Preprint Review Version 1 Preserved in Portico This version is not peer-reviewed

Aspirin in Primary Prevention: Looking for Who Enjoys It!

Version 1 : Received: 12 June 2024 / Approved: 13 June 2024 / Online: 13 June 2024 (11:51:45 CEST)

A peer-reviewed article of this Preprint also exists.

Della Bona, R.; Giubilato, S.; Palmieri, M.; Benenati, S.; Rossini, R.; Di Fusco, S.A.; Novarese, F.; Mascia, G.; Gasparetto, N.; Di Monaco, A.; Gatto, L.; Zilio, F.; Sorini Dini, C.; Borrello, F.; Geraci, G.; Riccio, C.; De Luca, L.; Colivicchi, F.; Grimaldi, M.; Giulizia, M.M.; Porto, I.; Oliva, F.G. Aspirin in Primary Prevention: Looking for Those Who Enjoy It. J. Clin. Med. 2024, 13, 4148. Della Bona, R.; Giubilato, S.; Palmieri, M.; Benenati, S.; Rossini, R.; Di Fusco, S.A.; Novarese, F.; Mascia, G.; Gasparetto, N.; Di Monaco, A.; Gatto, L.; Zilio, F.; Sorini Dini, C.; Borrello, F.; Geraci, G.; Riccio, C.; De Luca, L.; Colivicchi, F.; Grimaldi, M.; Giulizia, M.M.; Porto, I.; Oliva, F.G. Aspirin in Primary Prevention: Looking for Those Who Enjoy It. J. Clin. Med. 2024, 13, 4148.

Abstract

Based on a wealth of evidence, aspirin is one of the cornerstones of secondary prevention of cardiovascular disease. However, despite several studies showing efficacy also in primary prevention, an unopposed excess risk of bleeding leading to a very thin safety margin is evident in subjects without a clear acute cardiovascular event. Overall, the variability in recommendations from different scientific societies for aspirin use in primary prevention is a classic example of failure of simple risk stratification models based on competing risks (atherothrombosis vs. bleeding), perceived to be opposed but intertwined at the pathophysiological level. Notably, cardiovascular risk is dynamic in nature and cannot be accurately captured by scores, which do not always consider risk enhancers. Furthermore, the widespread use of other potent medications in primary prevention, such as lipid-lowering and anti-hypertensive drugs, might have reduced the benefit of aspirin in recent trials. Some authors, drawing from specific pathophysiological data, have suggested that specific subgroups might benefit more from aspirin. This includes patient with diabetes and those with obesity, as well as considering sex-based differences. Moreover, molecular analysis of platelet reactivity has been proposed. A beneficial effect of aspirin has also been demonstrated for the prevention of cancer, especially colorectal. This review explores evidence and controversies concerning the use of aspirin in primary prevention, considering new perspectives in order to develop a personalized approach.

Keywords

aspirin; primary prevention; cardiovascular risk; platelet; bleeding; thrombosis; diabetes; guidelines; cancer

Subject

Medicine and Pharmacology, Cardiac and Cardiovascular Systems

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