HealthPartners Institute, Minneapolis, Minnesota.
Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon.
JAMA. 2022 Apr 26;327(16):1598-1607. doi: 10.1001/jama.2022.3385.
The US Preventive Services Task Force (USPSTF) is updating its 2016 recommendation on the use of aspirin for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC).
To provide updated model-based estimates of the net balance in benefits and harms from routine use of low-dose aspirin for primary prevention.
DESIGN, SETTING, AND PARTICIPANTS: Microsimulation modeling was used to estimate long-term benefits and harms for hypothetical US cohorts of men and women aged 40 to 79 years with up to 20% 10-year risk for an atherosclerotic CVD event and without prior history of CVD or elevated bleeding risks.
Low-dose (≤100 mg/d) aspirin for lifetime use, unless contraindicated by a bleeding event, and with stopping ages in 5-year intervals from age 65 to 85 years.
Primary outcomes were lifetime net benefits measured in quality-adjusted life-years (QALYs) and life-years. Benefits included reduced nonfatal myocardial infarction and ischemic stroke. Harms included increased nonfatal major gastrointestinal bleeding and intracranial hemorrhage. Reduced CRC incidence was considered in sensitivity analysis.
Estimated lifetime net QALYs were positive for both men and women at 5% or greater 10-year CVD risk when starting between ages 40 and 59 years and at 10% or greater 10-year CVD risk when starting between ages 60 and 69 years. These estimates ranged from 2.3 (95% CI, -2.7 to 7.4) to 66.2 (95% CI, 58.2 to 74.1) QALYs per 1000 persons. Lifetime net life-years were positive for men at 5% or greater and women at 10% or greater 10-year CVD risk starting aspirin at ages 40 to 49 years and for men at 7.5% or greater and women at 15% or greater 10-year CVD risk at ages 50 to 59 years. These estimates ranged from 0.4 (95% CI, -6.1 to 6.9) to 52.4 (95% CI, 43.9 to 60.9) life-years per 1000 persons. Lifetime net life-years were negative in most cases for persons starting aspirin between ages 60 and 79 years, as were lifetime net QALYs for persons aged 70 to 79 years. Stopping aspirin between ages 65 and 85 years generally showed little advantage compared with lifetime use. Sensitivity analyses showed lifetime net benefits may be higher if aspirin reduced CRC incidence or CVD mortality and lower if aspirin increased fatal major gastrointestinal bleeding or reduced quality of life with routine use.
This microsimulation study suggested that several population groups may benefit from taking aspirin for the primary prevention of CVD, primarily in persons starting at younger ages with higher 10-year CVD risk.
美国预防服务工作组（USPSTF）正在更新其 2016 年关于使用低剂量阿司匹林进行心血管疾病（CVD）和结直肠癌（CRC）一级预防的建议。
提供常规使用低剂量阿司匹林进行一级预防的获益和危害的净平衡的更新基于模型的估计。
设计、设置和参与者：使用微观模拟模型来估计假设的美国 40 至 79 岁男性和女性队列的长期获益和危害，这些队列的 10 年动脉粥样硬化性 CVD 事件风险高达 20%，且无 CVD 病史或出血风险升高。
终生使用低剂量（≤100mg/d）阿司匹林，除非发生出血事件，并且从 65 岁到 85 岁每隔 5 年停止使用。
主要结局是终生净获益，以质量调整生命年（QALYs）和生命年来衡量。获益包括减少非致死性心肌梗死和缺血性卒中。危害包括增加非致死性主要胃肠道出血和颅内出血。敏感性分析考虑了 CRC 发病率降低的情况。
当起始年龄在 40 岁至 59 岁之间，10 年 CVD 风险为 5%或更高时，或者起始年龄在 60 岁至 69 岁之间，10 年 CVD 风险为 10%或更高时，估计的终生净 QALYs 对男性和女性都是阳性的。这些估计值范围为每 1000 人 2.3（95%CI，-2.7 至 7.4）至 66.2（95%CI，58.2 至 74.1）QALYs。当起始年龄在 40 岁至 49 岁之间，男性的 10 年 CVD 风险为 5%或更高，女性的 10 年 CVD 风险为 10%或更高时，男性的终生净生命年为阳性，当起始年龄在 50 岁至 59 岁之间，男性的 10 年 CVD 风险为 7.5%或更高，女性的 10 年 CVD 风险为 15%或更高时，男性的终生净生命年为阳性。这些估计值范围为每 1000 人 0.4（95%CI，-6.1 至 6.9）至 52.4（95%CI，43.9 至 60.9）生命年。对于起始年龄在 60 岁至 79 岁之间的人，以及起始年龄在 70 岁至 79 岁之间的人，终生净生命年通常为阴性。与终生使用相比，在 65 岁至 85 岁之间停止使用阿司匹林通常没有什么优势。敏感性分析表明，如果阿司匹林降低 CRC 发病率或 CVD 死亡率，或者如果阿司匹林增加致命性主要胃肠道出血或降低常规使用的生活质量，那么终生净获益可能更高。
这项微观模拟研究表明，一些人群可能会从使用低剂量阿司匹林进行 CVD 的一级预防中获益，主要是在起始年龄较小、10 年 CVD 风险较高的人群中。
