ACC / AHA Guideline Recommendations: Low Dose Aspirin for Primary CVD Prevention
Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Discuss the 2019 ACC/AHA recommendations for the use of low-dose aspirin for primary prevention of cardiovascular disease 2. State key risk factors for bleeding that should be assessed when considering the use of low-dose aspirin
Estimated time to complete activity: 0.25 hours
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from April 8 2019 through 07/15/2022, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the test and evaluation. Upon registering and successfully completing the test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.
Designated for 0.2 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.
The ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease (2019) provides guidance regarding low-dose aspirin use. Low-dose aspirin (70 to 100 mg orally daily) still plays a role in prevention of ASCVD. However, the new recommendations advise against routine administration of aspirin to those >70 years of age.
40 to 70 years of age
Low-dose aspirin “might be considered” for primary ASCVD if individual is
At higher ASCVD risk and
Not at increased bleeding risk
Class (strength) of recommendation
IIb: Weak (Benefit ≥ Risk)
Level (Quality) of Evidence
A: High (High quality RCT based)
Historically, studies demonstrated benefit at >10% estimated 10-year ASCVD risk but more recent studies are less conclusive and therefore
Specific risk cut-off not included in current guideline
Consider overall risk, including risk-enhancing factors
Base management on patient and clinician preferences
Some may opt to focus on modifiable risk factors
The guideline states
Recent trials show that absolute risk for ASCVD events typically exceeds that of bleeding and, although the gap of relative benefit to relative harm for aspirin has narrowed, the number needed to treat to prevent an ASCVD event remains lower than the number needed to harm to cause bleeding.
>70 years of age
Low-dose aspirin “should not be administered on
a routine basis” for primary ASCVD prevention
Risk of bleeding with potential harm greater
Class (strength) of recommendation
III: Harm (Risk > Benefit)
Level (Quality) of Evidence
B-R: (Randomized, Moderate quality)
There may be clinical scenarios where low-dose
aspirin ‘might’ be discussed, such as
Strong family history of premature MI
Inability to achieve lipid, BP or glucose
High coronary artery calcium score
<40 years of age
evidence to judge the risk–benefit ratio of routine aspirin for the primary
prevention of ASCVD
for those >70, there may be clinical high ASCVD scenarios where clinicians ‘might’
discuss with their patients the use of low-dose aspirin
Note: Low-dose aspirin should not be used for primary ASCVD prevention when there is increased risk of bleeding, regardless of age
Increased Bleeding Risk Factors
Increased bleeding risk includes, but is not limited, to the following
History of previous GI bleeding or peptic ulcer disease or bleeding at other sites
Age >70 years
Chronic kidney disease
Concurrent use of other medications that increase bleeding risk e.g.,
NSAID | Steroids | Direct oral anticoagulants | Warfarin
Family history of premature ASCVD
Males <55 years | Females <65 years
LDL-C 160 to 189 mg/dL (4.1 to 4.8 mmol/L)
Non-HDL-C 190 to 219 mg/dL (4.9 to 5.6 mmol/L)
Chronic kidney disease
eGFR 15 to 59 ml/min per 1.73m2 with or without albuminuria
Not treated with dialysis or kidney transplantation
Conditions specific to women
Premature menopause (<40 years)
Inflammatory disease, especially
Asian American | Hispanic/ Latino Americans / Blacks
There is heterogeneity in risk between and within racial and ethnic groups
Native American/ Alaskan populations have higher ASCVD rates compared to non-Hispanic whites
Persistently elevated triglycerides (≥175 mg/dL)
Additional markers if measured
High sensitivity (hs)-CRP: ≥2.0 mg/L
Lp(a) levels: ≥50 mg/dL or ≥125 nmol/l
apoB: ≥130 mg/dL especially at higher levels of Lp(a)
Elevated apo B ≥130 mg/dL corresponds to an LDL-C >160 mg/dL and constitutes a risk enhancing factor
ABI (ankle-brachial index) <0.9
ACC/AHA Guidelines Differ from the USPSTF Recommendations
The ACC/AHA guidelines differ from the USPSTF recommendations (see ‘Learn More – Primary Sources’ below)
Key differences include
Ages 40 to 59 years and ≥10-year CVD Risk
Decision to initiate low-dose aspirin use for the primary prevention of CVD should be an individual one
Evidence indicates that the net benefit of aspirin use in this group is small
Persons who are not at increased risk for bleeding and are willing to take low-dose aspirin daily are more likely to benefit
The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences
There is at least moderate certainty that the net benefit is small
Offer or provide this service for selected patients depending on individual circumstances
The USPSTF recommends against initiating low-dose aspirin use for the primary prevention of CVD
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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