Aspirin Therapy in Established Cardiovascular Disease

Introduction to Aspirin Benefits

The American Diabetes Association and European Society of Cardiology recommend aspirin for secondary prevention with their highest level of recommendation (Class A evidence), as it reduces the risk of another heart attack, stroke, or cardiovascular death by approximately 21-26% in patients with established cardiovascular disease 1, 2

The American College of Cardiology recommends using aspirin 75-100 mg daily for patients with established cardiovascular disease, as this dose range provides equivalent cardiovascular protection to higher doses while significantly reducing bleeding complications 1, 2, 4
Aspirin should be continued lifelong after any initial period of dual antiplatelet therapy, with a transition to aspirin alone indefinitely after coronary stenting 1, 2, 4

For patients who cannot tolerate aspirin due to a documented allergy, clopidogrel 75 mg daily should be substituted, as recommended by the American Heart Association 1, 2
Long-term dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor) should be considered for patients with recent acute coronary syndrome or coronary intervention with high ischemic risk and low bleeding risk 1
Combination therapy with aspirin plus low-dose rivaroxaban (2.5 mg twice daily) should be considered for patients with stable coronary or peripheral artery disease and low bleeding risk, to prevent major adverse limb and cardiovascular events 1

Treating 1,000 patients with established cardiovascular disease with aspirin for approximately 3 years prevents 33 cardiovascular events, including 12 nonfatal heart attacks and 25 nonfatal strokes, at the cost of causing 9 major bleeding events, resulting in a benefit-to-harm ratio of approximately 4:1 in favor of treatment 4