National Trends in Preventive Aspirin Use Shaped by ASCVD Risk

An analysis of preventive aspirin trends by atherosclerotic cardiovascular disease (ASCVD) risk revealed that self-reported primary prevention aspirin use decreased among older adults and adults with low ASCVD risk, but additionally among adults with higher ASCVD risk.1

Evidence-based recommendations released by the American College of Cardiology/American Heart Association (ACC/AHA) in 2019 narrowed the patient population for preventive aspirin use to those at higher ASCVD risk and ≤70 years old without increased bleeding risk.2

“These findings build on a study through 2021 that did not examine trends by ASCVD risk,” wrote the investigative team, led by Timothy S. Anderson, MD, division of general internal medicine, University of Pittsburgh.1 “Further attention to reducing low-value aspirin use is warranted given 2022 recommendations by the US Preventive Services Task Force (USPSTF) against initiating primary prevention aspirin in patients 60 years and older, which may have also contributed to observed changes.”

Anderson and colleagues examined national trends in primary and secondary preventive aspirin use built upon 5 cycles of the nationally representative National Health and Nutrition Examination Survey (NHANES) from 2011 to 2023. NHANES response rates ranged from nearly 26% to 70%, with adjustments performed to weaken non-response bias, among nonpregnant adults aged 40 to 79. The survey specifically inquiries the use of aspirin to prevent heart attacks, stroke, or cancer.1

For the analysis, the team estimated trends in adults using aspirin by 4 hierarchical groups, including adults with known ASCVD, adults aged ≥70 years, adults with a 10-year ASCVD risk of <10%, and adults with a 10-year ASCVD risk of ≥10%. A total of 18,294 participants were included in the study, with a mean age of 57 years and more than half (51.7%) female.

Upon analysis, the secondary prevention use of aspirin remained stable at 69.9% in 2011-2012 and 66.3% in 2021-2023; P = .86). In that same period, there was a significant reduction in primary prevention aspirin use from 23.5% in 2017-2020 to 17.2% in 2021-2023 (P <.001), after updated ACC/AHA recommendations.

Among primary prevention cohorts, reported aspirin use decreased from 46.1% in 2017-2020 to 34.4% (P <.001) in 2021-2023 in adults aged ≥70 and from 16.5% to 10.8% (P <.001) in adults with ASCVD risk <10% in the same period. Aspirin use decreased from 33.6% in 2017-2020 to 27.8% in 2021-2023 (P = .04) among adults with ASCVD risk of ≥10%.

For those recommended against primary prevention aspirin use, rates significantly lowered in 2021-2023, compared with 2011-2020, among all age categories and sexes. Notably, Anderson and colleagues reported aspirin use decreased in Other Hispanic and White populations, but not for Asian, Black, or Mexican American populations. Patients without a routine health care location, Medicaid insurance, or without insurance also revealed no significant reduction in aspirin use.

Citing landmark clinical trials, and the ACC/AHA recommendations, Anderson and colleagues indicated that while self-reported primary prevention use decreased in those who were not recommended aspirin and those with high ASCVD risk, some cohorts continued to report aspirin use despite a lack of observable benefit.1

“Despite these reductions, many patients with limited likelihood to benefit reported continuing to take aspirin,” Anderson and colleagues added. “Furthermore, historically disadvantaged groups were less likely to reduce aspirin use.”

References

1. Wilson LM, Anderson TS. Trends in Preventive Aspirin Use by Atherosclerotic Cardiovascular Risk. JAMA. Published online January 22, 2025. doi:10.1001/jama.2024.27333
2. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Circulation. 2019 Sep 10;140(11):e647-e648. doi: 10.1161/CIR.0000000000000724] [published correction appears in Circulation. 2020 Jan 28;141(4):e59. doi: 10.1161/CIR.0000000000000754] [published correction appears in Circulation. 2020 Apr 21;141(16):e773. doi: 10.1161/CIR.0000000000000770]. Circulation. 2019;140(11):e563-e595. doi:10.1161/CIR.0000000000000677