Should healthy older adults take aspirin for primary cardiovascular prevention?
ASPREE randomised 19,114 community-dwelling adults aged 70 and over (65 and over for US minority groups) without cardiovascular disease, dementia, or disability to low-dose aspirin or placebo. Aspirin did not significantly reduce cardiovascular events, while major haemorrhage occurred significantly more often on aspirin [1].
In the same trial, all-cause mortality was higher in the aspirin group than in the placebo group, a finding driven largely by cancer-related deaths, which was unexpected and remains incompletely explained [2]. Taken together, the two reports gave no support for routine primary-prevention aspirin in this age group.
The 2022 USPSTF recommendation reflects this evidence: it advises against starting aspirin for primary prevention in adults aged 60 and over, and frames initiation between ages 40 and 59 in higher-risk individuals as a decision requiring individual judgement about bleeding risk [3]. None of this applies to secondary prevention, where aspirin retains an established role.
- ASPREE enrolled a healthy, largely white population without established cardiovascular disease; results do not transfer to secondary prevention or to higher-risk primary-prevention groups.
- The excess cancer mortality signal was unanticipated, was not the primary endpoint, and has not been consistently replicated.
Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly
Effect of Aspirin on All-Cause Mortality in the Healthy Elderly
Aspirin Use to Prevent Cardiovascular Disease: US Preventive Services Task Force Recommendation Statement
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