From the Journals

Meta-analysis supports aspirin to reduce cardiovascular events

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Aspirin’s value persists despite guideline variations

Aspirin remains an important tool for the primary prevention of atherothrombotic vascular events, wrote J. Michael Gaziano, MD, in an accompanying editorial.

Historically, some guidelines have recommended against using aspirin for primary prevention of cardiovascular events because of the potential for harm, Dr. Gaziano noted, so a personalized approach to aspirin based on risk assessment is warranted. Dr. Gaziano also commented that risk is fluid; for example, patients who take action to improve their health and reduce risk by stopping smoking, eating differently, or exercising can reduce their risk for future CVD events.

“Because weighing the risks and benefits of aspirin in primary prevention is complicated, it should involve a shared decision-making discussion between the patient and the clinician,” he wrote. The current meta-analysis shows the consistency of recent trials with older studies, he remarked, noting that aspirin could be even more important as a cost-effective intervention in certain parts of the world where cardiovascular disease is on the rise and other treatments for CVD may be limited.

“Aspirin remains an important medication for acute management of vascular events; for use after certain procedures; for secondary prevention; and, after careful selection of the right patients, for primary prevention,” he concluded (JAMA. 2019;321[3]:253-5).

Dr. Gaziano is affiliated with Brigham and Women’s Hospital in Boston. He disclosed serving on the executive committee of the ARRIVE trial and serving as a consultant and receiving honoraria for speaking for Bayer.



Aspirin use is associated with a reduced risk of cardiovascular events among adults without cardiovascular disease, but this protection comes with a similarly increased risk for bleeding, according to data from a meta-analysis that included more than 1 million participant-years of follow-up.

©David Sucsy/iStockphoto

“The uncertain role of aspirin in primary prevention of cardiovascular events is reflected in contrasting recommendations offered by guideline bodies,” and has led to a decline in prescribing aspirin for primary prevention of such events, wrote Sean L. Zheng, MRCP, of Imperial College London (England) and his colleagues.

In a systematic review and meta-analysis published in JAMA, the researchers examined 13 randomized trials altogether including 164,225 participants and 1,050,511 participant-years of follow-up.

Overall, aspirin use significantly reduced a composite of cardiovascular outcomes, compared with no aspirin (hazard ratio, 0.89). The composite outcome included cardiovascular mortality, nonfatal myocardial infarction, and nonfatal stroke, and it occurred in 57.1 per 10,000 participant-years in aspirin users versus 61.4 per 10,000 participant-years among individuals who did not use aspirin. The absolute risk reduction was 0.38%.

The median age of the study participants was 62 years, and roughly half (47%) were male.

However, the risk of major bleeding events was significantly higher among aspirin users, compared with nonusers (23.1 per 10,000 participant-years and 16.4 per 10,000 participant-years, respectively), with a HR of 1.43 and an absolute risk increase of 0.47%.

Aspirin use was not associated with several secondary outcomes, including reductions in all-cause mortality or cardiovascular mortality, compared with no aspirin, but it was associated with a reduced risk specifically of myocardial infarction and ischemic stroke. Few deaths related to bleeding were reported.

The number needed to treat (265) and the number needed to harm (210) were similar, which emphasizes the need for an individual approach to treatment, the researchers noted.

“Consequently, the decision to use aspirin for primary prevention may need to be made on an individual basis, accounting for the patient’s risk of bleeding and their views on the balance of risk vs. benefit,” they concluded.

The researchers had no financial conflicts to disclose.

SOURCE: Zheng SL et al. JAMA. 2019;321(3):277-87.

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