2019 Chinese Expert Consensus on Aspirin Use in Primary Prevention of Cardiovascular Disease

Introduction

Aspirin has long been a topic of interest in the primary prevention of atherosclerotic cardiovascular disease (ASCVD). In recent years, there has been a growing body of research and discussion about its role. With the widespread use of other preventive measures like blood pressure control, smoking cessation, and statin use in Europe and the US, the benefit-risk ratio of aspirin for primary prevention has changed. Some large – scale clinical trials have even suggested that aspirin may not be beneficial in low – risk populations. However, there are still aspects that need to be explored regarding its primary prevention value.

Aspirin’s Effects in Primary Prevention

Benefits

• Reduction of Non – Fatal Ischemic Events: Aspirin can significantly reduce non – fatal ischemic events such as myocardial infarction, transient ischemic attack, ischemic stroke, and major cardiovascular events (cardiovascular death, non – fatal myocardial infarction, and non – fatal stroke). This is supported by an up – to – date summary of primary prevention clinical trial data [6,7]. For example, in patients who may not be able to take other primary prevention measures like statins (due to contraindications or other reasons), aspirin may still play a role.
• Target Population: It is mainly applicable to adults aged 40 – 69 years. These individuals should still have a high risk of ischemia (≥10% expected risk for 10 years) after active intervention, have a low risk of bleeding, and be willing to take low – dose aspirin (75 – 100 mg/day) for long – term prophylaxis.

Risks

• Increased Bleeding Risk: The main risk is a significant increase in non – fatal major bleeding events including gastrointestinal bleeding and intracranial hemorrhage [5 – 8]. For instance, in populations at high risk of bleeding (such as those using other drugs that increase bleeding risk like anti – platelet, anti – coagulant, hormone, and non – steroidal anti – inflammatory drugs; with a history of gastrointestinal bleeding, peptic ulcer, or other site bleeding; age ≥70 years; thrombocytopenia; coagulopathy; severe liver disease; chronic kidney disease stage 4 – 5; uneradicated H. pylori infection; or uncontrollable hypertension), the use of aspirin is not recommended.

Recommendations for Chinese Population

Pre – medication Measures

1. Benefit – Bleeding Risk Assessment:
   • Carefully weigh the benefit – bleeding risk ratio. Screen and exclude high – risk bleeding populations. Periodically or dynamically assess the ratio during usage and solve problems promptly. This is crucial as the risk – benefit balance can change over time. For example, a patient with a history of peptic ulcer may initially have a higher bleeding risk, but after proper treatment (such as H. pylori eradication), the risk may decrease.
2. Gastrointestinal Bleeding Prevention:
   • According to relevant medical specialist regulations [17], take preventive measures. Treat gastrointestinal active pathological changes in advance (including Helicobacter pylori). If necessary, prophylactically apply proton pump inhibitor or H2 receptor antagonists. This is important because gastrointestinal bleeding is one of the major risks associated with aspirin use.
3. Lifestyle and Risk Factor Control:
   • Adhere to a healthy lifestyle (smoking cessation, careful drinking, scientific diet, and proper exercise) and positively control blood pressure, blood sugar, and blood lipid levels. Aspirin should be considered when hypertensive patients keep their blood pressure at <140/90 mmHg. A healthy lifestyle can not only reduce the overall risk of ASCVD but also potentially reduce the risk of bleeding associated with aspirin.
4. Patient – Doctor Communication:
   • Doctors should communicate with patients and obtain their consent prior to prescribing aspirin. This ensures that patients are well – informed about the potential benefits and risks and can make an educated decision.

High – Risk Groups for Consideration

1. Age and Risk Assessment:
   • Adults aged 40 – 69 years. If the 10 – year expected risk of ASCVD is ≥10% for their initial risk assessment, and there are still ≥3 major risk factors that remain poorly controlled or difficult to change after active treatment intervention (e.g., family history of early onset of cardiovascular disease), aspirin can be considered to reduce the risk of ischemic cardiovascular disease.
2. Risk Factors for ASCVD:
   • The main risk factors include hypertension, diabetes, dyslipidemia (total cholesterol ≥6.2 mmol/L or low – density lipoprotein ≥4.1 mmol/L or high – density lipoprotein <1.0 mmol/L), smoking, family history of early onset of cardiovascular disease (first – degree relatives’ age <50 years), obesity (body mass index ≥28 kg/m2), coronary artery calcification score ≥100 [20 – 23] or non – obstructive coronary artery stenosis (<50%) [24 – 27]. Coronary imaging examination of primary prevention subjects is not recommended routinely.

Populations Not Recommended

1. Age – related:
   • Population aged ≥70 years or <40 years old (III, B). The current evidence is insufficient to make a primary prevention recommendation, and individualized evaluation is needed. For the elderly (≥70 years), the risk of bleeding may be relatively higher, and the potential benefit of aspirin may be less clear.
2. High – risk of bleeding:
   • Population at high risk of bleeding (III, C) as mentioned above.
3. Risk of bleeding > thrombosis risk:
   • Patients whose risk of bleeding was assessed to be greater than the risk of thrombosis (III, C).

Conclusion

This 2019 Chinese expert consensus provides a comprehensive set of guidelines for the use of aspirin in the primary prevention of ASCVD. It takes into account the latest evidence – based medicine and China’s national conditions. By carefully following these recommendations, healthcare providers can make more informed decisions about aspirin use, balancing the potential benefits of reducing ischemic events with the risks of bleeding. This can help optimize the primary prevention strategy for ASCVD in the Chinese population.

doi: 10.1097/CM9.0000000000000762

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