Who needs acetylsalicylic acid? Some order after many studies

The role of acetylsalicylic acid (ASA) in cardiovascular prevention is essentially consequence of its ability to inhibit platelet aggregation, thus reducing the impact of atherosclerotic disease. The preventive power of this drug is clear when used in patients with previous cardiovascular event (myocardial infarction, stroke, etc.), but the data are less dependable when considering patients who did not experienced a cardiovascular event or in the diabetic population, in whom recent studies reported neutral results in term of efficacy, in face of an increase in the risk of bleeding. Furthermore, the interpretation of the efficacy results of ASA should be reconsidered in light of the increasing clinical complexity, not addressed in the clinical studies on which current evidences are based. Accordingly the rationale for ASA use in cardiovascular prevention is ever more of current interest, and requires a particular attention, considering the crucial role of antithrombotic therapy in the foreseeable future. What could be learned on the use of ASA in cardiovascular prevention after a century since its chemical synthesis? In secondary prevention, supporting evidences have now a couple of decades of history, and the use of the drug appears to be firmly established: in this setting, the benefits clearly surpass the risks. On the other hand, in primary prevention, where age and diabetes are among the main risk factors, the risk/benefit ratio for prophylactic therapy with ASA does not support its widespread use. Deciding when this treatment should be implemented should require a case-by-case evaluation, considering, first, the correction of each risk factor, whose control has led to a reduction of global cardiovascular mortality. The other fundamental aspect is the compliance to the treatment, particularly in patients subjected to multiple drugs regimens, in whom the physician should take into account the specific needs of the patient, as not to provide a mere prescription service.