Monday, October 31, 2016

Aspirin for primary prevention: who and when?

- Jennifer Middleton, MD, MPH

It seems that the pendulum on aspirin use for primary cardiovascular disease (CVD) prevention has swung back and forth over the last few years. Dr. Lin wrote about the debate regarding aspirin's risks and benefits on the blog when the United States Preventive Services Task Force (USPSTF) had last updated their guidelines in 2011; at that time, the evidence was mixed regarding the net benefit for aspirin. Fast forward to 2016, and the current issue of AFP reviews the latest USPSTF recommendation: aspirin likely benefits adults aged 50-59 who meet certain criteria.

The USPSTF now recommends that adults aged 50-59 with at least a 10% 10-year-CVD risk, without risk factors for serious bleeding, and with the willingness to take aspirin for at least 10 years take aspirin to reduce the risk of both CVD and colorectal cancer. This is a B recommendation (USPSTF recommends this service, net benefit is moderate to substantial). The data they reviewed is less convincing for adults of other ages; aspirin use for adults aged 60-69 has a C recommendation (selectively offer or provide this service, net benefit is small), while aspirin use for those under 50 and over 70 are both I recommendations (current evidence is insufficient to assess balance of harms and benefits).

Increasingly, recommendations about preventive care becoming less general and more personalized. Calculating CVD risk is already commonplace in assessing which patients might benefit from statins (though the controversies surrounding the most recent 10-year-risk calculator continue). Screening mammography may benefit only high-risk women under the age of 50. The benefit of colorectal cancer screening for those aged 76-85 is likely limited to patients without limited life expectancy and/or multiple co-morbid conditions. Keeping track of who needs what preventive service and when is more complex when sweeping generalizations ("everybody over age 50 should take an aspirin/get colorectal cancer screening/have an annual mammogram") no longer apply.

Apps such as the Agency for Healthcare Research and Quality Electronic Preventive Services Selector (AHRQ ePSS) can provide a quick, convenient way to search for relevant recommendations at the point-of-care with patients. The AHRQ ePSS app is free and provides a search tool that displays current USPSTF recommendations stratified by age, gender, tobacco history, and sexual activity. Pre-visit planning can help make preventive care a whole-office endeavor as can using Electronic Health Records (EHR) to identify those patients who may be overdue for services via registries or other population health tools. Regardless of the system used, having a systematic way to identify which patients might benefit from preventive services can leave more time for physicians to provide counseling about these increasingly complex recommendations.

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