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Aspirin for the Primary Prevention of Vascular Ischemic Events: An Updated Systematic Review and Meta-analysis to
Chloë Laferrière1, Chloé Moazzami1, Emilie Belley-Côté2,3
1Université de Montréal, Faculté de médecine, Montréal, Quebec, Canada.
Insights
Aspirin (ASA) use in primary prevention reduces major adverse cardiovascular events (MACE) but increases bleeding risks. Individual patient values are crucial when deciding on ASA for preventing cardiovascular disease.
Area of Science:
- Cardiology
- Preventive Medicine
- Clinical Trials
Background:
- Updated systematic review and meta-analysis on aspirin (ASA) in primary prevention.
- Focus on patients without established atherosclerotic cardiovascular diseases.
- Evaluates ischemic and bleeding events post-2010 Canadian guidelines.
Purpose of the Study:
- Assess the efficacy and safety of ASA for primary cardiovascular prevention.
- Compare ASA use versus no ASA in a large patient cohort.
- Synthesize evidence from recent randomized controlled trials (RCTs).
Main Methods:
- Searched MEDLINE, Embase, and CENTRAL up to March 2023 for relevant RCTs.
- Included 14 RCTs with 167,587 participants and a median 5-year follow-up.
- Assessed risk of bias and certainty of evidence using Cochrane and GRADE criteria.
Main Results:
- Aspirin use significantly reduced major adverse cardiovascular events (MACE) (RR 0.90, 95% CI 0.86-0.94).
- Aspirin use increased intracranial hemorrhage (RR 1.33, 95% CI 1.13-1.56) and major extracranial bleeding (RR 1.67, 95% CI 1.36-2.06).
- Effect estimates were consistent across subgroups for age, sex, and diabetes.
Conclusions:
- Aspirin in primary prevention offers MACE reduction but elevates bleeding risks.
- The decision to use aspirin requires careful consideration of individual patient values and preferences.
- Balancing cardiovascular benefits against bleeding harms is essential for personalized primary prevention strategies.
Background:
Since the publication of the 2010 Canadian antiplatelet guidelines, several large randomized controlled trials (RCTs) have evaluated the role of aspirin (ASA) use in primary prevention. We evaluated the effect of ASA use, compared with no ASA, on ischemic and bleeding events in patients without known atherosclerotic cardiovascular diseases.
Methods:
We updated a published systematic review and meta-analysis by searching MEDLINE, Embase, and CENTRAL for the period up to March 2023. We included RCTs that enrolled patients for primary prevention of atherosclerotic cardiovascular diseases, and compared use of ASA to no ASA. We assessed risk of bias (RoB) using the Cochrane RoB tool, and certainty of evidence using the grading recommendations, assessment, development, and evaluation (GRADE) criteria. The primary efficacy outcome was major adverse cardiovascular events (MACE) (death, myocardial infarction, or stroke). The primary safety outcomes were intracranial hemorrhage and extracranial major bleeding events. We used a random-effects model to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs).
Results:
We included 14 RCTs (n = 167,587) at overall low RoB, with a median follow-up of 5 years. Compared to no ASA, ASA use reduced the incidence of MACE (RR 0.90, 95% CI 0.86-0.94), with a higher risk of intracranial hemorrhage (RR 1.33, 95% CI 1.13-1.56) and extracranial major bleeding (RR 1.67, 95% CI 1.36-2.06). In prespecified subgroups of age, sex, and diabetes, effect estimates were consistent.
Conclusions:
ASA use in primary prevention is associated with a consistent reduction in MACE, but at the expense of major bleeding events. Patient values and preferences should be taken into account when considering ASA use for primary prevention.
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