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This time in the journal club I am picking up a Meta-Analysis published in Archives of Internal Medicine on Aspirin use for the prevention of cardiovascular disease (CVD) and non-vascular events e.g. Cancer prevention. Aspirin use goes back to Hippocrates days. Probably it is one of the most widely consumed drugs around the world and the indications are valid.
However, the risk-benefit ration has to be assessed. The meta-analysis reports that the principal cardiovascular effect of the drug in primary prevention on nonfatal heart attack does not have any real benefit with regard to fatal heart attack, stroke, or CVD death. They also come out with no protective role for against cancer mortality in people at lowto-moderate risk for CVD events as well. They also report that the effect on cancer mortality is nonsignificant.
The benefit of Aspirin in prior CVD also comes with increased risk of nontrivial bleeding events. The Aspirin primarily blocks Thromboxane Synthesis in platelets. Thromboxane is a potent vasoconstrictor and important in platelet aggregation.
The pathophyosiological mechanism and especially dosage of Aspirin might be important area to explore for reducing this non-trival bleeding (side-effect) and preventing CVD.
In the meantime, should we stop using Aspirin for these non-trivial side-effects?
Background The net benefit of aspirin in prevention of CVD and nonvascular events remains unclear. Our objective was to assess the impact (and safety) of aspirin on vascular and nonvascular outcomes in primary prevention.
Data Sources MEDLINE, Cochrane Library of Clinical Trials (up to June 2011) and unpublished trial data from investigators.
Study Selection Nine randomized placebo-controlled trials with at least 1000 participants each, reporting on cardiovascular disease (CVD), nonvascular outcomes, or death were included.
Data Extraction Three authors abstracted data. Study-specific odds ratios (ORs) were combined using random-effects meta-analysis. Risks vs benefits were evaluated by comparing CVD risk reductions with increases in bleeding.
Results During a mean (SD) follow-up of 6.0 (2.1) years involving over 100 000 participants, aspirin treatment reduced total CVD events by 10% (OR, 0.90; 95% CI, 0.85-0.96; number needed to treat, 120), driven primarily by reduction in nonfatal MI (OR, 0.80; 95% CI, 0.67-0.96; number needed to treat, 162). There was no significant reduction in CVD death (OR, 0.99; 95% CI, 0.85-1.15) or cancer mortality (OR, 0.93; 95% CI, 0.84-1.03), and there was increased risk of nontrivial bleeding events (OR, 1.31; 95% CI, 1.14-1.50; number needed to harm, 73). Significant heterogeneity was observed for coronary heart disease and bleeding outcomes, which could not be accounted for by major demographic or participant characteristics.
Conclusions Despite important reductions in nonfatal MI, aspirin prophylaxis in people without prior CVD does not lead to reductions in either cardiovascular death or cancer mortality. Because the benefits are further offset by clinically important bleeding events, routine use of aspirin for primary prevention is not warranted and treatment decisions need to be considered on a case-by-case basis.
The commentary on the article is worth reading.
Commentary: Aspirin Therapy in Primary Prevention