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Aspirin in the primary prevention of cardiovascular disease: current knowledge and future research needs
Charles H Hennekens1, James E Dalen2
1Charles E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Road, Building 71, Room 337, Boca Raton, FL 33431.
Insights
Aspirin effectively prevents cardiovascular events in secondary prevention patients. For primary prevention, individual clinical judgment is crucial, balancing benefits against bleeding risks.
Area of Science:
- Cardiology
- Preventive Medicine
- Pharmacology
Background:
- Aspirin is widely used for secondary prevention of cardiovascular disease (CVD).
- Evidence for aspirin's role in primary prevention is less conclusive, particularly regarding stroke and CVD death.
- Low-risk populations show minimal absolute benefits from primary prevention aspirin.
Purpose of the Study:
- To evaluate the efficacy and risks of aspirin in secondary versus primary cardiovascular disease prevention.
- To inform clinical decision-making regarding aspirin prescription for different risk groups.
- To assess the potential for expanded aspirin use in primary prevention, especially in underserved regions.
Main Methods:
- Review of existing evidence on aspirin's effects on myocardial infarction (MI), stroke, and CVD death.
- Analysis of risk-benefit profiles in secondary prevention patients (prior CVD events, MI, stroke).
- Assessment of evidence in primary prevention patients, focusing on low-risk individuals and ongoing trials in intermediate-risk groups.
Main Results:
- Aspirin significantly decreases risks of MI, stroke, and CVD death in secondary prevention patients.
- In primary prevention, aspirin reduces the risk of a first MI, but evidence for stroke and CVD death reduction is inconclusive.
- Absolute benefits of aspirin in low-risk primary prevention groups are small, while bleeding risks remain consistent.
Conclusions:
- Aspirin should be widely prescribed for secondary prevention due to substantial benefits outweighing risks.
- Primary prevention aspirin decisions require individualized clinical judgment, weighing MI risk reduction against major bleeding risk.
- Ongoing trials in intermediate-risk populations may inform future guidelines, emphasizing aspirin as an adjunct to lifestyle changes and other therapies.
Abstract:
In secondary prevention, among a very wide range of survivors of prior occlusive cardiovascular disease (CVD) events and those suffering acute myocardial infarction (MI) or occlusive stroke, aspirin decreases risks of MI, stroke, and CVD death. In these high risk patients, the absolute benefits are large and absolute risks are far smaller so aspirin should be more widely prescribed. In contrast, in primary prevention, aspirin reduces risks of first MI but the evidence on stroke and CVD death remain inconclusive. Based on the current totality of evidence from predominantly low risk subjects where the absolute benefits is low and side effects the same as in secondary prevention, any decision to prescribe aspirin for primary prevention should be an individual clinical judgment by the healthcare provider that weighs the absolute benefit in reducing the risk of a first MI against the absolute risk of major bleeding. If the ongoing trials of intermediate risks subjects show net benefits then general guidelines may be justified with several caveats. First, any decision to use aspirin should continue to be made by the healthcare provider. Second, therapeutic lifestyle changes and other drugs of life saving benefit such as statins should be considered with aspirin as an adjunct, not alternative. The more widespread and appropriate use of aspirin in primary prevention is particularly attractive, especially in developing countries where CVD is emerging as the leading cause of death. In addition, aspirin is generally widely available over the counter and is extremely inexpensive.
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