Aspirin for primary prevention of cardiovascular disease: a review of recent literature and updated guideline recommendations

ABSTRACT

Introduction

Recent clinical trials evaluating the efficacy of aspirin in primary prevention of atherosclerotic cardiovascular disease (ASCVD) have suggested the risk of aspirin may outweigh its benefit in individuals once thought to be candidates for aspirin therapy. These results led to the publication of updated guideline recommendations in 2019 for aspirin use in primary prevention of cardiovascular disease from the American College of Cardiology (ACC) and American Heart Association (AHA).

Areas covered

Recent clinical trials and guidelines relevant to aspirin for primary prevention of ASCVD were identified using PubMed® (July 1, 2016 to April 1, 2019). Studies were limited to randomized, controlled clinical trials. The most current clinical practice guidelines were prioritized.

Expert opinion

Recent clinical trials demonstrated an increased risk of bleeding associated with aspirin use, which often outweighed cardiovascular risk reduction. In light of this new evidence, the ACC/AHA guidelines recommend aspirin for primary prevention in patients 40–70 years of age at a high ASCVD risk and low bleeding risk, who are unable to optimally control modifiable ASCVD risk factors.

KEYWORDS:

• Aspirin
• primary prevention
• cardiovascular disease
• stroke
• myocardial infarction
• guidelines

Article highlights

• Recent clinical trials have demonstrated a lack of efficacy regarding aspirin use for the prevention of cardiovascular disease, also noting a significant risk of bleeding events.

• The 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease has modified recommendations for the use of low-dose aspirin in primary prevention of cardiovascular disease.

• Low-dose aspirin should be considered only in patients aged 40–70 years who have a high ASCVD risk, with low bleeding risk.

• The use of aspirin in patients over 70 years of age should be considered with caution in light of increased risk of bleeding events.

• Prioritization should be given to controlling cardiovascular risk factors, such as hypertension, dyslipidemia, diabetes, and smoking.

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

One referee was on the adjudication committee of ARRIVE. Another referee reports grants and personal fees from Bayer and grants and personal fees from Otitopic during the conduct of the study; grants from Instrumentation Labs, grants from Haemonetics, grants and personal fees from Amgen, grants from Medicure, grants and personal fees from Janssen, grants from Idorsia, personal fees from UpToDate, and grants from Hikari Dx outside the submitted work; in addition, this referee has a patent for the Detection of restenosis risk in patients issued and a patent for the assessment of cardiac health and thrombotic risk in a patient pending. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This manuscript has not been funded.