Reference: J Am Heart Assoc. 2019 Dec 17;8(24)
The once “obvious” benefits of aspirin therapy for primary prevention of cardiovascular disease have recently been called into question, with newer data suggesting that the risk of bleeding outweighs cardiovascular benefits for many patients. However, more than 90% of participants in the three most recent aspirin trials (ASPREE, ASPIRE, ARRIVE) identified as non-Hispanic white, so more information is needed about the risks and benefits of aspirin in diverse populations.
The Southern Community Cohort Study (SCCS) is a prospective cohort of over 80,000 adults (about 70% black) in the Southeastern United States in a low-income, underinsured population. This paper analyzed survey data from 65,000 non-Hispanic black or white SCCS participants aged 40-79 years (median 51.5 years) without indications for aspirin for secondary prevention. Investigators defined low-dose aspirin use as 81-162 mg at least 2 days per week for at least one month at the time of enrollment. Aspirin use was self-reported, and details about frequency of aspirin use or whether participants were taking aspirin due to a doctor’s advice were not reported. Participants were stratified by a modified Framingham risk score that substituted body mass index for lipid levels into low (<6%), intermediate (6-9.9%), or high (≥10%) 10-year cardiovascular risk. Systolic blood pressure was known for 17% of participants and the researchers used reported prior diagnoses of hypertension to impute blood pressure values for the risk scores.
Black participants were less likely to take aspirin than white participants in all three risk categories (low 6.1% vs.10.2%, intermediate 9.8% vs.15.5%, high 17.8% vs. 26.8%, p <0.001 for all categories). When adjusted for covariates, black participants were less likely to take aspirin than their white counterparts (adjusted odds ratio 0.79, 95% CI 0.75-0.82). Participants with diabetes, concomitant NSAID use, health insurance, higher educational attainment, and higher household income were more likely to take aspirin. Fatal ischemic heart disease, as identified by national vital status data after mean 11 years follow-up, occurred at a higher rate among white participants than in black participants (incidence rate ratio 1.21, 95% CI 1.07-1.36). Low-dose aspirin was not associated with a lower rate of ischemic cardiac death among black (adjusted hazard ratio 1.18, 95% CI 0.98-1.4) or white (adjusted hazard ratio 0.86, 95% CI 0.68-1.1) participants. Adverse event data were not reported.
Several issues limit our ability to draw firm conclusions about true aspirin use and its related benefit. The authors failed to delineate frequency of aspirin use, and taking it 2 days a week vs. 7 makes a difference. Further, we don’t know if aspirin was recommended by a medical provider, so we can’t draw conclusions about adherence. It would also be helpful to know if combining an imputed blood pressure with substitution of BMI for lipid values results in a valid Framingham risk category. The authors do not provide information about Hispanic participants because of an insufficient sample size, so the study does not look at impact “across race and ethnicity.” On the other hand, this study offers information about a disproportionately under-studied population: non-Hispanic blacks had a lower rate of aspirin use compared with whites, and in this real-life cohort, aspirin use was not associated with a reduction in ischemic cardiac death.
For more information, see the topic Aspirin for Primary Prevention of Cardiovascular Disease in DynaMed.
DynaMed EBM Focus Editorial Team
This EBM Focus was written by Carina Brown, MD, Assistant Professor at Cone Health Family Medicine Residency. Edited by Alan Ehrlich, MD, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School, Dan Randall, MD, Deputy Editor for Internal Medicine at DynaMed, and Katharine DeGeorge, MD, MS, Associate Professor of Family Medicine at the University of Virginia and Clinical Editor at DynaMed.