Specifically whether the benefits of CVD risk reduction for those with high Lp(a) are worth the increased risk of major bleeding? As you know, the recommendation to use aspirin for CVD risk reduction was withdrawn for primary prevention, at least for older individuals, but I wonder if this changes the balance for those with high Lp(a).
The paper does end with a statement that further study is needed, but that’s not unusual.
I don’t have strong views on the topic at this point. This is mostly hypothesis-generating for further study in RCT form. However, I can understand the sense of urgency among patients with elevated levels that are not directly treatable at this time. As a result, if someone was interested in trying this, I would be evaluating for their risk of potential bleeding as compared with the potential benefit of CV event risk reduction and having that conversation with the person.
For example, if a person were already on other anticoagulant drugs, had a history of major / life-threatening bleeding, or other concerning risk factors for this, I may be less likely to suggest trying aspirin in the face of ongoing uncertainty re: CV outcomes. On the other hand, for a person with no other risk factors for bleeding and very high Lp(a) levels +/- other CV risk factors, any potential CV event risk reduction may be worthwhile, because even if the person does bleed, it is far easier to treat/fix bleeding than it is a major CV event.
“even if the person does bleed, it is far easier to treat/fix bleeding than it is a major CV event.”
That’s a very interesting point.
It would be helpful to have RCT results comparing longer term mortality/morbidity involving similar demographics to the patient, but that’s not happening anytime soon.
For the record:
For adults 60 years or older, the USPSTF recommends against initiating low-dose aspirin use for the primary prevention of CVD in adults 60 years or older. The USPSTF concludes with moderate certainty that initiating aspirin use for the primary prevention of CVD events in adults 60 years or older has no net benefit, due to increased risk of bleeding with advancing age. The benefit is decreasing an individual’s risk of a myocardial infarction or stroke. Recommendation: Aspirin Use to Prevent Cardiovascular Disease: Preventive Medication | United States Preventive Services Taskforce