Modern Hypertension Management May Redefine Cardiovascular Benefits of Aspirin

New findings suggest the modern management of hypertension may redefine the benefit associated with aspirin in decreasing the risk of first cardiovascular event and improved survival.

Data show nonexposure to aspirin use was associated with decreased risk of the primary outcome in patients with hypertension and no history of diabetes or stroke at increased risk of atherosclerotic cardiovascular disease (ASCVD).

“The use of multiple antihypertensive drugs, the downward redefinition of BP targets, and the improvement of additional cardiovascular prevention strategies may have been paramount in the association with decreased ASCVD risk in the examined context,” wrote Rita Del Pinto, MD, PhD, Department of Clinical Medicine, Public Health, Life and Environmental Sciences, University of L'Aquila.

Due to the lack of specific updated evidence, the current study investigated if aspirin use alongside blood pressure management is associated with decreased risk of first cardiovascular event and improved survival among those with hypertension at increased risk of ASCVD.

The multicenter Systolic Blood Pressure Intervention Trial (SPRINT) was a treat-to-target, 2-arm randomized clinical trial conducted from 2010 - 2013 (mean follow-up, 3.26 years). The trial compared intensive (<120 mm Hg) and standard (<140 mm Hg) guideline-directed BP-lowering strategies among patients with hypertension and no history of diabetes or stroke at increased risk of ASCVD.

Investigators obtained a primary prevention cohort by excluding individuals with baseline cardiovascular disease (CVD) and individuals with chronic kidney disease. Patients were included if valid baseline and consistent in-trial data on aspirin use (ie, the exposure) were available.

Data were analyzed from October 2021 - February 2022, with unpaired t and χ2 tests were used to test for differences in quantitative and qualitative data, respectively. Patients who were exposed versus not exposed were 1:1 propensity-matched for randomization group, sex, age, category, Black race, and smoking status.

The risk of cardiovascular event (adjudicated myocardial infarction, non–myocardial infarction acute coronary syndrome, stroke, acute heart failure, and CVD death) and all-cause mortality based on the exposure (expressed as hazard ratios [HR] with 95% CIs) were progressively adjusted for residual noncollinear confounders.

A total of 2664 participants in SPRINT were analyzed, with 1332 participants per study group. Data show 390 (29.3%) were women and 326 individuals (24.5%) were aged ≥75 years.

Those in the exposed group were older, had increased body mass index and better lipid profiles, and were more likely to have never smoked or been taking a statin, according to investigators. There were no-between group differences in history of peptic ulcer, chronic liver disease, or daily nonsteroidal anti-inflammatory drug use recorded.

Investigators observed non exposure was associated with decreased risk of the primary outcome. In multivariate analysis, 42 of 707 individuals with exposure experienced the primary outcome, compared to 20 of 720 without exposure (HR, 2.30; 95% CI, 1.31 - 3.90).

There were consistent findings in subgroups of younger patients, former and current smokers, and patients taking a statin, as well as in the sensitivity analysis among 2444 participants.

Data show the primary outcome rates of exposed and non-exposed groups were similar independent of randomization group, including standard (5.85%; 95% CI, 4.24% - 7.98% versus 3.60%; 95% CI, 2.37% - 5.39%) and intensive (4.66%; 95% CI, 3.24% - 6.63% versus 2.56%; 95% CI, 1.54% - 4.15%; P = .06).

“Long-term data on aspirin use in combination with emerging therapies for cardiovascular prevention may clarify the future role of this pivotal drug in similar clinical settings,” investigators concluded.

The research letter, “Analysis of Aspirin Use and Cardiovascular Events and Mortality Among Adults With Hypertension and Controlled Systolic Blood Pressure,” was published in JAMA Network Open.