Aspirin Therapy for Primary Prevention of Cardiovascular Disease (Counseling)

Evidence Statement Benefit Plan Language Other Information and Resources Author(s)

References


Updated 4/29/11

Evidence Statement

Clinical Preventive Service Recommendations

U.S. Preventive Services Task Force Recommendation
The U.S. Preventive Services Task Force (USPSTF) recommends that asymptomatic men aged 45-79 years use aspirin to prevent myocardial infarctions (heart attacks). USPSTF recommends that asymptomatic women aged 55-79 years use aspirin to prevent strokes when the benefit of aspirin use outweighs the potential harm of gastrointestinal hemorrhage or other serious bleeding, including hemorrhagic stroke. It also recommends that doctors should discuss the potential benefits and harm of aspirin therapy with their patients.1 This recommendation is for primary prevention in people who have not had a heart attack or stroke.

Evidence Rating for Recommendations: A (Strongly Recommended/ Good Evidence)
The USPSTF found good evidence that aspirin use decreases the incidence of myocardial infarctions (heart attacks) among men and ischemic strokes among women.1 However, it also found good evidence that aspirin use increases the incidence of gastrointestinal bleeding among men and women and fair evidence that it increases the incidence of hemorrhagic strokes among men.1 The American College of Chest Physicians, the American College of Cardiology Foundation, and the American Heart Association similarly recommend the use of aspirin for cardiovascular disease prevention by people whose cardiovascular danger is sufficiently high for the benefits of aspirin use to outweigh the harm.2-3

Additional Recommendations
In a set of guidelines for women,4 the American Heart Association (AHA) recommends aspirin therapy for patients with increased likelihood of cardiovascular disease, unless their physician recommends otherwise. For women aged 65 years and older with controlled hypertension, AHA recommends considering aspirin therapy (81 mg/day or 100 mg every other day) to prevent ischemic stroke and heart attack if the reduction in risk for these events outweighs the increased danger of gastrointestinal bleeding and hemorrhagic stroke. For women younger than 65 years, AHA recommends considering aspirin therapy to prevent ischemic stroke if the reduction in risk is likely to outweigh the adverse effects of therapy.

NOTE:
The USPSTF recommends against routine use of aspirin therapy in certain populations. For more information, see D recommendations.

The USPSTF finds insufficient evidence for aspirin therapy in certain populations. For more information, see I statements.




Specific Information About Cardiovascular Disease

Epidemiology of Cardiovascular Disease
Heart disease and stroke are two of the most common types of cardiovascular disease (hypertension being more prevalent), and are the first and third leading causes of death for both men and women in the United States.5 In 2007, cardiovascular disease in the U.S. resulted in 813,804 deaths, including 135,952 stroke deaths.5

Indicators for Cardiovascular Disease
Each year, more than 1.3 million Americans experience new or recurrent heart attacks or die of coronary heart disease. Most of these events occur in older people and those with health indicators associated with cardiovascular disease.5 During 1999-2006, 45% of American adults had at least one of three indicators for cardiovascular disease (high blood pressure, high cholesterol or diabetes).6 More than one in three adults in the U.S. were considered obese during 2007-2008, another major health indicator associated with the likelihood of developing cardiovascular disease.7

In deciding whether to recommend aspirin therapy to their patients, physicians should consider all factors associated with the likelihood of the patient developing coronary heart disease, stroke or other vascular disease. A risk calculation should include factors such as older age, male sex, diabetes, high blood pressure, positive family history of cardiovascular disease (for younger adults), tobacco use, weight, physical inactivity, elevated total cholesterol level, decreased high-density lipoprotein cholesterol (HDL-C) level, elevated low-density lipoprotein cholesterol level (LDL-C), and vascular disease status.5



The Value of Prevention

Economic Burden of Cardiovascular Disease
In 2010, cardiovascular disease in the United States was expected to cost more than $503 billion, including expenses related to health care services, medications and lost productivity.5 This cost projection includes $177.1 billion for coronary heart disease alone and $73.7 billion for stroke.5

Workplace Costs of Cardiovascular Disease
The projected workplace costs of cardiovascular disease in 2010 included $41.7 billion in lost productivity because of worker morbidity and an additional $137.4 billion dollars in lost future earnings because of premature deaths.5 These projected costs were nearly 25% higher than corresponding costs in 2006.

Four of the 10 most expensive health conditions to U.S. employers—heart attacks, angina pectoris (chest pain), hypertension and diabetes—are conditions correlated with cardiovascular disease.8 Already a leading cause of death and disability in the U.S. working population, cardiovascular disease is expected to be an increasing burden in the U.S. workplace as the workforce ages.

