Aspirin Deprescribing Guidelines
Patient-specific recommendations to change or discontinue aspirin that may lead to fewer adverse events
Jennifer Glen
Provided by
EVAL FoundationThere are multiple medical indications for the chronic use of aspirin due to its antiplatelet effect. Draeger et al (2022) highlight that, "there are a significant number of patients taking aspirin when it is not appropriate or at a dose higher than recommended." Further, inappropriate aspirin use can increase the risk of serious adverse events. The authors discuss the implementation of quality improvement programs designed to reduce the rate of inappropriate aspirin use (deprescribing) that may lead to improved prescribing practices and may demonstrate improvements in patient mortality. Patient-specific recommendations for changes in or discontinuation of aspirin is key to improved outcomes.
Draeger et al (2022) published a guideline summary flowchart (p. 222) that walks a clinician through a set of evidence-based decisions to determine the appropriate use of daily aspirin. When the question is asked if a patient ought to be deprescribed aspirin, this app replicates the guideline flowchart for quick access to aspirin best practices and provides a source of documentation.
To understand how the guideline summary flowchart was converted into this app, refer to the app logic flowchart for decision logic.
All questions & possible results
Zone 1Title not visible
Is the patient anticoagulated?
Select one option:
- Yes
- No
What is the indication?
Select all that apply:
- Venous thromboembolism (VTE)
- Heart valve replacement
- Atrial fibrillation (Afib) or Atrial flutter
- Not listed
What is the valve type?
Select one option:
- Bioprosthetic valve
- Transcatheter aortic valve
- Mechanical valve
Does the patient have coronary artery disease (CAD)?
Select one option:
- Yes
- No
Is the coronary artery disease (CAD) stable?
Select one option:
- Yes
- No
Zone 2Title not visible
Previous cardiovascular event or procedure?
Events or procedures include:
- Peripheral Arterial Disease (PAD)
- Ischemic Stroke or Transient Ischemic Attack (TIA)
- Venous Thromboembolism (VTE)
- Coronary Artery disease (CAD)
- Elective Percutaneous Coronary Intervention (PCI)
- Acute Coronary Syndrome (ACS) within the last year
- Carotid Artery Disease (Carotid artery dissection or Ischemic artery disease)
Select one option:
- Yes
- No
Is the patient diabetic?
Select one option:
- Yes
- No
What is the patient's age?
Select one option:
- <40 years
- 40-69 years
- ≥70 years
Is the patient at high risk of bleeding?
- There are no US-based externally validated risk prediction tools for bleeding risks associated with low-dose aspirin use for the primary prevention of CVD.*
- Risk factors consistently and independently associated with bleeding risk in multivariable analyses include*
- Older age (>59)
- Male sex (Risk for serious GI bleeding is 2 times greater in men than women)
- Diabetes
- Liver disease
- Alcohol disease
- Peptic ulcer disease, and history of gastrointestinal issues, such as prior gastrointestinal hospitalization.
- Additional risk factors are associated with increased bleeding risk (nonexhaustive):
- Thrombocytopenia^
- Coagulopathy^
- Chronic kidney disease (CKD)^
- Concurrent use of other medications that increase bleeding risk, such as nonsteroidal anti-inflammatory drugs (NSAID), steroids^
References
^ 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease
* 2022 Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer (USPSTF)
Select one option:
- Yes
- No
High risk of atherosclerotic cardiovascular disease (ASCVD)?
To estimate the risk of ASCVD, go to the American College of Cardiology (ACC) online ASCVD Risk Calculator
Select one option:
- Yes
- No
What was the event or procedure?
Peripheral artery disease (PAD)?
Select one option:
- No
- Yes
Is the PAD symptomatic?
Common symptoms of PAD include:
- Aching, heaviness, pain or cramping in the leg/calf/thighs/buttock muscles, especially during walking an other activities
- Loss of feeling or tingling in the legs or feet
- Leg pain that disturbs sleep or pain at rest
- Sores, wounds or ulcers on toes, feet or legs that heal slowly or not at all
- Toes or feet look pale, discolored, darkened, black or bluish
- Feet that are cold to touch or one foot is colder than the other
Select one option:
- Yes
- No
Ischemic stroke or transient ischemic attack (TIA) without anticoagulant?
Select one option:
- No
- Yes
Venous thromboembolism(VTE)?
Select one option:
- No
- Yes
Coronary artery disease (CAD)?
Select one option:
- No
- Yes
Elective percutaneous coronary intervention (PCI)?
Select one option:
- No
- Yes
Acute coronary syndrome (ACS) within the last year?
Select one option:
- No
- Yes
Carotid artery disease (CAD)?
Select one option:
- No
- Yes
Select one
Select one option:
- Carotid artery dissection
- Ischemic carotid artery disease
Possible results
In bioprosthetic heart valves: Weigh risks versus benefits of Aspirin
If Aspirin is elected, dosing recommendation is 75-100mg daily
Guidelines:
In carotid artery dissection: Aspirin is recommended for at least 3-6 months
In Afib/flutter without CAD: Aspirin is NOT recommended
In mechanical heart valves: Aspirin is recommended
Aspirin dosing recommendation is 75-100mg daily
Guidelines:
In a non-diabetic without anticoagulation or previous cardiovascular event/procedure without a high risk of bleeding but is at high risk of ASCVD (Age 40-69 years): Weigh risks versus benefits of Aspirin
If Aspirin is elected, dosing recommendation is 75-100 mg daily
In VTE: Aspirin is recommended AFTER anticoagulation is stopped
In acute coronary syndrome (within the last year) without anticoagulation: Aspirin is recommended as part of DAPT
Aspirin dosing recommendation is 75-100mg daily.
