Changing place for aspirin in primary prevention of cardiovascular disease

In contrast to its generally accepted benefit in secondary prevention, the role of low-dose aspirin in the primary prevention of cardiovascular disease (CVD) has long been controversial. Despite a 30% decrease in the number of prescriptions dispensed between 2008 and 2018, aspirin remains one of the top 10 most dispensed medications in England.1 This gradual decline is similar to what has been reported in the USA and likely represents reduced support for aspirin in primary prevention guidelines from European and US professional societies.2 For example, in the 2016 European Society of Cardiology (ESC) guideline on CVD prevention, aspirin was not recommended for primary prevention.3 A 2018 National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summary (which is not a formal NICE guideline) also reported that the available evidence does not support routinely prescribing aspirin for primary prevention of CVD.4 This publication further states that aspirin is not licensed for primary CVD prevention, aspirin is associated with harm and that adults can reduce their CVD risk by other means such as smoking cessation and statin therapy. However, in contrast to the ESC position, NICE suggests that physicians may consider aspirin on a case-by-case (non-routine) basis in people with high risk for stroke or myocardial infarction (MI). In some alignment with NICE, the 2019 American Heart Association/American College of Cardiology (AHA/ACC) guidelines for the primary prevention of CVD provide only a weak recommendation for aspirin use among selected high-risk adults who on a case-by-case basis want to remain on or start aspirin after a discussion of the risks and benefits; but only among those aged less than 70 years.5 For adults aged over 70 years, AHA/ACC guidelines do not recommend aspirin for the routine primary prevention of CVD due to excess bleeding risk and a …