Corrected post: June 11, 2025, citation corrected
Written by Babatunde Carew
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Daily low-dose aspirin did not improve disability-free survival in healthy elderly individuals but did increase the risk of major bleeding.
ASPREE shows aspirin isn’t risk-free
An estimated 11.6% of individuals use aspirin for primary prevention. As of 2019, ACC/AHA guidelines recommend against the routine use of aspirin in primary prevention of atherosclerotic cardiovascular disease (ASCVD) due to lack of net benefit. This recommendation was likely partially fueled by the ASPREE study. This randomized, double-blind, placebo-controlled trial investigated whether daily low-dose aspirin (100 mg) improved disability-free survival in generally healthy (most significantly, no baseline ASCVD) elderly individuals (≥70 years, or ≥65 for Black and Hispanic participants). Among 19,114 participants followed for a median of 4.7 years, aspirin did not significantly reduce the composite outcome of death, dementia, or persistent physical disability (HR 1.01, 95%CI 0.92–1.11, P=0.79). However, aspirin increased major hemorrhage risk (3.8% vs. 2.8%; HR 1.38, 95%CI 1.18–1.62, P<0.001). A key limitation is the relatively short trial duration, which could underestimate the potential benefits of aspirin therapy. The ASPREE trial resulted in significant deprescribing of low-dose aspirin for primary prevention in low- to no-risk patients.
How does this change my practice?
Because of this study, I always reassess ongoing aspirin use in elderly patients and almost never recommend aspirin for primary prevention. However, with a growing arsenal of cardiovascular risk stratification tools (hsCRP, lipoprotein a, coronary calcium score, etc.), we need studies exploring aspirin for primary prevention in the context of more nuanced patient selection. In the absence of an elevated risk for cardiovascular disease, I continue to recommend against aspirin for primary prevention.
Source
Effect of Aspirin on Disability-free Survival in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1499-1508. doi: 10.1056/NEJMoa1800722. Epub 2018 Sep 16. PMID: 30221596; PMCID: PMC6426126.
Incorrect citation on initial post:
Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med. 2018 Oct 18;379(16):1519-1528. doi: 10.1056/NEJMoa1803955. Epub 2018 Sep 16. PMID: 30221595
