
Aspirin has long been a cornerstone in the prevention of atherosclerotic cardiovascular disease (ASCVD). Its role in primary prevention, however, has been a subject of extensive debate and research. The 2019 Chinese Expert Consensus Statement on Aspirin Application in Primary Prevention of Cardiovascular Disease provides a comprehensive review of the current evidence and offers tailored recommendations for the Chinese population. This article delves into the key aspects of the consensus, covering the benefits, risks, and specific guidelines for aspirin use in primary prevention.
The Role of Aspirin in Primary Prevention of ASCVD
Aspirin’s primary mechanism of action is through its antiplatelet effect, which reduces the risk of thrombotic events. In the context of primary prevention, aspirin has been shown to significantly reduce non-fatal ischemic events such as myocardial infarction, transient ischemic attack, and ischemic stroke. However, its impact on all-cause mortality and cardiovascular mortality is less clear. The primary benefit of aspirin in primary prevention is the reduction of major cardiovascular events, which include cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke.
Despite these benefits, aspirin use is not without risks. The most significant risk associated with aspirin is an increased incidence of non-fatal major bleeding events, particularly gastrointestinal bleeding and intracranial hemorrhage. Therefore, the decision to prescribe aspirin for primary prevention must be carefully weighed, ensuring that the benefits clearly outweigh the risks.
Changing Landscape of Aspirin Use in Primary Prevention
In recent years, the benefit-risk ratio of aspirin for primary prevention has shifted. This change is largely due to the widespread adoption of other primary prevention measures, such as blood pressure control, smoking cessation, and statin therapy. These interventions have collectively reduced the overall risk of cardiovascular events, thereby diminishing the relative benefit of aspirin.
Several large-scale clinical trials have further questioned the net clinical benefit of aspirin in low-risk populations. These studies have shown that aspirin does not provide a significant advantage in terms of reducing cardiovascular events in individuals with a low baseline risk of ASCVD. As a result, the consensus emphasizes the need for caution when considering aspirin for primary prevention.
Identifying the Right Candidates for Aspirin Therapy
Given the nuanced benefit-risk profile of aspirin, the consensus highlights the importance of identifying individuals who are most likely to benefit from its use. Primary prevention with aspirin is primarily recommended for adults aged 40 to 69 years who have a high risk of ischemic events (≥10% expected risk over 10 years) despite active intervention measures. Additionally, these individuals should have a low risk of bleeding and be willing to commit to long-term low-dose aspirin therapy.
The consensus also underscores the importance of a thorough evaluation before initiating aspirin therapy. This includes assessing the patient’s bleeding risk, implementing preventive measures to reduce gastrointestinal bleeding, and ensuring that the patient adheres to a healthy lifestyle. Physicians are advised to engage in detailed discussions with patients to obtain informed consent before prescribing aspirin.
Recommendations for Aspirin Use in Primary Prevention
The consensus provides a set of detailed recommendations for aspirin use in primary prevention, tailored to the Chinese population. These recommendations are based on the latest evidence and take into account China’s unique healthcare landscape.
Pre-Medication Measures
Before initiating aspirin therapy, four key measures must be taken:
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Benefit-Bleeding Risk Assessment: Physicians must carefully weigh the benefit-bleeding risk ratio for each patient. High-risk populations for bleeding should be screened and excluded. The benefit-bleeding risk ratio should be periodically reassessed during therapy, and any issues should be addressed promptly.
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Gastrointestinal Bleeding Prevention: Preventive measures should be taken to reduce the risk of gastrointestinal bleeding. This includes treating active gastrointestinal pathologies, such as Helicobacter pylori infection, and prophylactically using proton pump inhibitors or H2 receptor antagonists when necessary.
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Lifestyle and Risk Factor Control: Patients should adhere to a healthy lifestyle, including smoking cessation, moderate alcohol consumption, a balanced diet, and regular exercise. Blood pressure, blood sugar, and blood lipid levels should be actively controlled. Aspirin should be considered for hypertensive patients only if their blood pressure is consistently below 140/90 mmHg.
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Patient Communication and Consent: Physicians must communicate the potential benefits and risks of aspirin therapy to patients and obtain their informed consent before prescribing the medication.
Specific Recommendations for High-Risk Groups
The consensus identifies specific high-risk groups that may benefit from low-dose aspirin (75–100 mg/day) for primary prevention:
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Adults Aged 40 to 69 Years: Individuals in this age group with a 10-year expected risk of ASCVD ≥10% and at least three major risk factors that remain poorly controlled despite active intervention may consider aspirin therapy. Major risk factors include hypertension, diabetes, dyslipidemia, smoking, family history of early-onset cardiovascular disease, obesity, and certain coronary artery imaging findings.
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ASCVD Risk Assessment: The assessment of ASCVD risk should be based on relevant domestic guidelines. Key risk factors include hypertension, diabetes, dyslipidemia (total cholesterol ≥6.2 mmol/L or low-density lipoprotein ≥4.1 mmol/L or high-density lipoprotein <1.0 mmol/L), smoking, family history of early-onset cardiovascular disease, obesity (body mass index ≥28 kg/m²), coronary artery calcification score ≥100, and non-obstructive coronary artery stenosis (<50%). Routine coronary imaging for primary prevention is not recommended.
Populations Not Recommended for Aspirin Therapy
The consensus also identifies populations for whom aspirin is not recommended for primary prevention:
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Age Considerations: Aspirin is not recommended for individuals aged ≥70 years or <40 years due to insufficient evidence for primary prevention in these age groups. Individualized evaluation is necessary for these populations.
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High Bleeding Risk: Individuals at high risk of bleeding, including those taking other medications that increase bleeding risk (e.g., antiplatelet drugs, anticoagulants, hormones, and non-steroidal anti-inflammatory drugs), those with a history of gastrointestinal bleeding, peptic ulcers, or bleeding at other sites, and those with conditions such as thrombocytopenia, coagulopathy, severe liver disease, chronic kidney disease stage 4 to 5, uneradicated H. pylori infection, or uncontrollable hypertension.
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Bleeding Risk Exceeds Thrombosis Risk: Aspirin should not be prescribed if the assessed risk of bleeding is greater than the risk of thrombosis.
Conclusion
The 2019 Chinese Expert Consensus Statement on Aspirin Application in Primary Prevention of Cardiovascular Disease provides a comprehensive and evidence-based approach to the use of aspirin in primary prevention. While aspirin remains a valuable tool in reducing non-fatal ischemic events, its use must be carefully considered, particularly in light of the associated bleeding risks. The consensus emphasizes the importance of individualized patient assessment, thorough benefit-risk evaluation, and adherence to preventive measures to optimize the use of aspirin in primary prevention. By following these guidelines, healthcare providers can make informed decisions that maximize the benefits of aspirin while minimizing its risks for their patients.
doi.org/10.1097/CM9.0000000000000762
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