Journal of General Internal Medicine

, Volume 13, Issue 12, pp 824–835 | Cite as

Aspirin for primary prevention of cardiovascular events

  • Federico A. Augustovski
  • Scott B. Cantor
  • Chau T. Thach
  • Stephen J. Spann
Original Articles


OBJECTIVE: The use of aspirin for primary prevention of cardiovascular events in the general population is controversial. The purpose of this study was to create a versatile model to evaluate the effects of aspirin in the primary prevention of cardiovascular events in patients with different risk profiles.

DESIGN: A Markov decision-analytic model evaluated the expected length and quality of life for the cohort’s next 10 years as measured by quality-adjusted survival for the options of taking or not taking aspirin.

SETTING: Hypothetical model of patients in a primary care setting.

PATIENTS: Several cohorts of patients with a range of risk profiles typically seen in a primary care setting were considered. Risk factors considered included gender, age, cholesterol levels, systolic blood pressure, smoking status, diabetes, and presence of left ventricular hypertrophy. The cohorts were followed for 10 years. Outcomes were myocardial infarction, stroke, gastrointestinal bleed, ulcer, and death.

MAIN RESULTS: For the cases considered, the effects of aspirin varied according to the cohort’s risk profile. By taking aspirin, the lowest-risk cohort would be the most harmed with a loss of 1.8 quality-adjusted life days by taking aspirin; the highest risk cohort would achieve the most benefit with a gain of 11.3 quality-adjusted life days. Results without quality adjustment favored taking aspirin in all the cohorts, with a gain of 0.73 to 8.04 days. The decision was extremely sensitive to variations in the utility of taking aspirin and to aspirin’s effects on cardiovascular mortality. The model was robust to other probability and utility changes within reasonable parameters.

CONCLUSIONS: The decision of whether to take aspirin as primary prevention for cardiovascular events depends on patient risk. It is a harmful intervention for patients with no risk factors, and it is beneficial in moderate and high-risk patients. The benefits of aspirin in this population are comparable to those of other widely accepted preventive strategies. It is especially dependent on the patient’s risk profile, patient preferences for the adverse effects of aspirin, and on the level of beneficial effects of aspirin on cardiovascular-related mortality.

