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Aspirin Deprescribing Guidelines

Patient-specific recommendations to change or discontinue aspirin that may lead to fewer adverse events

CreatoreDr. Cameron Draeger, PharmD
Prova
Preferiti

There 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.

Tutte le domande e i risultati possibili

Zone 1Titolo non visibile
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 2Titolo non visibile
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
Risultati possibili
In bioprosthetic heart valves: Weigh risks versus benefits of Aspirin

If Aspirin is elected, dosing recommendation is 75-100mg daily

 

Guidelines: 

1. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. 

2. Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report. Chest. 2018 Nov;154(5):1121-1201. 

In <40 years without known risk factors: No Aspirin recommendation
In carotid artery dissection: Aspirin is recommended for at least 3-6 months

Guidelines: 2011 AHA/ASA Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease.

In Afib/flutter without CAD: Aspirin is NOT recommended

Guidelines: 

Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report. Chest. 2018 Nov;154(5):1121-1201. 

In mechanical heart valves: Aspirin is recommended

Aspirin dosing recommendation is 75-100mg daily

 

Guidelines: 

1. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. 

2. Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report. Chest. 2018 Nov;154(5):1121-1201. 

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

 

Guidelines:  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.

 

In VTE: Aspirin is recommended AFTER anticoagulation is stopped

Guidelines: Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016 Feb;149(2):315-352. 

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

  1. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease 
  2. 2012 CHEST Guideline: Primary and Secondary Prevention of Cardiovascular Disease
In ischemic stroke/TIA without anticoagulation: Aspirin is recommended

Aspirin dosing recommendations

  • Initial: 50-325mg
  • Long-term: 75-100mg

 

Guidelines

  1. 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. 
  2. 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

 

Guidelines: 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. 

Based on your selection there are no aspirin recommendations
In diabetics without anticoagulation: Weigh risks versus benefits of Aspirin

If Aspirin is elected, dosing recommendation is 75-162 mg daily

 

Guidelines: 

1. 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.

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

Guidelines:  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.

In symptomatic PAD: Aspirin is recommended

Aspirin dosing recommendation is 75-325mg daily

 

Guidelines: 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. 

In Afib/flutter with stable CAD: Aspirin is NOT recommended

Guidelines: 

Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report. Chest. 2018 Nov;154(5):1121-1201. 

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: 

1. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. 

2. Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report. Chest. 2018 Nov;154(5):1121-1201. 

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

  1. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease 
  2. 2012 CHEST Guideline: Primary and Secondary Prevention of Cardiovascular Disease
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.

Guidelines:  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.

In CAD without anticoagulation: Aspirin is recommended

Aspirin dosing recommendation is 75-100mg daily.

 

Guidelines

  1. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease 
  2. 2012 CHEST Guideline: Primary and Secondary Prevention of Cardiovascular Disease
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.

Guidelines:  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.

In VTE without anticoagulation: Aspirin is recommended AFTER anticoagulation is stopped

Guidelines: Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016 Feb;149(2):315-352. 

In transcatheter aortic valves: Aspirin is recommended

Aspirin dosing recommendation is 75-100mg daily

 

Guidelines: 

1. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. 

2. Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report. Chest. 2018 Nov;154(5):1121-1201. 

Citazione

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.

Letteratura

  • 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.

    https://pubmed.ncbi.nlm.nih.gov/36301649/

  • Antiplatelet and Anticoagulant Use in Nursing Home Residents With Atrial Fibrillation. JAMA Intern Med. 2024 Oct 1;184(10):1256-1258. doi: 10.1001/jamainternmed.2024.3819.

    Ko D, Lee Y, Kim DH, Shah SJ, Hayes KN, Zullo AR, Berry SD.

    https://pubmed.ncbi.nlm.nih.gov/39133502/

  • Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016 Feb;149(2):315-352.

    Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, Huisman M, King CS, Morris TA, Sood N, Stevens SM, Vintch JRE, Wells P, Woller SC, Moores L.

    https://www.sciencedirect.com/science/article/pii/S0012369215003359

  • 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017 Jun 20;135(25):e1159-e1195.

    Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Fleisher LA, Jneid H, Mack MJ, McLeod CJ, O'Gara PT, Rigolin VH, Sundt TM 3rd, Thompson A.

    https://pubmed.ncbi.nlm.nih.gov/28298458/

  • Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report. Chest. 2018 Nov;154(5):1121-1201.

    Lip GYH, Banerjee A, Boriani G, Chiang CE, Fargo R, Freedman B, Lane DA, Ruff CT, Turakhia M, Werring D, Patel S, Moores L.

    https://pubmed.ncbi.nlm.nih.gov/30144419/

  • 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.

    https://diabetesjournals.org/care/article/42/Supplement_1/S103/30856/10-Cardiovascular-Disease-and-Risk-Management

  • 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.

    https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000678?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org

  • 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.

    https://pubmed.ncbi.nlm.nih.gov/27840332/

  • 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.

    https://pubmed.ncbi.nlm.nih.gov/24788967/

  • 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.

    https://pubmed.ncbi.nlm.nih.gov/22315273/

  • 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.

    https://pubmed.ncbi.nlm.nih.gov/35471507/

  • 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.

    https://pubmed.ncbi.nlm.nih.gov/27036918/

  • 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

    https://journal.chestnet.org/article/S0012-3692(12)60134-2/pdf

  • 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation. 2011 Jul 26;124(4):489-532. doi: 10.1161/CIR.0b013e31820d8d78. Epub 2011 Jan 31. Erratum in: Circulation. 2011 Jul 26;124(4):e145. Dosage error in article text.

    Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ; American College of Cardiology Foundation; American Stroke Association; American Association of Neurological Surgeons; American College of Radiology; American Society of Neuroradiology; Congress of Neurological Surgeons; Society of Atherosclerosis Imaging and Prevention; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society of NeuroInterventional Surgery; Society for Vascular Medicine; Society for Vascular Surgery.

    https://pubmed.ncbi.nlm.nih.gov/21282505/

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