What pharmacists need to know about the 2019 ACC guidelines on

New evidence suggests aspirin should not be used to prevent ASCVD

Ever since McNeil and his colleagues published their study last fall refuting long-held recommendations for broad low-dose aspirin therapy for cardiac health, many physicians have been unsure exactly what to do. As our February blog was aptly titled: “To aspirin or not to aspirin…That is the question.”

In that blog (which we encourage you to read if you have not as yet), we discussed the McNeil et al. study that was widely covered by the media, including a record three distinct articles in the Oct. 18 edition of the highly respected New England Journal of Medicine (NEJM). Our blog concluded that “At RxLive, we strongly believe that in most cases aspirin is NOT recommended for primary prevention, and that having a private consultation with a skilled clinical pharmacist such as ours is strongly advised.”

Our recommendation hasn’t changed. But now there’s the recent publication of further supporting evidence and guidelines by the American College of Cardiology/American Heart Association Task Force which is worthy of discussion. The group’s 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease updates evaluations and recommendations based on the class of risk (COR) and level of evidence (LOE) for the prevention of atherosclerotic cardiovascular disease (ASCVD). Task force guidelines also review and take into consideration lifestyle factors such as tobacco use, and co-morbidities including diabetes, lipid abnormalities,  and hypertension, as well as treatment efficacy including, yes, aspirin.

If you don’t have an evening or weekend to read the entire set of guidelines just yet, the nearly 100-page report offers a helpful “top-10 list” summary on the primary prevention of ASCVD on page 4.

Beginning on page 45, it drills down to today’s issue — aspirin use. In a chart from the report, the task force summarizes the risks and level of evidence succinctly:

As you can see, use of low-dose aspirin for the routine prevention of ASCVD is no longer recommended for patients over the age of 70, nor those at an increased risk of bleeding, as the risk of harm exceeds the risk of benefit.

However, the task force stops short of recommending against the use of aspirin in select patients at an increased risk of ASCVD. Rather, they have left it in the provider’s court to decide: “Low-dose aspirin might be considered for the primary prevention of ASCVD among select adults 40 to 70 years of age who are at higher ASCVD risk but not at increased bleeding risk.”

Partner with a clinical pharmacology provider to ensure your health care aligns with the latest research

Earlier in the document, the task force notes that in general, “The method of assessing quality is evolving including the application of standardized, widely used, and preferably validated evidence-grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee.”

As with everything in healthcare, we’re always studying, always learning, and almost always revising clinical best practices based on the latest trusted evidence.

The appropriate guidelines will continue to evolve with that ongoing study. For now, this is a valuable resource that can help guide physicians and their care team, including clinical pharmacists, in how best to consider prescribing aspirin use to each individual patient.

We at RxLive continue to keep abreast of the latest ever-evolving evidence and trends in pharmacology and pharmacogenomics. Our skilled team of clinical pharmacists would welcome the opportunity to be an extension of your team to serve both you and your patients. Contact us here for more information!

Kristen Engelen, PharmD
Kristen Engelen, PharmD, is the chief pharmacy officer of RxLive and a certified consultant pharmacist; she has over a decade of experience in retail pharmacy settings. Kristen became an RxLive co-founder because of her passion for geriatric pharmacy, with a focus on the intersection of pharmacy and aging.