Department of Medicine, University of Toronto, Toronto, Canada.
Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, 55905, USA.
Curr Atheroscler Rep. 2018 Feb 21;20(3):15. doi: 10.1007/s11883-018-0717-y.
The role of aspirin in secondary cardiovascular prevention is well understood; however, the role in primary prevention is less clear, and requires careful balancing of potential benefits with risks. Here, we summarize the evidence base on the benefits and risks of aspirin therapy, discuss clinical practice guidelines and decision support tools to assist in initiating aspirin therapy, and highlight ongoing trials that may clarify the role of aspirin in cardiovascular disease prevention.
In 2016, the USPSTF released guidelines on the use of aspirin for primary prevention. Based on 11 trials (n = 118,445), aspirin significantly reduced all-cause mortality and nonfatal myocardial infarction, and in 7 trials that evaluated aspirin ≤ 100 mg/day, there was significant reduction in nonfatal stroke. The USPSTF recommends individualized use of aspirin based on factors including age, 10-year atherosclerotic cardiovascular disease risk score, and bleeding risk. Several ongoing trials are evaluating the role of aspirin in primary prevention, secondary prevention, and in combination therapy for atrial fibrillation. Evidence-based approaches to aspirin use should consider the anti-ischemic benefits and bleeding risks from aspirin. In this era of precision medicine, tools that provide the personalized benefit to risk assessment, such as the freely available clinical decision support tool (Aspirin-Guide), can be easily incorporated into the electronic health record and facilitate more informed decisions about initiating aspirin therapy for primary prevention. Aspirin has a complex matrix of benefits and risks, and its use in primary prevention requires individualized decision-making. Results from ongoing trials may guide healthcare providers in identifying appropriate candidates for aspirin therapy.
阿司匹林在二级心血管预防中的作用已得到充分认识；然而，其在一级预防中的作用尚不明确，需要仔细权衡潜在获益与风险。本文总结了阿司匹林治疗的获益与风险证据，讨论了用于指导起始阿司匹林治疗的临床实践指南和决策支持工具，并重点介绍了可能阐明阿司匹林在心血管疾病预防中作用的正在进行的临床试验。
2016 年，USPSTF 发布了阿司匹林用于一级预防的使用指南。基于 11 项试验（n=118445），阿司匹林显著降低了全因死亡率和非致死性心肌梗死，在评估阿司匹林≤100mg/天的 7 项试验中，非致死性卒中显著减少。USPSTF 建议根据年龄、10 年动脉粥样硬化性心血管疾病风险评分和出血风险等因素个体化使用阿司匹林。正在进行的多项试验正在评估阿司匹林在一级预防、二级预防以及房颤联合治疗中的作用。阿司匹林使用的循证方法应考虑阿司匹林的抗缺血获益和出血风险。在精准医学时代，能够提供个性化获益风险评估的工具，如免费的临床决策支持工具（Aspirin-Guide），可方便地整合到电子健康记录中，从而促进更明智地决定是否起始阿司匹林用于一级预防。阿司匹林具有复杂的获益风险谱，其在一级预防中的应用需要个体化决策。正在进行的试验结果可能为临床医生确定适合阿司匹林治疗的患者提供指导。
