阿司匹林与心血管疾病一级预防。利弊之间的平衡尚不确定。

Prescrire Int. 2010 Nov;19(110):258-61.

Most individuals with no pre-existing cardiovascular disease have a low risk of experiencing arterial thrombosis. Using the standard Prescrire methodology, we reviewed the literature on the risk-benefit balance of aspirin in the primary prevention of cardiovascular events. In the general population, a meta-analysis in 95 456 persons suggests that aspirin has no effect on either total or cardiovascular mortality. Aspirin may slightly reduce the risk of stroke in women and myocardial infarction in men, but it increases the risk of bleeding. It is unclear whether the benefits outweigh the risks. Aspirin does not reduce mortality in the elderly. in one trial, aspirin reduced the risk of ischaemic stroke and myocardial infarction in women aged 65 and over. However, the risk of cerebral haemorrhage associated with aspirin increases with age. Therefore, the risk-benefit balance of aspirin in primary cardiovascular prevention in the elderly is uncertain. Aspirin is more beneficial in patients with cardiovascular risk factors, but the bleeding risk is sometimes higher too. In clinical trials, aspirin did not reduce either total or cardiovascular mortality in hypertensive or diabetic patients. In contrast, it reduced the risk of myocardial infarction in hypertensive patients and diabetic men. Aspirin did not prevent cardiovascular events in smokers, and has not been assessed in patients with hypercholesterolaemia. In practice, the risks outweigh the benefits when aspirin is used to prevent a first thrombotic event in people at low risk. When the cardiovascular risk is higher than in the general population, for example in patients with risk factors, the weak preventive effects of aspirin on myocardial infarction and ischaemic stroke may outweigh the small extra risk of bleeding. The possible value of aspirin for cardiovascular prevention should be discussed with each individual patient. In general, it is preferable to recommend measures with a proven impact on mortality, such as dietary changes, smoking cessation, or drug therapy for patients with risk factors.

大多数无心血管疾病病史的个体发生动脉血栓形成的风险较低。我们采用标准的《处方》方法，回顾了关于阿司匹林在心血管事件一级预防中风险效益平衡的文献。在普通人群中，一项纳入95456人的荟萃分析表明，阿司匹林对全因死亡率或心血管死亡率均无影响。阿司匹林可能会略微降低女性中风和男性心肌梗死的风险，但会增加出血风险。尚不清楚其益处是否超过风险。阿司匹林不能降低老年人的死亡率。在一项试验中，阿司匹林降低了65岁及以上女性缺血性中风和心肌梗死的风险。然而，与阿司匹林相关的脑出血风险会随着年龄增长而增加。因此，阿司匹林在老年人心血管一级预防中的风险效益平衡尚不确定。阿司匹林对有心血管危险因素的患者更有益，但出血风险有时也更高。在临床试验中，阿司匹林对高血压或糖尿病患者的全因死亡率或心血管死亡率均无降低作用。相比之下，它降低了高血压患者和糖尿病男性心肌梗死的风险。阿司匹林不能预防吸烟者发生心血管事件，且尚未在高胆固醇血症患者中进行评估。在实践中，对于低风险人群，使用阿司匹林预防首次血栓形成事件时，风险大于益处。当心血管风险高于普通人群时，例如有危险因素的患者，阿司匹林对心肌梗死和缺血性中风的微弱预防作用可能超过额外的少量出血风险。应与每位患者讨论阿司匹林在心血管预防方面的潜在价值。一般而言，更宜推荐采取已证实对死亡率有影响的措施，如饮食改变、戒烟或对有危险因素的患者进行药物治疗。