In a time when complex medical communication to the public is on display, the need to ensure patient comprehension is of utmost importance for vascular neurologists.
FOR THOSE WHO HAVE BEEN treating patients who suffered a stroke both in and out of the hospital, you are likely familiar with patients who come in and report that they had stopped taking medication for prevention leading up to the time of their stroke. Some report that they just fell out of the habit, and others might have been holding on to medication in anticipation of some surgery or because of an adverse effect. Now, though, we will start to hear a new-old excuse: “I heard it was bad for you.”
A headline in October 2021 stated, “US task force proposes adults 60 and older should not take daily aspirin to prevent heart disease or stroke.”1 As a board-certified vascular neurologist who frequently recommends aspirin, I was surprised, to say the least. Further reading of the article revealed that a draft recommendation—not finalized—was available for public comment, suggesting that people older than 60 years should not start aspirin for primary prevention but that patients who already take aspirin for a previous heart attack or stroke should not stop unless told to do so by their provider. According to a study quoted in the Washington Post, at least 6 of 10 Americans never get beyond the headline when reading a news story,2 implying that, unfortunately, important clarifications often go unnoticed.
Heart attack and stroke remain among the leading causes of death and disability in the United States and elsewhere. The best stroke is the one that never happens, and for that reason, a significant amount of time, energy, and resources are used to aid in both primary and secondary prevention of stroke. This is usually accomplished through a combination of anticipation of risk, introduction of lifestyle modifications, and the use of medications. Recently, the United States Preventive Services Task Force (USPSTF) opened for public comment a recommendation against the use of aspirin for primary prevention in certain populations, but this will almost certainly lead to headaches for neurologists treating patients for stroke.
The USPSTF is made up of 16 volunteer members who are nationally recognized experts in prevention, evidence-based medicine, and primary care. Their fields of practice and expertise include behavioral health, family medicine, geriatrics, internal medicine, pediatrics, obstetrics and gynecology, and nursing.3 Note that there are no neurologists—a fact that we should aim to address. The USPSTF mission “is to improve the health of people nationwide by making evidence-based recommendations on clinical preventive services and health promotion in primary care settings.”4 USPSTF was initially established in 1984, but its mandate has evolved over the years; today, insurers are required to cover preventive services that receive a high recommendation from the USPSTF.
Considering the prevalence of cardiovascular disease and stroke among the US population, the focus for some of the task force’s recent recommendations is not surprising. The last finalized guidance from the USPSTF regarding aspirin for primary prevention of heart attack and stroke was in 2016,5 when it concluded that for people aged 50 to 59 years who have at least a 10% risk of cardiovascular disease (CVD) over the next 10 years, aspirin is recommended for primary prevention. And for people aged 60 to 69 years, life expectancy and risk for complications should be considered and the decision individualized with their physician. There was insufficient evidence to make any recommendation for those younger than 50 years or older than 69 years.
With this most recent proposed revision—that at the time of this writing remains unfinalized—patients aged 40 to 59 years with more than a 10% risk for CVD over 10 years should have a conversation with their physician about aspirin for an individualized decision, taking bleeding risk into account; however, for those 60 years or older, aspirin should not be started for primary prevention of stroke or heart attack because the task force’s review of the evidence suggests that the risk outweighs the benefit. Importantly, this may not apply in the same way for patients who have a history of transient ischemic attack or significant carotid, coronary (without heart attack), or peripheral artery disease. We will need to wait for the final recommendation and explanation of the evidence for further clarification.
Unfortunately, with reporting like the aforementioned headline, those who provide guidance on secondary prevention of stroke can anticipate that patients who have been taking aspirin for secondary prevention will stop, placing themselves at higher risk for a new cerebrovascular event. Joshua Z. Willey, MD, an associate professor of neurology at Columbia University Vagelos College of Physicians and Surgeons and an attending neurologist for the Stroke Service at NewYork-Presbyterian Hospital in New York City, was quoted in a recent article in Neurology Today, saying, “Within 12 hours of a prominently displayed New York Times article on the new thinking on aspirin, I had about 20 messages from patients asking if they should stop taking their aspirin.”6
Furthermore, this comes at a time when our recommendations for antiplatelet medications for secondary stroke prevention are becoming more complex rather than less, with expanded options and important stipulations on time of treatment (TABLE).5,7-9 Many of us may remember an increased need to answer questions and concerns about the benefits of aspirin for secondary stroke prevention following the release of the 2016 USPSTF recommendation. Although this may not be a new issue, with the adjustment of the recommendation and considering headlines like the one referenced previously, it is crucial that we take this opportunity to communicate with our patients as well as our hospital colleagues and those in primary care to help limit the risk of patients inappropriately stopping their secondary prevention medications.
So how do we do that?
Being familiar with these recommendations as well as the recommendations from the American Heart Association/American Stroke Association on both primary and secondary prevention will go a long way toward being able to answer questions about which patients should be treated.
Ensure that your communication about this topic is clear and concise. Improved open communication between providers and patients has never been more important. To preserve patient autonomy, we need to have a simple and understandable message to help empower patients to make informed decisions about their care.
Office staff can be scripted to ask patients during visit preparation if they are aware of the new recommendations or if they have any concerns about their current medication for secondary stroke prevention. It is possible that those who are reluctant to continue their medication may also be more reluctant to talk with you about their concerns. This may also be the population most likely to quickly, and incorrectly, conclude that they no longer should take aspirin for stroke prevention.
Consider reaching out directly to patients with a message describing and clarifying this recommendation and reinforcing that they should continue their current regimen for now and contact the office with any concerns. This is a great way to leverage the communications capabilities of the electronic medical record.
Primary care teams and hospitals that refer patients to your practice may also need guidance regarding how to apply these recommendations in the setting of so many specific caveats and in the face of the ever-present level C evidence. Expert opinion is sometimes the hardest to adjust, regardless of the evidence behind a new recommendation. Communicating through a letter, email, or other means and reinforcing an open pipeline for communication will help clarify best practices regarding stroke prevention for individual patients.
Recommendations can and should change over time. As the quality and quantity of specific evidence grows, we can expect that best practices will continue to be a moving target. A new and important challenge for health care providers, however, is broad-based dissemination of information with limited clinical accuracy. Headlines look to stimulate readers to investigate further, but a push for sensationalism can have important unintended consequences when misinterpreted by patients. By following the principles discussed here and staying ahead of the information curve, we will be positioned to provide counsel, guidance, and reinforcement to help our patients avoid being 1 of the nearly 200,000 people in the United States every year with a recurrent stroke.