Muhammad Waleed ( Final Year Student, CMH Institute of Medical Sciences Multan, Pakistan )
August 2020, Volume 70, Issue 8
Student's Corner
https://doi.org/10.5455/JPMA.75909
Madam, Aspirin is an anti-inflammatory and anti-platelet drug used in cardiovascular disease prevention. There is plenty of evidence to support the use of low dose aspirin for secondary prevention of coronary artery disease but its role as a primary prevention drug has been questioned recently.1 A trial published in the New England Medical Journal known as the ASPREE trial studied the effects of aspirin in 19,114 people with age > 70 when given as a primary prevention drug. The trial showed that people who took daily Aspirin had no difference in mortality than those who took placebo but there was greater risk of haemorrhage with aspirin.2 Another trial the ARRIVE trial showed that aspirin when taken as a primary prevention drug in people of age >55 years in men or > 60 years in women with moderate cardiovascular risk showed no net benefit from the daily dose aspirin compared to placebo but was associated with higher rates of gastrointestinal haemorrhage.3 In diabetic patient benefits of aspirin have been well supported by evidence, ASCEND trial showed that people who took aspirin had lower percentage of vascular events in contrast to those who were on placebo (absolute risk reduction of 1.1%) given that they had no previous evidence of cardiovascular disease. In the same trial there was significantly increased risk of major haemorrhage (absolute risk increase of 0.9%) in the aspirin arm.4 American Heart Association latest guidelines for primary prevention in cardiovascular disease limits the use of aspirin as a primary prevention drug. It is only recommended in people between 40-70 years of age without any risk of bleeding.5 In conclusion low dose aspirin is well supported by evidence for secondary prevention of coronary artery disease but its use as a primary prevention drug for cardiovascular disease has been questioned in the light of the recent evidence. All this data points towards the fact that aspirin role as a drug for primary prevention is limited and great caution must be taken when prescribing aspirin for primary prevention in older patients and those who are high risk for major bleeding.
Disclaimer: None.
Conflict of interest: None.
Funding disclosure: None.
References
1. Antithrombotic Trialists' (ATT) Collaboration, Baigent C, Blackwell L, Collins R, Emberson J, Godwin J, et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative metaanalysis of individual participant data from randomised trials. Lancet. 2009; 373:1849-60.
2. McNeil JJ, Woods RL, Murray AM, ASPREE Investigator Group. Effects of Aspirin in the Healthy Elderly. Reply. N Engl J Med. 2019; 380:1776- 7.
3. Gaziano JM, Brotons C, Coppolecchia R, Cricelli C, Darius H, Gorelick PB, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet. 2018; 392:1036-46.
4. ASCEND Study Collaborative Group, Bowman L, Mafham M, Wallendszus K, Stevens W, Buck G, et al. Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus. N Engl J Med. 2018; 379:1529-39.
5. Correction to: 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019; 140:e649- e50.
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