Abstract 326: De-escalation of Aspirin for Primary Prevention of Atherosclerotic Cardiovascular Disease in the Primary Care Setting
Authors: Berookhim Joshua , Kahen Michael , Bernal Gabriela , Das Subrat , Berookhim Brian , Patel Dipal 
Published: May 2020

Background:
For several decades, aspirin (ASA) has been used as primary prevention against ASCVD in adults. In 2018, three major trials (ASPREE, ARRIVE, and ASCEND) redefined our understanding of ASA and showed a net harm rather than benefit when ASA is used for primary prevention of ASCVD. These trials greatly impacted the current 2019 ACC/AHA Primary Prevention Guidelines, which now recommend the following: (a) Low-dose ASA might be considered for primary prevention of ASCVD in select higher ASCVD adults aged 40-70 years who are not at increased bleeding risk and (b) Low-dose ASA should not be administered for primary prevention of ASCVD among adults over the age of 70. The objective of the project was to re-evaluate the use and indications of ASA in our patient population and appropriately remove ASA when no longer indicated. With proper resident education and intervention, we hypothesized that we could reduce the number of inappropriate ASA prescriptions by 10%.

Methods/Results:
During a 6-month observational period, 254 patients at Ryan Health/Adair (a federally qualified health center which also serves as a primary care site for an internal medicine residency clinic) were found to be taking ASA, and of those 140 patients were found to be on ASA for primary ASCVD prevention. The interventions included implementation of an algorithm that reflected the most up to date guidelines. The intervention lasted 3 months. Any patient that was found to be on ASA inappropriately was discontinued. During this period ASA was successfully removed from 25 patients’ medication list, with an overall reduction by 17.9%. Of the 25 patients, 20% were over the age of 70, 80% were between the ages of 40-70, and 48% were male. In the remaining 115 patients in which ASA was continued, 27.8% were over the age of 70, 69.6% were between the ages of 40-70, 2.6% were under the age of 40, and 49.6% were male. The successful ASA removal group comprised of 44% Hispanic/Latino, 44% African American, 4% White, and 8% Unidentified. The ASA non-removal group comprised of 34.8% Hispanic/Latino, 44.3% African American, 5.2% White, and 15.7% Unidentified. Additionally, 80% of the patient taken off ASA spoke English, while only 69.6% of patient in the ASA non-removal group spoke English.

Conclusions:
Several differences were found between the two groups. Some key limitations between the two groups included (a) unclear past medical history leading to physicians being uncomfortable with removing ASA, (b) inability to speak in patient’s native language to facilitate proper discussion about ASA removal, and (c) patient refusal to stop ASA. Next steps include further cardiac testing (CT coronaries, stress test) to better characterize the risk of patients with unclear history. However, overall, there is likely a net benefit in prioritizing ASA removal in the primary care setting now that it is no longer recommended in key populations.