- Taking low-dose aspirin to prevent heart disease is reasonable for adults with diabetes who are at increased risk of cardiovascular disease and not at increased risk for bleeding.
- Low-dose aspirin therapy is recommended for most men over age 50 and women over 60 with diabetes who have one or more additional heart disease risk factors.
- Aspirin should not be recommended for heart disease prevention for men under 50 and women under 60 with diabetes with no major additional heart risk factors, because the potential adverse effects from gastrointestinal bleeding offset potential benefits of treatment.
Low-dose aspirin therapy is a reasonable measure to prevent a first heart attack or stroke among people with diabetes who also have a high risk for heart disease, according to a joint statement of the American College of Cardiology Foundation, the American Diabetes Association and the American Heart Association and published online in the journals of each organization, the Journal of the American College of Cardiology, Diabetes Care, and Circulation: Journal of the American Heart Association.
People with diabetes eligible for low-dose aspirin therapy based on this guideline include most men over age 50 and most women over age 60 who have additional risk factors.
Trials to determine whether aspirin can prevent a first heart attack or stroke in adults with diabetes have had mixed results, but overall suggest that aspirin modestly reduces the risk of cardiovascular events. More research is needed to better define the specific effects of aspirin in patients with diabetes, including gender-specific differences, according to the joint statement.
“Because the relative risk reduction appears to be modest, the panel felt that we are on strongest ground recommending aspirin for those at increased cardiovascular disease (CVD) risk, defined by the age categories and risk factors mentioned or by a calculation of CVD risk,” said Michael Pignone, M.D., lead author of the statement and chief of the general medicine division and professor of medicine at the University of North Carolina in Chapel Hill.
“We felt that the benefits were likely to exceed the downsides, such as gastrointestinal bleeding, for the groups mentioned. There will be some younger people with sufficient risk to warrant aspirin, but many who are not at sufficient risk.”
Authors of the statement said scientific evidence to support aspirin therapy depends on the underlying CVD risk. Those with higher risk should have greater benefit, they said, but the decision to use aspirin therapy depends on the use of other treatments such as cholesterol-lowering medicines, blood pressure control and quitting smoking.
On average people with diabetes are at three times the increased risk of cardiovascular events compared with age- and sex-matched people without diabetes, according to the Centers for Disease Control and Prevention. In patients with diabetes who are older than 65, 68 percent die from coronary heart disease and 16 percent from stroke. Researchers have proposed numerous mechanisms for the increased cardiovascular risk with diabetes, including increased tendency toward clot formation, platelet activity and damage to the arterial wall lining.
In 2007, the American Diabetes Association and AHA jointly recommended that aspirin therapy (75–162 mg/day) be started for both men and women above age 40 with another major risk factor, such as a family history of CVD, high blood pressure, smoking, high cholesterol or protein in the urine.
“The new recommendations only address primary prevention,” said Craig Williams, PharmD., a co-author of the statement and associate professor of pharmacy and medicine at Oregon Health Sciences University in Portland Oregon. “All three organizations continue to strongly recommend low-dose aspirin for all patients who have previously had a heart attack or stroke, so-called secondary prevention.”
The major adverse effects of aspirin therapy include intracranial bleeding, which can lead to hemorrhagic stroke, and gastrointestinal bleeding. Based on data from primary and secondary prevention trials conducted in patients with and without diabetes, low-dose aspirin appears to be associated with an absolute risk of hemorrhagic stroke of one per 10,000 people annually.
Co-authors are: Mark J. Alberts, M.D.; John A. Colwell, M.D., Ph.D.; Mary Cushman, M.D., M.Sc.; Silvio E. Inzucchi, M.D.; Debabrata Mukherjee, M.D.; Robert S. Rosenson, M.D.; Peter W. Wilson, M.D.; and M. Sue Kirkman, M.D.
The American College of Cardiology is leading the way to optimal cardiovascular care and disease prevention. The College is a 39,000-member nonprofit medical society and bestows the credential Fellow of the American College of Cardiology upon physicians who meet its stringent qualifications. The College is a leader in the formulation of health policy, standards and guidelines, and is a staunch supporter of cardiovascular research. The ACC provides professional education and operates national registries for the measurement and improvement of quality care. More information about the association is available online at www.acc.org.
The American Diabetes Association is leading the fight to stop diabetes and its deadly consequences and fighting for those affected by diabetes. The Association funds research to prevent, cure and manage diabetes; delivers services to hundreds of communities; provides objective and credible information; and gives voice to those denied their rights because of diabetes. Founded in 1940, our mission is to prevent and cure diabetes and to improve the lives of all people affected by diabetes. For more information please call the American Diabetes Association at 1-800-DIABETES (1-800-342-2383) or visit www.diabetes.org. Information from both these sources is available in English and Spanish.
The American Heart Association, founded in 1924, is the nation’s oldest and largest voluntary health organization dedicated to building healthier lives, free of heart disease and stroke. To help prevent, treat and defeat these diseases — America’s No. 1 and No. 3 killers — we fund cutting-edge research, conduct lifesaving public and professional educational programs, and advocate to protect public health. To learn more or join us in helping all Americans, call 1-800-AHA-USA1 or visit www.americanheart.org.