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Aspirin Use to Prevent Cardiovascular Disease and Colorectal CancerUpdated Modeling Study for the US Preventive Services Task Force

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Abstract

Importance  The US Preventive Services Task Force (USPSTF) is updating its 2016 recommendation on the use of aspirin for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC).

Objective  To provide updated model-based estimates of the net balance in benefits and harms from routine use of low-dose aspirin for primary prevention.

Design, Setting, and Participants  Microsimulation modeling was used to estimate long-term benefits and harms for hypothetical US cohorts of men and women aged 40 to 79 years with up to 20% 10-year risk for an atherosclerotic CVD event and without prior history of CVD or elevated bleeding risks.

Exposures  Low-dose (≤100 mg/d) aspirin for lifetime use, unless contraindicated by a bleeding event, and with stopping ages in 5-year intervals from age 65 to 85 years.

Main Outcomes and Measures  Primary outcomes were lifetime net benefits measured in quality-adjusted life-years (QALYs) and life-years. Benefits included reduced nonfatal myocardial infarction and ischemic stroke. Harms included increased nonfatal major gastrointestinal bleeding and intracranial hemorrhage. Reduced CRC incidence was considered in sensitivity analysis.

Results  Estimated lifetime net QALYs were positive for both men and women at 5% or greater 10-year CVD risk when starting between ages 40 and 59 years and at 10% or greater 10-year CVD risk when starting between ages 60 and 69 years. These estimates ranged from 2.3 (95% CI, −2.7 to 7.4) to 66.2 (95% CI, 58.2 to 74.1) QALYs per 1000 persons. Lifetime net life-years were positive for men at 5% or greater and women at 10% or greater 10-year CVD risk starting aspirin at ages 40 to 49 years and for men at 7.5% or greater and women at 15% or greater 10-year CVD risk at ages 50 to 59 years. These estimates ranged from 0.4 (95% CI, −6.1 to 6.9) to 52.4 (95% CI, 43.9 to 60.9) life-years per 1000 persons. Lifetime net life-years were negative in most cases for persons starting aspirin between ages 60 and 79 years, as were lifetime net QALYs for persons aged 70 to 79 years. Stopping aspirin between ages 65 and 85 years generally showed little advantage compared with lifetime use. Sensitivity analyses showed lifetime net benefits may be higher if aspirin reduced CRC incidence or CVD mortality and lower if aspirin increased fatal major gastrointestinal bleeding or reduced quality of life with routine use.

Conclusions and Relevance  This microsimulation study suggested that several population groups may benefit from taking aspirin for the primary prevention of CVD, primarily in persons starting at younger ages with higher 10-year CVD risk.

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Article Information

Corresponding Author: Steven P. Dehmer, PhD, HealthPartners Institute, 8170 33rd Ave S, Mail Stop 21112R, Minneapolis, MN 55440-1524 (steven.p.dehmer@healthpartners.com).

Accepted for Publication: February 21, 2022.

Author Contributions: Dr Dehmer had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Dehmer, Guirguis-Blake, Maciosek.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Dehmer, Maciosek.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Dehmer, O'Keefe, Guirguis-Blake, Maciosek.

Obtained funding: Maciosek.

Administrative, technical, or material support: Evans, Perdue, Maciosek.

Supervision: Dehmer.

Conflict of Interest Disclosures: Dr Dehmer reported receiving the Emerging Aspirin Investigator Award in 2018 from the International Aspirin Foundation, with international travel to an award ceremony and a small 1-time stipend. Dr Maciosek reported receiving a contract from the US government paid to his employer. No other disclosures were reported.

Funding/Support: This research was funded under contract HSA-290-2015-00007-I-EPC5, Task Order 9, from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services, under a contract to support the US Preventive Services Task Force (USPSTF).

Role of the Funder/Sponsor: Investigators worked with USPSTF members and AHRQ staff to develop the scope and key questions for this decision analysis. AHRQ staff provided project oversight, reviewed the report to ensure that the analysis met methodological standards, and distributed the draft for public comment. Otherwise, AHRQ had no role in the conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript findings. The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the US Department of Health and Human Services.

Additional Contributions: We thank the following individuals for their contributions to this project: Howard Tracer, MD (AHRQ); current and former members of the US Preventive Services Task Force who contributed to topic deliberations; Elizabeth S. Grossman, MPH (HealthPartners Institute), for project management support and contributions to the full modeling report; Holly G. Woodrow, MPH (HealthPartners Institute), for project management support; Sarah I. Bean, MPH, and Caitlyn A. Senger, MPH, from the systematic review team for their collaboration; and Jennifer S. Lin, MD (Kaiser Permanente Evidence-based Practice Center), for mentoring and project oversight. USPSTF members and peer reviewers did not receive financial compensation for their contributions.

Additional Information: A draft version of this evidence report underwent external peer review from 3 content experts (Jack Cuzick, PhD, Queen Mary University of London; Vanessa Selak, PhD, University of Auckland; and Steven M. Teutsch, MD, MPH, University of California, Los Angeles). Comments from the reviewers were considered in preparing the final decision analysis.

Editorial Disclaimer: This decision analysis modeling study is presented as a document in support of the accompanying USPSTF Recommendation Statement. It did not undergo additional peer review after submission to JAMA.

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