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Aspirin in the Modern Era of Cardiovascular Disease Prevention
Ella Murphy1, James M G Curneen1, John W McEvoy1
1National University of Ireland, Galway, Ireland.
Insights
Aspirin
Area of Science:
- Cardiology
- Pharmacology
Background:
- Aspirin is a traditional therapy for cardiovascular disease (CVD) prevention.
- Newer antiplatelet agents and bleeding risks challenge aspirin's established role.
- Recent trials explore aspirin-free strategies for secondary CVD prevention.
Purpose of the Study:
- To review the evolving role of aspirin in primary and secondary cardiovascular disease (CVD) prevention.
- To discuss factors influencing current aspirin use in CVD prevention.
- To analyze the impact of new evidence on aspirin's place in modern cardiovascular care.
Main Methods:
- Review of contemporary trials and meta-analyses on aspirin and antiplatelet therapies.
- Analysis of factors influencing CVD prevention strategies.
- Discussion of updated clinical practice guidelines.
Main Results:
- P2Y12 inhibitor monotherapy shows lower bleeding risk without increased adverse cardiovascular events compared to dual antiplatelet therapy including aspirin after percutaneous coronary intervention.
- Contemporary primary prevention trials suggest diminishing benefits and potential harm from aspirin.
- Changing population demographics, improved risk factor control, and evolving outcome definitions impact aspirin's efficacy.
Conclusions:
- The role of aspirin in secondary prevention is being re-evaluated, with P2Y12 inhibitor monotherapy emerging as a safer alternative in certain contexts.
- Aspirin's benefit in primary prevention is less certain and potentially outweighed by bleeding risks in contemporary practice.
- Updated guidelines and evolving clinical landscapes necessitate a nuanced approach to aspirin use in cardiovascular disease prevention.
Abstract:
Aspirin's antithrombotic effects have a long-established place in the prevention of cardiovascular disease (CVD), and its traditional use as a core therapy for secondary prevention of CVD is well recognized. However, with the advent of newer antiplatelet agents and an increasing understanding of aspirin's bleeding risks, its role across the full spectrum of modern CVD prevention has become less certain. As a consequence, recent trials have begun investigating aspirin-free strategies in secondary prevention. For example, a contemporary metanalysis of trials that assessed P2Y12 inhibitor monotherapy versus prolonged (≥ 12 months) dual antiplatelet therapy (which includes aspirin) after percutaneous coronary intervention reported a lower risk of major bleeding and no increase in stent thrombosis, all-cause mortality, myocardial infarction (MI), or stroke in the P2Y12 monotherapy group. In contrast to secondary prevention, aspirin's role in primary prevention has always been more controversial. While historical trials reported a reduction in MI and stroke, more contemporary trials have suggested diminishing benefit for aspirin in this setting, with no reduction in hard outcomes, and some primary prevention trials have even indicated a potential for harm. In this review, we discuss how changing population demographics, enhanced control of lipids and blood pressure, changes in the definition of outcomes like MI, evolution of aspirin formulations, and updated clinical practice guidelines have all impacted the use of aspirin for primary and secondary CVD prevention.
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