Department of Pharmacology, Catholic University School of Medicine, Rome, Italy.
Medical Research Council Population Health Research Unit, and Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
Nat Rev Cardiol. 2019 Nov;16(11):675-686. doi: 10.1038/s41569-019-0225-y. Epub 2019 Jun 26.
The benefits of aspirin therapy for the secondary prevention of cardiovascular disease clearly outweigh the risks of bleeding, and low-dose aspirin is uniformly recommended in this setting. However, no clear consensus exists about whether, and if so in whom, aspirin therapy is appropriate for the primary prevention of cardiovascular disease. Three trials of low-dose aspirin versus placebo in three populations at increased risk of myocardial infarction or ischaemic stroke in the absence of established cardiovascular disease were reported in 2018. The ASPREE trial in elderly people was terminated early for futility because aspirin had no effect on disability-free survival but significantly increased the risk of major haemorrhage and, unexpectedly, all-cause mortality. In the ASCEND trial in patients with diabetes mellitus and no evidence of vascular disease, aspirin significantly reduced serious vascular events but increased major bleeding. In the ARRIVE trial in people with multiple risk factors for cardiovascular disease, aspirin had no effect on major cardiovascular events but increased gastrointestinal bleeding. The aim of this Review is to place these new results in the context of previous evidence on aspirin for the primary prevention of cardiovascular disease and to appraise whether the new evidence is likely to enable the more targeted use of aspirin in particular individuals for whom the net benefit is both clinically worthwhile and statistically definite.
阿司匹林治疗在心血管疾病二级预防中的获益明显超过出血风险，因此在这种情况下，低剂量阿司匹林被普遍推荐。然而，对于阿司匹林是否以及在哪些情况下适用于心血管疾病一级预防，目前尚无明确共识。2018 年，三项关于低剂量阿司匹林与安慰剂在无明确心血管疾病但存在心肌梗死或缺血性卒中风险增加的三种人群中进行的试验报告。在缺乏心血管疾病证据的情况下，老年人群中的 ASPREE 试验因无效而提前终止，因为阿司匹林对无残疾生存没有影响，但显著增加了大出血的风险，而且出乎意料的是，全因死亡率也增加了。在糖尿病患者且无血管疾病证据的 ASCEND 试验中，阿司匹林显著减少了严重血管事件，但增加了大出血。在心血管疾病多种危险因素人群中的 ARRIVE 试验中，阿司匹林对主要心血管事件没有影响，但增加了胃肠道出血。本综述旨在将这些新结果置于阿司匹林用于心血管疾病一级预防的先前证据背景下，并评估新证据是否可能使特定人群更有针对性地使用阿司匹林，对于这些人群，净获益在临床和统计学上都是有意义的。
