Acetylsalicylic acid, ACE inhibitors, statins and cardiovascular risk

Acetylsalicylic acid (ASA), angiotensin-converting enzyme inhibitors (ACE inhibitors), and statins have been shown to reduce long-term morbidity and mortality in primary prevention among patients at high and very high cardiovascular risk. Epidemiological reviews show that these medications are overprescribed in patients at low risk and underprescribed in patients at high risk.

In those over 70 years old, evidence-based medicine (EBM), although generally supporting the same approach as for younger patients, is weak. Thus, the decision should be correlated with the risks of iatrogenic effects, life expectancy, and the patient’s level of autonomy.

Cardiovascular Risk

Patients are classified as:

• Very High Cardiovascular Risk:
  • Documented cardiovascular disease, including coronary syndrome, arterial revascularization, ischemic stroke, peripheral artery disease (PAD), or significant carotid stenosis.
  • Diabetes with at least one other cardiovascular risk factor (smoking, hypertension, dyslipidemia, albuminuria, family history of premature cardiovascular disease) or target organ damage (including microalbuminuria).
  • Chronic kidney disease (CKD) with GFR < 30 ml/min/1.73 m².
  • Risk of cardiovascular death within 10 years > 10% (according to the European Score or equivalent tool).

• High Cardiovascular Risk:
  • Familial dyslipidemia or severe hypertension.
  • Isolated diabetes without target organ damage.
  • Chronic kidney disease with GFR 30-59 ml/min/1.73 m².
  • Risk of cardiovascular death within 10 years between 5 and 10% (according to the European Score or equivalent tool).

• Moderate Cardiovascular Risk:
  • Risk of cardiovascular death within 10 years between 1 and 5% (according to the European Score or equivalent tool).

• Low Cardiovascular Risk:
  • Patients not falling into the other categories.

There is no indication for cardiovascular primary prevention prescriptions for patients at low to moderate risk.

Prescription of Acetylsalicylic Acid in Prevention

Overall, ASA reduces the risk of cardiovascular events by approximately 10% but increases the risk of gastrointestinal bleeding by 0.1-0.5% per year. Recommendations are ASA 80 to 160 mg/day for:

• Patients at very high cardiovascular risk over 50 years old (men) or 60 years old (women).
• Consideration for other patients at very high cardiovascular risk.

Relative contraindication to evaluate: history of bleeding.

Prescription of ACE Inhibitors in Prevention

Indicated if:

• Patient is at very high cardiovascular risk.
• Patient has heart failure or a history of myocardial infarction or dilated cardiomyopathy.
• Patient has hypertension and target organ damage.

Prescription of Statins in Prevention

Indicated if:

• Patients are at very high cardiovascular risk.
• Familial dyslipidemia.
• Hypercholesterolemia with failure of lifestyle and dietary measures after 1 month.

Consideration for other diabetic patients.

Bibliography

AHA, recommandations 2024

EMC, Traité de médecine AKOS, Elsevier, 2018