Appraising the contemporary role of aspirin for primary and secondary prevention of atherosclerotic cardiovascular events

ABSTRACT

Introduction

Although the role of aspirin for primary prevention of atherosclerotic cardiovascular disease (ASCVD) has been disputed, its use in secondary ASCVD prevention is well established. Recent trials of primary prevention do not suggest a significant net benefit with aspirin, whereas accruing evidence supports adopting aspirin-free strategies in the context of potent P2Y₁₂ inhibition for the secondary prevention of selected patients undergoing percutaneous coronary intervention.

Areas covered

This updated review aims at summarizing and appraising the pharmacological characteristics and the contemporary role of aspirin for the primary and secondary prevention of ASCVD.

Expert opinion

Recent trials and metanalyses in the context of primary prevention highlighted a modest reduction in ischemic events with aspirin use, counterbalanced by a significant increase in bleeding events. However, ongoing studies on cancer prevention could modify the current paradigm of the unfavorable benefit-risk ratio of aspirin in patients with no overt ASCVD. Conversely, aspirin use is crucial for secondary ASCVD prevention, both in chronic and acute coronary syndromes. Nevertheless, after a brief period of dual antiplatelet therapy, patients at high bleeding risk may benefit from discontinuation of aspirin if a P2Y₁₂ inhibitor is used, hence reducing the bleeding risk with no rebound in thrombotic events.

KEYWORDS:

• Antiplatelet therapy
• aspirin
• aspirin-free strategies
• cardiovascular disease
• primary prevention
• secondary prevention

Article highlights

• Four contemporary primary prevention trials overall suggested that aspirin was associated with none or modest antithrombotic benefit and increased bleeding across the spectrum of cardiovascular risk. Current guidelines do not recommend the routine use of aspirin for primary prevention.

• Aspirin plays an established role in the context of secondary ASCVD prevention for patients with a prior myocardial infarction or coronary revascularization.

• Adding a second antithrombotic agent to aspirin may be effective in the context of chronic management of established ASCVD for selected individuals at higher thrombotic risk until the risk of bleeding exceeds the expected benefit.

• PCI patients at higher bleeding risk may benefit from the discontinuation of aspirin after an event-free period of dual antiplatelet therapy if they continue with a potent P2Y₁₂ inhibitor (e.g. ticagrelor), due to similar ischemic protection and lower bleeding events compared to continuation of dual antiplatelet therapy.

Declaration of interest

Davide Capodanno reports advisory board or speaker’s honoraria from Amgen, Daiichi Sankyo, Sanofi. DJ Angiolillo reports consulting fees or honoraria from Abbott, Amgen, Aralez, AstraZeneca, Bayer, Biosensors, Boehringer Ingelheim, Bristol-Myers Squibb, Chiesi, Daiichi-Sankyo, Eli Lilly, Haemonetics, Janssen, Merck, PhaseBio, PLx Pharma, Pfizer, Sanofi, and The Medicines Company; and has received payments for participation in review activities from CeloNova and St. Jude Medical. They also report that their institution has received research grants from Amgen, AstraZeneca, Bayer, Biosensors, CeloNova, CSL Behring, Daiichi- Sankyo, Eisai, Eli Lilly, Gilead, Idorsia, Janssen, Matsutani Chemical Industry Co., Merck, Novartis, Osprey Medical, Renal Guard Solutions, and the Scott R. MacKenzie Foundation. The authors have no other 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 apart from those disclosed.

Reviewer disclosures

A peer reviewer of this paper reports previously being a speaker and consultant to Amgen, Servier, and other pharmaceutical companies. They also report that they have been a local PI for several trials in ACS and stable CAD with PY212 inhibitors. Peer reviewers in this manuscript have no other relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.