Thread by @UREssien

Inpatient Lesson of the Day 7:

I remember the findings from this 2018 @NEJM study that aspirin ⬆️ bleeding risk but didn't ⬇️ CVD risk in the elderly.

What I didn't remember is that "elderly" was defined as >70 for White and >65 for Black/Hispanic.

🧵1/ nejm.org/doi/10.1056/NE…

According to the study Supplement, the following eligibility criteria were provided:

"...the age differential was permitted to ensure that Black and Hispanic populations could be represented in the trial, given evidence of higher burden of disease necessitating aspirin use." 2/

According the study design manuscript, "minority recruitment has been challenging due to a ⬇️ number of minorities w/o prior cardiovascular events, disability or dementia, who are not taking aspirin, and a reluctance to cease aspirin..." 3/
ncbi.nlm.nih.gov/pmc/articles/P…

"In addition, after an NIH moratorium on recruiting US Caucasians was enacted in 2011, there was increased hesitancy expressed by minorities regarding why ASPREE was only recruiting minorities..." 4/
ncbi.nlm.nih.gov/pmc/articles/P…

"Facilitation of US minority participation led to a differential age inclusion criterion... due to a ⬆️ prevalence of exclusion criteria, a survival disadvantage and greater risk of other elements of the primary composite endpoint in minorities compared with non-minorities." 5/

In summary, the age-limit, a key outcome of this study was set lower for minority patients because they had:

1. ⬆️ baseline CVD
2. ⬆️ death from CVD
3. ⬆️ hesitancy to join the trial

Achieving #HealthEquity will be impossible without creative & multidisciplinary strategies. 6/6

P.S. What do these data mean for clinical care?

Should I discontinue aspirin in a Black/Hispanic patient >65 because it was too hard to recruit those patients?

Or because those patients have been shown to die earlier?

Are there really two standards for “elderly” in the U.S.?