Aspirin Use in Primary Prevention of Cardiovascular Disease

Guideline Recommendations

The American College of Cardiology and American Heart Association recommend that aspirin is not used for primary prevention in adults over 70 years of age due to increased bleeding risk, which is a Class III recommendation 2
The American College of Cardiology and American Heart Association suggest that aspirin should not be routinely used in adults 40-70 years of age at average cardiovascular risk, which is a Class IIb recommendation 2
The American College of Cardiology and American Heart Association recommend that aspirin may be considered selectively in adults 40-70 years at higher ASCVD risk who are not at increased bleeding risk and are unable to achieve optimal control of other risk factors 2
The European Society of Cardiology guidelines state that aspirin cannot be recommended in primary prevention due to its increased risk of major bleeding 1

Aspirin reduces serious vascular events from 0.57% to 0.51% per year, which is only a 0.06% absolute reduction, primarily through reduction in non-fatal MI 3
Major gastrointestinal bleeding occurs in 2-4 per 1,000 middle-aged adults over 5 years, and 4-12 per 1,000 older adults 3
Meta-analyses show that aspirin does not reduce total mortality, with an odds ratio of 0.93 and a 95% confidence interval of 0.84-1.02 3

The American College of Cardiology and American Heart Association recommend immediate discontinuation of aspirin for adults over 70 years of age, adults under 40 years of age, and those with a history of gastrointestinal bleeding or peptic ulcer disease 2
The American College of Cardiology and American Heart Association also recommend discontinuation for patients with thrombocytopenia, coagulopathy, or chronic kidney disease, and those taking concurrent NSAIDs, steroids, anticoagulants, or other medications increasing bleeding risk 2

For diabetic patients without established cardiovascular disease, the decision to use aspirin should follow the same 2019 ACC/AHA framework, which recommends aspirin only for those 40-70 years old, at high ASCVD risk, not at increased bleeding risk, and unable to achieve optimal control of other risk factors 2
The American Heart Association and American Diabetes Association previously recommended aspirin for diabetic patients over 40 years or with additional risk factors, but this recommendation predates the more recent evidence showing limited benefit and significant bleeding risk in primary prevention populations 4

Aspirin should not be stopped in patients with established cardiovascular disease, recent coronary stenting, or acute coronary syndrome, as the risk-benefit ratio is clearly favorable in secondary prevention 1
Specific cardiac conditions requiring antiplatelet therapy also necessitate continued aspirin therapy 5