Jeffrey Berger, MD: Evolving Role of Aspirin

Once a staple in treatment algorithms for decades, a bevy of new research released in the past year have called into question the true role of aspirin for prevention of cardiovascular events.

Beginning at ACC 2019 with the release of ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease, new data has changed the way cardiologists and clinicians view regular use of low-dose aspirin in a few could have expected decades ago.

Included in the new guidelines were several recommendations based on meta-analysis and recent trials, including recommending low-dose aspirin should not be administered on a routine basis for prevention of atherosclerotic cardiovascular disease in adults older than 70 and that is should not be administered for primary prevention among adults at any age who are at increased bleeding risk. The new guidelines also recommended low-dose aspirin might be considered for primary prevention of ASCVD in certain adults between 40 and 70 years old who are not at an increased risk of bleeding.

For more perspective on how the role of aspirin has changed in the eyes of cardiologists, MD Magazine® sat down with Jeffrey Berger, MD, associate professor of Medicine and Surgery and director of Center for Prevention of Cardiovascular Disease at NYU Langone Health, to hear his thoughts on the topic.

MD Mag: What do you think was the most significant study examining aspirin to be released in 2019?

Berger: There have been several studies looking at the effects of aspirin in both the primary prevention or the prevention of a first heart attack or stroke, as well as in patients who are on multiple antiplatelet or antithrombotic therapies, can we start peeling off medicines? And I think they're two very, very separate areas, but both with very, very interesting data and compelling.

So, regarding the prevention of a first heart attack or stroke, there have been a lot of trials published in the last few years that really have demonstrated that aspirin really needs to be counterbalanced by its benefit versus risk, such that while aspirin probably prevents first heart attack or stroke by a marginal benefit, there is a significantly increased risk of major bleeding and I think it just reminds us of why we are all physicians and why it is the art of medicine and it's not black or white.

It's not that every patient should be on a drug, be it aspirin in this example—because while it does prevent the first heart attack or stroke in certain individuals, it really does need to be balanced against its risk. I think there was an interesting trial that showed that perhaps in the elderly, there really is no benefit of aspirin for the prevention of a first heart attack or stroke and I think it's probably because elderly patients are at higher risk of bleeding. I think it really does call into question, the whole use of aspirin in this topic regarding peeling off medicines.

So, there have been a lot of trials in the last year that really have looked at when you're treating patients for a heart attack or an acute coronary syndrome and there are multiple antiplatelet and antithrombotic therapies. So, they are on very, very strong therapies and the question now is, can we start peeling off medicine. So, there have been a few studies that have looked at what about if you remove aspirin and the data to date I think is compelling that that's a potential option and a lot of patients, I think that it's not definitive yet. I think there is less bleeding and I think there's not a significant increased risk of having a cardiovascular event but I think numerically, there are more events and I think we really have to sort of see more data larger trials before we start taking off drugs such as aspirin.