Aspirin deprescribing in primary prevention of cardiovascular disease: a prospective risk–benefit approach

BACKGROUND: Current evidence and practice guidelines do not recommend aspirin for primary prevention of cardiovascular disease (CVD). Insufficient all-cause mortality benefits juxtaposed to increased gastrointestinal bleeding rates are well established. Pharmacists are well placed to assess the clinical appropriateness of aspirin in CVD and initiate deprescribing as required with medical colleagues. AIM: The aim of this study was to identify medical inpatients taking aspirin for primary prevention of CVD and initiate deprescribing utilising a risk-benefit approach. METHODS: A single-arm prospective feasibility study of general medicine patients admitted to a major tertiary hospital over 5 weeks (July-August 2020) was conducted. Screened patients were categorised as either taking aspirin for primary or secondary prevention. A 5-year benefit-risk analysis of bleeding and cardiovascular risk was calculated using a validated tool from the Cardiac Society of Australia and New Zealand to guide recommendations. RESULTS: This study screened 277 patients, of which 71 patients were identified as taking aspirin. Ten of these patients (14%) were categorised as taking aspirin for primary prevention and thus were deemed suitable for deprescribing. The analysis showed that aspirin continuance would, on average, increase major bleeding events by 39%, whilst reducing major cardiovascular events by 13.4%. Pharmacists recommended aspirin cessation in seven of the cases identified, and deprescribing was successful in five cases. CONCLUSIONS: This study described an impactful pharmacist-led initiative utilising a validated aspirin-specific tool to conduct risk-benefit analysis to reduce potential major bleeding associated with inappropriate aspirin use.