Economic Benefit of Preventive Intervention
The economic benefit of counseling patients about the potential benefits of aspirin therapy primarily results from the improved quality of life and the averted cost of illness among those who choose to follow an aspirin regimen. The pooled results of all the trials show that aspirin therapy reduces myocardial infarctions (heart attacks) by 32% in men, and reduces strokes by 17% in women.2,9-10

Estimated Cost of Preventive Intervention
The average annual cost of an aspirin regimen is estimated to be $15 per person per year.11

In 2008, the private-sector cost of aspirin prevention counseling averaged $74 per session.12

Estimated Cost of Treatment
In 2010, the estimated direct and indirect cost for coronary heart disease was expected to exceed $177 billion.5 The average lifetime cost of a stroke was estimated to be $140,048 in 1999 dollars.5 In 2007, Americans made 79.7 million office visits to physicians, 4.05 million emergency department visits, and 7.9 million outpatient visits for cardiovascular disease (including high blood pressure). The total inpatient hospital cost for cardiovascular disease was approximately 25% of all inpatient hospital costs.5

Cost-Effectiveness of Aspirin Use
Study results have shown that the cost of aspirin use per quality-adjusted life year (QALY) gained was $2,779 among people in danger of developing cardiovascular disease12 and $8,801 among people with diabetes.13 Because aspirin use reduces adults' chances for experiencing cardiovascular disease events but also increases their likelihood of gastrointestinal bleeding, the net expected health benefit of aspirin use depends on their risk for cardiovascular disease and the possibility for gastrointestinal bleeding.10 Results of a 2006 study showed that among men with a moderate or greater chance for developing coronary heart disease, aspirin was more effective and less costly than not taking aspirin.14



Preventive Intervention

Preventive Intervention: Purpose of Counseling
Because aspirin use has been shown to decrease the incidence of coronary heart disease or stroke among adults who are at increased risk for coronary heart disease or stroke, physicians should assess their patients' likelihood for coronary heart disease or stroke and discuss with them the benefits and harm of aspirin therapy.9

Benefits and Risks of Intervention
Although aspirin therapy can reduce patients' chances for myocardial infarctions (heart attacks) and stroke, it may increase the likelihood of experiencing gastrointestinal bleeding and hemorrhagic stroke, especially among older patients and those with hypertension. The net projected benefit of aspirin use for individual patients generally increases as their cardiovascular health declines.8 Although older patients may derive greater benefits from aspirin therapy because they generally are at higher risk for coronary heart disease (CHD) and stroke, the possibility of bleeding may also be higher.8 Taking non-steroidal anti-inflammatory agents or anticoagulants at the same time increases patients' chances for experiencing serious bleeding.15

Here is an illustration of the relationship between the benefits and potential harm of aspirin use: Among 1,000 men aged 45-59 with a 6% risk of experiencing a CHD event over 10 years, aspirin use would be expected to prevent 19 heart attacks (range 6 to 20), but to cause 1 hemorrhagic stroke and 8 major episodes of gastrointestinal bleeding. In contrast, among 1,000 men with only a 2% risk of experiencing a CHD event over 10 years, aspirin use would be expected to prevent only 6 heart attacks while still causing 1 hemorrhagic stroke and 8 major episodes of gastrointestinal bleeding.9

Initiation, Cessation and Interval of Counseling
According to the USPSTF, physicians should discuss the benefits and potential harms of aspirin therapy with adults who are at increased risk for coronary heart disease or stroke.9

Although the optimal timing and frequency of discussions related to aspirin therapy are unknown, reasonable options include every 5 years in middle-aged and older people or whenever cardiovascular health issues are detected.9 The American College of Cardiology and the American Heart Association recommend that patients should have a comprehensive assessment of their cardiovascular health at least every 5 years starting at age 18 and that a cardiovascular disease risk assessment should be completed at least every 5 years starting at age 35 for men and age 45 for women.2 Those with conditions such as diabetes, obesity or a history of cigarette smoking should have their cardiovascular health status assessed more frequently.2

Intervention Process
Physicians' discussions about aspirin therapy with their patients should include both the potential benefits (the prevention of myocardial infarction/heart attack or stroke) and the potential dangers (gastrointestinal and intracranial or other serious bleeding) of the therapy. In deciding whether to recommend aspirin therapy, physicians should take into account their patients' attitudes about whether a reduction in risk for myocardial infarction (heart attack) and stroke is worth an increased likelihood of gastrointestinal and intracranial or other serious bleeding.9

Treatment Information
When physicians determine that the benefits of taking aspirin for the prevention of cardiovascular disease events outweigh the potential harm for a particular patient, they should encourage that patient to begin an aspirin regimen. The optimum dose of aspirin for prevention is not known. Primary and secondary prevention trials have demonstrated benefits with a variety of regimens, including 75 mg per day, 100 mg per day and 325 mg every other day but have shown that doses of approximately 75 mg per day appear to be as effective as higher doses.5,9



Strength of Evidence Supporting Recommendations in This Chapter

A (Strongly Recommended/Good Evidence)

The USPSTF recommends that physicians encourage men aged 45-79 to use aspirin to prevent myocardial infarction (heart attack), that they encourage women aged 55-79 to use aspirin to prevent stroke, when the potential benefit outweighs the potential harm, and that they discuss both the potential benefits and the potential harm of aspirin therapy with their patients.