Key Words

aspirin primary prevention cardiovascular disease decision analysis risk stratification 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    United States Preventive Task Force. Guide to Clinical Preventive Services. 2nd ed. Baltimore, Md: Williams and Wilkins; 1996.Google Scholar
  2. 2.
    Antiplatelet Trialists’ Collaboration. Collaborative overview of randomized trials of antiplatelet therapy, I: prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ. 1994;308:81–106.Google Scholar
  3. 3.
    Patrono C. Aspirin as an antiplatelet drug. N Engl J Med. 1994;330:1287–94.PubMedCrossRefGoogle Scholar
  4. 4.
    The Medical Research Council’s General Practice Research Framework. Thrombosis prevention trial: randomised trial of low-intensity oral anticoagulation with warfarin and low-dose aspirin in the primary prevention of ischemic heart disease in men at increased risk. Lancet. 1998;351:233–41.CrossRefGoogle Scholar
  5. 5.
    Sonnenberg FA, Beck JR. Markov models in medical decision making: a practical guide. Med Decis Making. 1993;13:322–38.PubMedCrossRefGoogle Scholar
  6. 6.
    Anderson KM, Wilson PW, Odell PM, Kannel WB. An updated coronary risk profile. Circulation. 1991;83:356–62.PubMedGoogle Scholar
  7. 7.
    Steering Committee of the Physician’s Health Study Research Group. Final report of the aspirin component of the ongoing Physician’s Health Study. N Engl J Med. 1989;321:129–35.CrossRefGoogle Scholar
  8. 8.
    Peto R, Gray R, Collins R, et al. Randomized trial of prophylactic daily aspirin in British male doctors. BMJ. 1988;296:313–6.PubMedGoogle Scholar
  9. 9.
    Wolf PA, D’Agostino RB, Belange AJ, Kennel WB. Probability of stroke: a risk profile from Framingham study. Stroke. 1991;22:312–8.PubMedGoogle Scholar
  10. 10.
    Manson JE, Stampfer MJ, Colditz GA, et al. A prospective study of aspirin use and primary prevention of cardiovascular disease in women. JAMA. 1991;266:521–7.PubMedCrossRefGoogle Scholar
  11. 11.
    Wilson PW, Evans JC. Coronary artery disease prediction. Am J Hypertens. 1993;6:S309–13.Google Scholar
  12. 12.
    Kannel WB, Larson M. Long-term epidemiologic prediction of coronary disease: the Framingham experience. Cardiology. 1993;82:137–52.PubMedGoogle Scholar
  13. 13.
    Leaverton PE, Sorlie PD, Kleinman JC, et al. Representativeness of the Framingham risk model for coronary heart disease mortality: a comparison with a national cohort study. J Chron Dis. 1987;40:775–84.PubMedCrossRefGoogle Scholar
  14. 14.
    The Salt Collaborative Group. Swedish Aspirin Low-Dose Trial (SALT) of 75 mg aspirin as secondary prophylaxis after cerebrovascular ischaemic events. Lancet. 1991;338:1345–9.CrossRefGoogle Scholar
  15. 15.
    Giovanucci E, Rim EB, Stampfer MS, Colditz GA, Aschero A, Willer WC. Aspirin use and the risk for colorectal cancer and adenoma in male health professionals. Ann Intern Med. 1994;121:241–6.Google Scholar
  16. 16.
    Orencia A, Bailey K, Yawn BP, Kottke TE. Effect of gender on long term outcome of angina pectoris and myocardial infarction/sudden unexpected death. JAMA. 1993;269:2392–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Beck JR. Technical note. Med Decis Making. 1989;9:150.CrossRefGoogle Scholar
  18. 18.
    Weinstein MC, Coxson PG, Williams LW, Pass TM, Stason WB, Goldman L. Forecasting coronary disease incidence, mortality, and cost: the coronary heart disease policy model. Am J Public Health. 1987;77:1417–26.PubMedCrossRefGoogle Scholar
  19. 19.
    Stevenson R, Ranjadayalan K, Wilkinson P, Roberts R, Timmis A. Short and long term prognosis of acute myocardial infarction since the introduction of thrombolysis. BMJ. 1993;307:349–53.PubMedGoogle Scholar
  20. 20.
    Wolf PA, D’Agostino EB, O’Neal A, et al. Secular trends in stroke incidence and mortality: the Framingham study. Stroke. 1992;23:1551–5.PubMedGoogle Scholar
  21. 21.
    McGovern PG, Burke GL, Sprafka JM, Xue S, Folsom AR, Blackburn H. Trends in mortality, morbidity, and risk factor levels for stroke from 1960 through 1990: the Minnesota heart survey. JAMA. 1992;268:753–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Howard G, Toole JF, Becker C, et al. Changes in survival following stroke in five North Carolina counties observed during two different periods. Stroke. 1989;20:345–50.PubMedGoogle Scholar
  23. 23.
    Dennis MS, Burn JP, Sandercock PA, Bamford JM, Wade DT, Warlow CP. Long term survival after first-ever stroke: the Oxfordshire Community Stroke Project. Stroke. 1993;24:796–800.PubMedGoogle Scholar
  24. 24.
    Sacco RL, Shi T, Zamanillo MC, Kargman DE. Predictors of mortality and recurrence after hospitalized cerebral infarction in an urban community: the Northern Manhattan Stroke Study. Neurology. 1994;44:626–34.PubMedGoogle Scholar
  25. 25.
    Department of Health and Human Services. Vital Statistics of the United States, 1988. Hyattsville, Md: National Center for Health Statistics; 1992.Google Scholar
  26. 26.
    Naglie IG, Detsky AS. Treatment of chronic nonvalvular atrial fibrillation in the elderly: a decision analysis. Med Decis Making. 1992;12:239–49.PubMedCrossRefGoogle Scholar
  27. 27.
    Gage BF, Cardinalli AB, Albers GW, Owens DK. Cost-effectiveness of warfarin and aspirin for prophylaxis of stroke in patients with nonvalvular atrial fibrillation. JAMA. 1995;274:1839–45.PubMedCrossRefGoogle Scholar
  28. 28.
    Tsevat J, Goldman L, Soukup JR, et al. Stability of time-tradeoff utilities in survivors of myocardial infarction. Med Decis Making. 1993;13:161–5.PubMedCrossRefGoogle Scholar
  29. 29.
    Gabriel SE, Campion EM, Fallon WM. Patient preferences for nonsteroidal antiinflammatory drug related gastrointestinal complications and their prophylaxis. J Rheumatol. 1993;20:358–61.PubMedGoogle Scholar
  30. 30.
    Canadian Task Force on the Periodic Health Examination. Periodic health examination, 1991 update, 6: actylsalicylic acid and the primary prevention of cardiovascular disease. Can Med Assoc J. 1991;145:1091–5.Google Scholar
  31. 31.
    Fuster V, Dyken ML, Vokonas PS, Hennekens C. AHA Medical/Scientific Statement: aspirin as a therapeutic agent in cardiovascular disease. Circulation. 1993;87:659–75.PubMedGoogle Scholar
  32. 32.
    Hirsh J, Dalen JE, Fuster V, Harker LB, Salzman EW. Aspirin and other platelet-active drugs: the relationship between dose, effectiveness and side effects. Chest. 1992;102:S327–36.Google Scholar
  33. 33.
    Salzmann P, Kerlikowske K, Phillips K. Cost-effectiveness of extending screening mamography guidelines to include women 40 to 49 years of age. Ann Intern Med. 1997;127:955–65.PubMedGoogle Scholar
  34. 34.
    Kassirer JP. Incorporating patients’ preferences into medical decisions. N Engl J Med. 1994;330:1895–6.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 1998

Authors and Affiliations

  • Federico A. Augustovski
    • 1
  • Scott B. Cantor
    • 4
  • Chau T. Thach
    • 2
  • Stephen J. Spann
    • 3
  1. 1.Unidad de Medicina Familiar y Preventivathe Hospital Italiano de Buenos AiresBuenos AiresArgentina
  2. 2.Department of BiostatisticsThe University of WashingtonSeattle
  3. 3.Department of Family and Community MedicineBaylor College of MedicineHouston
  4. 4.Department of Medical Specialties, Section of General Internal MedicineThe University of Texas, M.D. Anderson Cancer CenterHouston

Personalised recommendations