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

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

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 April 8 2021, 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 post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-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.

Read Disclaimer & Fine Print

SUMMARY:

The new ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease (2019) provides updated guidance regarding low-dose aspirin use. Low-dose aspirin (70-100 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 than benefit
• 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 targets
  • High coronary artery calcium score

<40 years of age

• Insufficient evidence to judge the risk–benefit ratio of routine aspirin for the primary prevention of ASCVD
  • As above 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

KEY POINTS:

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
  • Thrombocytopenia
  • Coagulopathy
  • Chronic kidney disease
  • Concurrent use of other medications that increase bleeding risk e.g.,
    • NSAID | Steroids | Direct oral anticoagulants | Warfarin

Risk Enhancers

• Family history of premature ASCVD
  • Males <55 years | Females <65 years
• Primary hypercholesterolemia
  • LDL-C 160-189 mg/dL (4.1-4.8 mmol/L)
  • Non-HDL-C 190-219 mg/dL (4.9-5.6 mmol/L)
• Chronic kidney disease
  • eGFR 15- 59 ml/min per 1.73m2 with or without albuminuria
  • Not treated with dialysis or kidney transplantation
• Metabolic syndrome
• Conditions specific to women
  • Preeclampsia
  • Premature menopause (before age 40)
• Inflammatory disease, especially
  • Psoriasis
  • RA
  • HIV
• Ethnicity
  • 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
• Lipid/biomarkers
  • 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

Learn More – Primary Sources:

2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease

JAMA Viewpoint: A Practical Approach to Low-Dose Aspirin for Primary Prevention

Hypertension: New heart-disease prevention guideline: What physicians must know (AMA)

Related ObG Topics:

2018 ACC/AHA Multisociety Guideline: Cholesterol Assessment and Primary ASCVD Prevention

ACOG Redefines the Postpartum Visit – The ‘Fourth Trimester’

ACC/AHA Blood Pressure Guideline: New Classification System and Treatment Targets