Summary Plan Description

Covered Screening
Counseling to discuss the benefits and harm of aspirin therapy is a covered benefit.



CPT Codes

Aspirin for the Primary Prevention of Cardiovascular Events (Counseling)
99401 Preventive medicine counseling/risk factor reduction, 15 minutes
99402 Preventive medicine counseling/risk factor reduction, 30 minutes
99403 Preventive medicine counseling/risk factor reduction, 45 minutes
99404 Preventive medicine counseling/risk factor reduction, 60 minutes



Other Information and Resources

Business Group Resource

CDC Resource



Author(s)

Mary G. George, MD, MSPH, Yuling Hong, MD, PhD, Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion. Update 2010.16



References

  1. U.S. Preventive Services Task Force. Aspirin for the primary prevention of cardiovascular events: recommendations and rationale. Rockville, MD: Agency for Healthcare Research and Quality; 2009. http://www.uspreventiveservicestaskforce.org/uspstf/uspsasmi.htm.
  2. Redberg RF, Benjamin EJ, Bittner V, et al. AHA/ACCF 2009 performance measures for primary prevention of cardiovascular disease in adults. Circulation. 2009;120:1296-1336.
  3. Becker RC, Meade TW, Berger PB, et al. The primary and secondary prevention of coronary artery disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008; 133:776S.
  4. Mosca L, Banka CL, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. J Am Coll Cardiol. 2007;49(11):1230-1250.
  5. Roger VL, Go AS, Lloyd-Jones DL. Heart disease and stroke statistics-2011 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2011;123(4):e18-e209.
  6. Fryar DC, Hirsch R, Eberhardt MS, Yoon SS, Wright JD. Hypertension, high serum total cholesterol, and diabetes: racial and ethnic prevalence differences in U.S. adults, 1999-2006. National Center for Health Statistics. NCHS Data Brief No. 36, April 2010.
  7. Ogden CL, Carroll MD, Prevalence of overweight, obesity, and extreme obesity among adults: United States, trends 1976-1980 through 2007-2008. June 2010. http://www.cdc.gov/NCHS/data/hestat/obesity_adult_07_08/obesity_adult_07_08.pdf
  8. Goetzel RZ, Hawkins K, Ozminkowski RJ, Wang S. The health and productivity cost burden of the "top 10" physical and mental health conditions affecting six large U.S. employers in 1999. J Occup Environ Med. 2003;45(1):5-14.
  9. U.S. Preventive Services Task Force. Aspirin for the prevention of cardiovascular disease: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;150:396-404.
  10. Wolff T, Miller T, Ko S. Aspirin for the primary prevention of cardiovascular events: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2009;150:405-410.
  11. Maciosek MV, Edwards NM, Nelson WW, Kanchandani HS, McGree DA. Aspirin for the primary prevention of cardiovascular disease: technical report prepared for the National Commission on Prevention Priorities. Health Partners Research Foundation 2008; Version 06.1. http://www.prevent.org/data/files/initiatives/discuss%20daily%20aspirin%20use.pdf
  12. Kahn R, Robertson RM, Smith R, Eddy D. The impact of prevention on reducing the burden of cardiovascular disease. Diabetes Care. 2008;31:1686-1696.
  13. Li R, Zhang P, Barker LE, Hoerger TJ. Cost-effectiveness of aspirin use among persons with newly diagnosed type 2 diabetes. Diabetes Care. 2010;33(6):1193-1199.
  14. Pignone M, Earnshaw S, Tice JA, Pletcher MJ. Aspirin, statins, or both drugs for the primary prevention of coronary heart disease events in men: a cost-utility analysis. Ann Intern Med. 2006;144(5):326-336.
  15. Pignone M, Alberts MJ, Colwell JA, et al. Aspirin for primary prevention of cardiovascular events in people with diabetes. Circulation. 2010;121:2694-2701.
  16. Lanza A, Campbell KP, Sotnikov S. Evidence statement: aspirin therapy for the prevention of cardiovascular disease (counseling). In: Campbell KP, Lanza A, Dixon R, Chattopadhyay S, Molinari N, Finch RA, editors. A Purchaser's Guide to Clinical Preventive Services: Moving Science into Coverage. Washington, DC: National Business Group on Health; 2006.