To the Editor:

I would like to recognize Dr. Phil Mohler’s effort to explain the challenging aspirin chemoprevention recommendation made by the U.S. Preventive Services Task Force (USPSTF). In “Weighing the Risks and Benefits of Clinical Interventions” [January 2004, page 53], Dr. Mohler states, “ … patients without known cardiovascular disease but with at least a five-year 3-percent risk for a CV event be treated with 81 mg of aspirin daily” and that the USPSTF “… gave this intervention its highest rating, an ‘A,’ meaning it is strongly recommended.” While the USPSTF did give its aspirin chemoprevention recommendation its highest rating, it was not explicitly recommending aspirin’s use, but rather recommending that “(C)linicians discuss [emphasis added] aspirin chemoprevention with adults who are at increased risk for coronary heart disease” and that these discussions “… should address both the potential benefits and harms of aspirin therapy.”¹ It is also worth noting that the USPSTF found no study that demonstrated a decrease in all-cause mortality using aspirin as chemoprevention.¹

To put it another way, the USPSTF does not appear to recommend aspirin for primary chemoprevention for coronary heart disease per se, but rather recommends a discussion of the incidence of cardiovascular disease and the risks and benefits of using aspirin to modify cardiovascular disease risk. It should also be noted that both Dr. Mohler and the USPSTF recommend that the discussion between the clinician and patient be based on estimating the patient’s risk of CAD, which can be done using the tools in the article. A worthwhile synopsis of the USPSTF’s approach to shared decision making was recently published, explaining how risk can be individualized to help come to an informed decision in line with a patient’s unique preferences.²