Department of Medicine and Epidemiology, College of Public Health and Health Professions, College of Medicine, University of Florida, Gainesville, FL.
Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, FL.
Am J Cardiol. 2021 Feb 15;141:38-48. doi: 10.1016/j.amjcard.2020.11.014. Epub 2020 Nov 19.
Aspirin has been the mainstay of both secondary and primary prevention of cardiovascular disease for half a century. In 2018, 3 trials showed a modest reduction in cardiovascular outcomes that appeared counterbalanced by the risk of clinically significant bleeding. The latest ACC/AHA primary prevention guidelines downgraded their recommendation for aspirin use in primary prevention to that of physician preference. Despite the consistent and robust evidence previously supporting the use of aspirin in cardiovascular disease prevention, little discussion has been given to mechanisms or analytic explanations for this revision of recommendations. In this review, we explore 3 possible mechanisms that may have contributed to the alteration of our perception of aspirin's role in primary prevention. These include changes in the population potentially using aspirin in primary prevention, changes in cardiovascular disease and its presentation, and changes in aspirin itself. Here we present a translational look at knowledge gaps that should be addressed to better guide contemporary aspirin use in primary prevention. In conclusion, based on these considerations, the current recommendations might be improved by recalibration of the cardiovascular risk threshold above which aspirin should be recommended for primary prevention, including the incorporation of newer risk assessment modalities such as calcium scoring. A second enhancement would be developing a bleeding risk calculator to support clinicians' assessment of risk vs benefit. The use of enteric-coated aspirin vs noncoated aspirin should also be reassessed.
阿司匹林作为二级和一级预防心血管疾病的主要药物已长达半个世纪。2018 年，3 项临床试验显示心血管结局略有改善，但与临床意义上的出血风险相平衡。最新的 ACC/AHA 一级预防指南将阿司匹林用于一级预防的推荐级别降为医生的个人偏好。尽管此前有一致且强有力的证据支持阿司匹林在心血管疾病预防中的应用，但对于这一建议的修订，很少有讨论涉及机制或分析解释。在这篇综述中，我们探讨了可能导致我们对阿司匹林在一级预防中作用的看法发生改变的 3 种可能机制。这些机制包括可能在一级预防中使用阿司匹林的人群变化、心血管疾病及其表现的变化以及阿司匹林本身的变化。在此，我们从转化医学的角度探讨了应该解决的知识空白，以更好地指导当代阿司匹林在一级预防中的应用。总之，基于这些考虑因素，当前的建议可能需要通过重新校准推荐阿司匹林用于一级预防的心血管风险阈值来改进，包括纳入新的风险评估模式，如钙评分。另一个改进方法是开发出血风险计算器以支持临床医生对风险与获益的评估。还应重新评估肠溶阿司匹林与非肠溶阿司匹林的使用。
