Vast Majority of Eligible Patients Not Taking Aspirin for Primary Prevention

August 07, 2014

ROCHESTER, NY ( UPDATED ) — The majority of men and women at risk for cardiovascular disease who are eligible for primary-prevention aspirin therapy have not received a recommendation for the drug from their physician, according to the results of a new study[1].

Of men eligible on the basis of their Framingham risk score, just 34% recall their physician suggesting they take aspirin. For women, 42% of those eligible for aspirin recalled receiving a recommendation from the physician.

"After accounting for patient age and access, there was no significant association between eligibility and recommendation," write Dr Kevin Fiscella (University of Rochester School of Medicine and Dentistry, NY) and colleagues in their study, published online August 5, 2014 in the Journal of General Internal Medicine. "This finding is consistent with earlier studies suggesting that physicians underrecommend aspirin to prevent cardiovascular disease."

In 2009, as reported by heartwire , the United States Preventive Services Task Force (USPSTF) released guidelines on the use of aspirin in primary prevention. The USPSTF gave  aspirin an "A recommendation" for the prevention of MI in men and stroke in women. The USPSTF recommendations for aspirin in the primary prevention setting have come under increasing scrutiny, however, and have not been adopted by other groups. Earlier this spring, the FDA once again turned down a request by aspirin manufacturer Bayer to allow marketing for primary prevention of MI in patients with no prior history of CVD.

Back in 2003, following an FDA advisory committee meeting, the FDA opted to hold off on the company’s request for a primary-prevention indication, saying it needed to wait for new evidence. Those studies have steadily trickled in showing no significant benefit of aspirin in the primary-prevention setting, most strikingly from the same Oxford researchers who first published a key meta-analysis supporting primary-prevention benefits. The Oxford group's second meta-analysis showed that any benefits were likely offset by harms in most patients with no heart disease. Subsequently, the major cardiology organizations have downgraded their recommendations for aspirin use in the primary-prevention setting. The USPSTF typically updates its guidance once every five to seven years. The task force has finalized its research plan and is currently working on a draft recommendation document that will then be opened to public comment. A spokesperson told heartwire that given the number of different recommendations in development, the USPSTF does not provide timeline estimates.

In the present study, Fiscella et al examined physician recommendations for aspirin in individuals 40 years of age and older in the 2011–2012 National Health and Nutrition Survey (NHANES). Among 2929 participants, 87% of men and 16% of women were eligible for aspirin based on the Framingham risk equation for men and a similar risk calculator for women.

Using data from the NHANES home interview, just one-third of aspirin-eligible men said they recalled a recommendation from their physician that they "take low-dose aspirin each day to prevent heart attacks, stroke, or cancer." Just over 40% of eligible women recalled receiving the recommendation. Those with diabetes, those aged 65 to 79 years old, and those in poor health were more likely to have been recommended aspirin.

In a sample of 470 individuals with cardiovascular disease, 76% recall their physicians recommending they take aspirin to prevent MI or stroke.

"Setting aside the merits of aspirin for primary prevention of cardiovascular disease, our study findings underscore the challenge clinicians face in implementing any recommendation that requires risk calculation," write Fiscella and colleagues. "Potentially, incorporation of automated cardiovascular disease risk assessments into electronic health records could improve clinicians' estimation of risk and recommendation for prescribing."

The researchers note the study is limited by the participants' recall. Also, there is no available information about the physician specialty. Past research has suggested that cardiologists are more likely than primary-care doctors to prescribe aspirin.

The researchers report no conflicts of interest.

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