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Featured Clinical Reviews

June 28, 2019

A Practical Approach to Low-Dose Aspirin for Primary Prevention

Author Affiliations
  • 1Department of Medicine, Stanford University, Palo Alto, California
JAMA. 2019;322(4):301-302. doi:10.1001/jama.2019.8388

Acetylsalicylic acid (or aspirin) has numerous biological effects, including anti-inflammatory properties and reduced platelet activation. These mechanisms explain the benefits of aspirin for prevention of atherosclerotic cardiovascular disease (CVD) and its propensity to cause unwanted bleeding.

While older studies suggested that aspirin was associated with a relative reduction of first cardiovascular events by up to 20%, 3 clinical trials published in 2018 suggest at most modest reductions in cardiovascular outcomes of a magnitude comparable with the risk of clinically significant bleeding.1-3 These trials were designed to clarify earlier doubts, but have fueled continuing controversy. Recommendations accounting for these studies range from continued cautious use to abandonment of aspirin for primary prevention. Recent American Heart Association/American College of Cardiology prevention guidelines suggest that “aspirin should be used infrequently in the routine primary prevention” of CVD and limited to selected high-risk patients with low bleeding risk.4

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3 Comments for this article
Why not try combo pill?
Thomas Heston, MD | Washington State University
I typically prescribe an antacid when recommending aspirin in order to get the cardiovascular benefits while decreasing bleeding. Use of proton pump inhibitors is fairly common regardless. It makes sense to control for PPI use when assessing the risk:benefit ratio of aspirin for primary prevention. This does not appear to have been done yet.
Chronic PPI Risk
Kyle Ames, PharmD | Hennepin County Medical Center
Prescribing chronic PPI's with aspirin solely to decrease the risk of bleeding does not come without risks. Chronic PPI use is associated with increased risks of Clostridium difficile, osteoporosis, pneumonia, acute interstitial nephritis, chronic kidney disease and acute kidney injury. As for the combination pill, it has already exists as a combination of aspirin and omeprazole known as Yosprala.
Samir Saha, MD, PhD | Umeå University, Umeå, Sweden, at Sundsvalls Primary Care Center
The Viewpoint may reduce doubts about use of aspirin for primary prevention of cardiovascular events, such as acute coronary syndrome, stroke, and peripheral arterial disease. The discussion part is very balanced and carries much practical wisdom for clinicians.

As a cardiologist with a special interest in type 2 diabetes I use aspirin (75 mg, standard in Sweden) and a statin, most commonly atorvastatin 40 mg, if the patient is > 55 years, male, and has coexisting hypertension without any history of prior vascular event(s). This approach is supported by the 2019 guidelines of the American Diabetes Association.