Key result
Aspirin daily did not reduce first major CV events vs usual care in adults with CKD.
Why the study?
Although aspirin for primary prevention of CVD reduces atherosclerotic vascular events while increasing bleeding in the general population, the balance of benefits and harms in people with CKD was unclear.
Does aspirin 75 mg once daily reduce the risk of first major cardiovascular events compared with usual care in adults with chronic kidney disease (G1-4) and no prior cardiovascular disease?
RCT (n=4,633)
Open-label
Randomly assigned
Yes
Does aspirin 75 mg once daily reduce the risk of first major cardiovascular events compared with usual care in adults with chronic kidney disease (G1-4) and no prior cardiovascular disease?
In an underpowered trial of patients with CKD (G1-4) without prior CVD, low-dose aspirin did not statistically significantly reduce primary major cardiovascular events compared with usual care.
Answers are grounded in this paper and cite their sources.
ATTACK trial data on aspirin for primary prevention in CKD should not yet change practice; leaves open net clinical benefit versus bleeding risk.
Background CKD is strongly associated with cardiovascular disease (CVD). In the general population the use of aspirin for primary prevention of CVD reduces atherosclerotic vascular events but increases bleeding; the balance of benefits and harms in people with CKD is unclear. Methods We recruited adults with CKD (G1-4) and no history of CVD through primary care practices across the UK and randomly assigned them to receive aspirin 75 mg od or no aspirin in an open label design. The trial was powered at a sample size of 25210. The primary outcome was time to first major CV event (non-fatal MI, non-fatal stroke, CV death [excluding intracranial haemorrhage/other fatal CV bleeding]). Secondary outcomes reported here include time to first major bleed and all-cause mortality. Results Recruitment was adversely affected by the COVID pandemic. 4633 participants were randomised between March 2019 and December 2023 (2317 aspirin, 2316 control) and followed for a mean of 3.1 years. The primary outcome was observed in 56 (2.4%) and 76 (3.3%) participants in aspirin and non-aspirin arms respectively (Sub HR [SHR] 0.73, 95% CI 0.52 to 1.03). There were 29 (10 intracranial) major bleeding events in the aspirin arm vs. 19 (9 intracranial) in the non-aspirin arm (SHR 1.54, 95% CI 0.86 to 2.74). Death occurred during follow-up in 124 (5.4%) of the aspirin arm vs. 113 (4.9%) of the non-aspirin arm (HR 1.11, 95% CI 0.86 to 1.43). Conclusion The ATTACK trial provides inconclusive evidence on whether aspirin reduces the risk of first atherosclerotic events in people with CKD. Whilst a clinically meaningful 27% reduction in the primary outcome was observed, the results were not statistically significant. This may be because the trial was underpowered, but the findings are also consistent with a lack of effect. Further trials or a meta-analysis combining data from similar studies are required to answer the research question.
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Gallagher et al. (2026) conducted an RCT in Chronic kidney disease (G1-4) without prior cardiovascular disease (n=4,633). Aspirin vs. Usual care (no aspirin) was evaluated on Time to first major cardiovascular event (composite of non-fatal MI, non-fatal stroke, or cardiovascular death excluding intracranial haemorrhage/other fatal cardiovascular bleeding) (SHR 0.73, 95% CI 0.52-1.03). Aspirin 75 mg daily did not significantly reduce first major CV events vs usual care in adults with CKD (2.4% vs 3.3%; SHR 0.73, 95% CI 0.52-1.03).
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