DAPT: Dual Antiplatelet Therapy
Guidelines
In ischemic stroke/TIA without anticoagulation: Aspirin is recommended
Aspirin dosing recommendations
- Initial: 50-325mg
- Long-term: 75-100mg
Guidelines
- 2014 Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
- 2012 Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis
In asymptomatic PAD: Weigh risks versus benefits of Aspirin
If Aspirin is elected, dosing recommendation is 75-325mg daily
In diabetics without anticoagulation: Weigh risks versus benefits of Aspirin
If Aspirin is elected, dosing recommendation is 75-162 mg daily
Guidelines:
2. 10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2019.
In a non-diabetic without anticoagulation or a previous cardiovascular event/procedure (age ≥ 70 years): Aspirin in NOT recommended
In symptomatic PAD: Aspirin is recommended
Aspirin dosing recommendation is 75-325mg daily
In Afib/flutter with stable CAD: Aspirin is NOT recommended
In ischemic carotid artery disease: Aspirin is recommended
Aspirin dosing recommendation is 75-325mg daily
Guidelines: 2011 AHA/ASA Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease.
In Afib/flutter with unstable CAD: Aspirin is recommended
Aspirin dosing recommendation is 75-100mg daily
Guidelines:
In elective percutaneous coronary intervention without anticoagulation: Aspirin is recommended as part of DAPT or monotherapy after DAPT
Aspirin dosing recommendation is 75-100mg daily.
DAPT: Dual Antiplatelet Therapy
Guidelines
In a non-diabetic without anticoagulation or previous cardiovascular event/procedure without a high risk of bleeding or high risk of ASCVD (Age 40-69 years): Aspirin in NOT recommended.
In CAD without anticoagulation: Aspirin is recommended
Aspirin dosing recommendation is 75-100mg daily.
Guidelines
In a non-diabetic without anticoagulation or previous cardiovascular event/procedure with a high risk of bleeding (Age 40-69 years): Aspirin in NOT recommended.
In VTE without anticoagulation: Aspirin is recommended AFTER anticoagulation is stopped
In transcatheter aortic valves: Aspirin is recommended
Aspirin dosing recommendation is 75-100mg daily
Guidelines:
Citation
Draeger C, Lodhi F, Geissinger N, Larson T, Griesbach S. Interdisciplinary Deprescribing of Aspirin Through Prescriber Education and Provision of Patient-Specific Recommendations. WMJ. 2022 Oct;121(3):220-225. PMID: 36301649. See diagram on page 222.
Literature
- Interdisciplinary Deprescribing of Aspirin Through Prescriber Education and Provision of Patient-Specific Recommendations. WMJ. 2022 Oct;121(3):220-225. — Draeger C, Lodhi F, Geissinger N, Larson T, Griesbach S.
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- 10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2019. Diabetes Care. 2019 Jan;42(Suppl 1):S103-S123. — American Diabetes Association.
- 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. — Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC Jr, Virani SS, Williams KA Sr, Yeboah J, Ziaeian B.
- 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017 Mar 21;135(12):e686-e725. — Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, Fleisher LA, Fowkes FG, Hamburg NM, Kinlay S, Lookstein R, Misra S, Mureebe L, Olin JW, Patel RA, Regensteiner JG, Schanzer A, Shishehbor MH, Stewart KJ, Treat-Jacobson D, Walsh ME.
- Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014 Jul;45(7):2160-236. doi: 10.1161/STR.0000000000000024. Epub 2014 May 1. Erratum in: Stroke. 2015 Feb;46(2):e54. — Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, Fang MC, Fisher M, Furie KL, Heck DV, Johnston SC, Kasner SE, Kittner SJ, Mitchell PH, Rich MW, Richardson D, Schwamm LH, Wilson JA; American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease.
- Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e601S-e636S. — Lansberg MG, O'Donnell MJ, Khatri P, Lang ES, Nguyen-Huynh MN, Schwartz NE, Sonnenberg FA, Schulman S, Vandvik PO, Spencer FA, Alonso-Coello P, Guyatt GH, Akl EA.
- Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2022 Apr 26;327(16):1585-1597. — Guirguis-Blake JM, Evans CV, Perdue LA, Bean SI, Senger CA.
- 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2016 Sep 6;68(10):1082-115. — Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, Granger CB, Lange RA, Mack MJ, Mauri L, Mehran R, Mukherjee D, Newby LK, O'Gara PT, Sabatine MS, Smith PK, Smith SC Jr.
- Primary and Secondary Prevention of Cardiovascular Disease Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines: CHEST 2012; 141(2)(Suppl):e637S–e668S — Per Olav Vandvik , MD , PhD ; A. Michael Lincoff , MD ; Joel M. Gore , MD ; David D. Gutterman , MD , FCCP ; Frank A. Sonnenberg , MD ; Pablo Alonso-Coello , MD, PhD ; Elie A. Akl , MD , MPH, PhD ; Maarten G. Lansberg , MD, PhD ; Gordon H. Guyatt , MD , FCCP ; and Frederick A. Spencer , MD
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