Dr. Xiong is assistant clinical professor, departments of internal medicine and psychiatry and behavioral sciences, University of California, Davis. Dr. Kenedi is an adjunct professor of psychiatry at Duke University Medical Center in Durham, NC, and a consultant (attending physician) in internal medicine and liaison psychiatry, Auckland City Hospital, Auckland, New Zealand.
Principal Source: U.S. Preventive Services Task Force. Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;150:396-404.
Practice Points
- Consider discussing or recommending daily aspirin for men age 45 to 79 and women age 55 to 79 who are at risk for CVD, such as those who smoke or have diabetes.
- Psychiatric patients are at higher risk of CVD and often face systemic barriers to medical care. Collaborate with primary care physicians to determine which patients are good candidates for daily aspirin therapy.
- In psychiatric patients, watch for a potential drug-drug interaction between aspirin and valproate and increased risk of bleeding with selective serotonin reuptake inhibitors.
- Aspirin is associated with increased risk of serious gastrointestinal (GI) bleeding, hematuria, easy bruising, and epistaxis. Risk factors for GI bleeding include upper GI pain, history of GI ulcers, nonsteroidal anti-inflammatory drug (NSAID) use, alcohol dependence, and other anticoagulant use.
Cardiovascular disease (CVD) is the leading cause of death in the United States, accounting for >50% of all deaths. In persons age >40, the lifetime risk of death from CVD is 2 in 3 for men and more than 1 in 2 for women.1 Persons with severe mental illness have nearly twice the risk of death from CVD compared with the general population, which may be attributed to:
- lifestyle factors, including poor diet, lack of exercise, and tobacco dependence2
- antipsychotic medications, which have been shown to increase the risk of CVD3
- lower likelihood of undergoing cardiovascular procedures—including percutaneous transluminal coronary angioplasty and coronary artery bypass graft surgery—after myocardial infarction (MI).4
Psychiatrists are often the primary contact for patients with mental illness, giving us an opportunity to collaborate with primary care physicians and apply preventative measures that can reduce illness and improve patients’ morbidity and mortality. In addition to evaluating patients for possible hypercholesterolemia and diabetes, adding daily aspirin for primary prevention of heart attacks and strokes is an easily implementable option that could make a real difference in their health and quality of life.
New aspirin recommendations
The U.S. Preventive Services Task Force (USPSTF) found evidence that daily aspirin decreases the incidence of MI in men and ischemic strokes in women.1 However, total mortality for either gender was not significantly reduced.5 The USPSTF’s updated recommendations reflect results of the Women’s Health Study6 with different guidelines for men and women.
The USPSTF recommends daily aspirin for men age 45 to 79 and for women age 55 to 79 when the benefits of decreased MI for men and ischemic strokes for women outweigh the risks of increased GI bleeding ( Table 1 ).1 This grade A recommendation means there is high certainty of substantial net benefit.
Aspirin is not recommended for patients age ≥80 because of insufficient evidence of harm or benefit. The risks of MI in men age <45 and stroke in women age <55 are low, and daily aspirin generally is not indicated.
Optimal aspirin dose is unclear. The USPSTF recommends approximately 75 mg/d (effectively 81 mg/d or 1 “baby aspirin” in most U.S. settings). Higher aspirin doses might not be more effective for primary prevention and could increase the risk of GI bleeding. Note that some patients with a history of cardiovascular or cerebrovascular events might receive higher aspirin doses for secondary prevention of additional injury.
Risk assessment. In addition to age, other risk factors for CVD include:
- diabetes
- high total cholesterol (>240 mg/dL)
- low high-density lipoprotein cholesterol or so-called “good cholesterol” (<40 mg/dL for men, <50 mg/dL for women)
- hypertension
- smoking
- family history.
Several online tools—based on data from the Framingham Heart Study and other cohorts—can help estimate a patient’s CVD risk ( see Related Resources ), or consult with your patient’s primary care physician.
Potential harm of aspirin. USPSTF considers age and gender the most important risk factors for GI bleeding. GI bleeding is defined as serious hemorrhage, perforation, or other complications that could lead to hospitalization or death. Other risk factors include:
- upper GI pain
- history of gastric or duodenal ulcers
- NSAID use
- heavy, regular alcohol consumption.