Summary

USPSTF 2022 recommendation on low-dose aspirin for primary prevention of cardiovascular disease. For adults 40–59 with ≥10% 10-year CVD risk, initiation is an individual decision (Grade C); for adults ≥60, do not initiate aspirin for primary prevention (Grade D). This replaces the 2016 statement: age range lowered from 50 to 40 for shared decision-making, a new D recommendation added for ≥60, and the prior colorectal cancer benefit claim withdrawn due to inadequate evidence.

Key Recommendations

Adults 40–59 with ≥10% 10-year CVD risk: individualize decision to start low-dose aspirin via shared decision-making (Grade C).
Adults ≥60: do not initiate low-dose aspirin for primary prevention of CVD (Grade D).
Recommendation applies only to adults without known CVD and not at increased bleeding risk (no GI ulcer history, recent bleeding, or bleeding-risk medications).
Use ACC/AHA Pooled Cohort Equations to estimate 10-year CVD risk in adults 40–59 being considered for aspirin.
When initiating aspirin, use 81 mg/day.
Consider stopping aspirin around age 75 given declining net benefit with advancing age.
Greater absolute benefit accrues at higher CVD risk (>15–20% 10-year risk) and at younger initiation age.
Do not use aspirin for primary prevention with the goal of reducing colorectal cancer incidence or mortality — evidence is now inadequate.
Patients already on aspirin should not stop without consulting their clinician; reassess based on age, CVD risk, bleeding risk, and preferences.
Counsel on bleeding harms: low-dose aspirin increases major GI bleeding (~58%) and intracranial bleeding; risk rises with age, especially ≥60.

Thresholds & Doses

Age 40–59 with ≥10% 10-year CVD risk → Grade C, individualized initiation.
Age ≥60 → Grade D, do not initiate.
Aspirin dose for primary prevention: 81 mg/day (low-dose ≤100 mg/d).
Consider stopping aspirin around age 75.
10-year CVD risk threshold for considering aspirin: ≥10%; greater benefit at >15–20%.
Low-dose aspirin: 58% increase in major GI bleeding (Peto OR 1.58, 95% CI 1.38–1.80).
Low-dose aspirin: increased intracranial bleeding (Peto OR 1.31, 95% CI 1.11–1.54).
Nonfatal MI reduction with low-dose aspirin: Peto OR 0.88 (95% CI 0.80–0.96).
Nonfatal ischemic stroke reduction: Peto OR 0.88 (95% CI 0.78–1.00).

Citations

Recommendation Summary table — population-specific grades (C for 40–59, D for ≥60).
Clinician Summary, ‘How to implement’ — 81 mg/day dose and age-based approach.
Practice Considerations: Treatment or Intervention — dosing rationale (50–500 mg/d equivalent; 81 mg/d pragmatic).
Practice Considerations: Stopping Age — consider discontinuation around age 75.
Supporting Evidence: Benefits — pooled RCT effect estimates for MI and stroke.
Supporting Evidence: Harms — GI and intracranial bleeding pooled ORs.
Update of Previous USPSTF Recommendation — changes from 2016 statement and withdrawal of CRC benefit.
Table. Summary of USPSTF Rationale — net benefit assessment by age group.