off record
Shaukat Ali Jawaid

Primary Prevention of CAD
Clinical judgment should
guide on use of Low
Dose Aspirin Therapy

There have been numerous studies and Meta analysis on the use of Aspirin in primary prevention of coronary artery disease with different results which has made its use a bit controversial and confusion persists among the medical profession. However, majority of the investigators have a consensus as they believe it is the individual patient’s clinical judgment by the treating physicians which should guide the decision on primary prevention. Eminent cardiologists in the developing world however further believe that why the patients should be first allowed to suffer from a cardiac event and then start using Aspirin for secondary prevention? Why not use it in primary prevention in high risk cases to reduce or minimize the cardiac events, morbidity and mortality?

Most recent guidelines also recommend the use of Aspirin therapy for those between the age of 40-70 years who are at a higher risk of first cardiac event.1 In Pakistan since our life expectancy is less as compared to the developed world, hence the Experts Panel of Pakistan Aspirin Foundation headed by an eminent interventional cardiologist Prof. Abdus Samad recommends use of low dose aspirin therapy in high risk patients in patients above the age of thirty five years.

The most recent trials include “ A Study of Cardiovascular Events in Diabetes (ASCEND) which enrolled 15,480 subjects at least forty years of age in which 100mg of Aspirin daily was used compared with Placebo.2 The second trial was The Aspirin to Reduce Risk of Initial Vascular Events (ARRIVE) which enrolled 12,546 subjects with mean age of sixty four years which also used 100mg of Aspirin daily who had a ten years risk of first event between 10-20%.3 The third trial The Aspirin in Reducing Events in the Elderly (ASPREE) which randomized 19,114 subjects with median age of seventy four years and it also used 100mg of Aspirin daily compared with placebo.4

Most of the investigators have come to the conclusion that” in primary prevention, the prescription of aspirin should be based on an individual clinical judgment only when the magnitude of the absolute benefit exceeds the magnitude of absolute risks”. However, if the benefits and risks are same, the patient’s preference should be considered. Though the balance of benefits and risks of aspirin in primary prevention is far less clear than in secondary prevention, Guidelines only provide guidance and any general guidelines on primary prevention does not seem to be justified. Since the treating physician or ”primary care provider most often has the complete information about each of their patients, hence for the good of the patients, the prescription of aspirin for primary prevention should be made by the healthcare provider in consultation with each of their patients and it should be based on individual clinical judgments”.5


  1. Arnett DK, Blumenthal RS, Albert MA. 2019. ACC/AHA Guidelines on the Primary Prevention of Cardiovascular Disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019; 140(11):e596-646.
  2. The ASCEND Study Collaborative Group. Effects of aspirin for primary prevention in persons with diabetes mellitus. N Eng J Med.2018; 379(16):1529-1539.
  3. Gaziano JM, Brotons, Coppolecchia R. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE); a randomized double-blind, placebo-controlled trial. Lancet 2018; 392(10152):1036-1046.
  4. McNeil JJ, Nelson MR, Woods RL. Effect of aspirin on all-cause mortality in the health elderly. N Eng J Med 2018; 379(16):1519-1528.
  5. Gitin a, Pfeffer MA, DeMets DL, Hennekens CH. Aspirin in Primary Prevention: Needs Individual Clinical Judgments. (Commentary). American Journal of Medicine. Https://doi.org/10.1016/j.mjmed.2020.01.006
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