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Why we should not skip aspirin in cardiovascular prevention
1Prof. Dr. med. Karsten Schrör, em. Direktor, Institut für Pharmakologie und Klinische Pharmakologie, Heinrich-Heine-Universität Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany, Tel. +49/(0)211/81 15490/12501,
Insights
Aspirin remains a cornerstone in cardiovascular prevention due to its unique antiplatelet action. Current evidence is insufficient to replace aspirin with other agents, especially with new anticoagulants, necessitating further research.
Area of Science:
- Cardiology
- Pharmacology
- Vascular Medicine
Background:
- Aspirin has been a first-line antiplatelet agent for over 20 years in cardiovascular prevention.
- Its efficacy stems from unique COX-1 inhibition and thromboxane formation suppression.
- Aspirin is crucial in dual antiplatelet therapy for acute coronary syndromes and percutaneous coronary interventions.
Purpose of the Study:
- To evaluate the current role of aspirin in cardiovascular prevention in light of new oral anticoagulants (NOACs).
- To discuss the necessity of dual antiplatelet therapy, including aspirin, versus alternative antiplatelet agents.
- To highlight the need for further research on aspirin's chemopreventive role, particularly in high-risk populations.
Main Methods:
- Review of existing clinical data and pharmacological evidence on aspirin's antiplatelet effects.
- Analysis of the role of aspirin in combination therapies (dual antiplatelet therapy) and monotherapy.
- Assessment of the benefit/risk ratio of aspirin compared to newer anticoagulants and antiplatelet agents.
Main Results:
- Aspirin's unique mechanism and reliable efficacy support its continued use in cardiovascular prevention.
- Current data are insufficient to recommend skipping aspirin in favor of other oral antiplatelet agents or NOACs.
- The benefit/risk ratio, particularly concerning bleeding, remains uncertain for alternative strategies.
Conclusions:
- Aspirin's established role in cardiovascular prevention is supported by its unique pharmacological profile.
- Further research is essential to clarify the optimal use of aspirin and other antiplatelet agents alongside NOACs.
- Investigating aspirin's chemopreventive potential in high-risk groups like diabetics and those with venous thromboembolism is a priority.
Abstract:
Since more than 20 years, aspirin is an approved and established first-line antiplatelet medication in cardiovascular prevention. This is partially due to ist unique mode of action which is not shared with any other antiplatelet agent as well by the reliability of its pharmacological efficacy: inhibition of platelet COX-1 and subsequent thromboxane formation in almost every patient. Aspirin acts synergistic with ADP-antagonists in dual antiplatelet therapy of acute coronary syndromes (ACS) and percutaneous coronary interventions (PCI) and is also approved for long-term secondary prevention. Patients with atrial fibrillation are an exception and benefit more from anticoagulants. After the introduction of the new oral anticoagulants (NOACs), i.e. direct inhibitors of factor Xa or thrombin formation, there is a renewed discussion about the role of antiplatelet agents, specifically if additional dual antiplatelet treatment is still necessary for an optimum clinical effect or whether one component, such as aspirin might be skipped in favor of other classes of oral antiplatelet agents, such as ADP-antagonists. The available data are insufficient to recommend this because of a low number of studies and a still uncertain benefit/risk (bleeding) ratio. More research on aspirin as a chemopreventive appears also to be necessary and is going on, in particular in individuals at high-risk for vascular thrombotic diseases (diabetics, preeclampsia, venous thromboembolism).
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