Authors : Victor Gil e Diana Aguiar de Sousa Cardiovascular and cerebrovascular diseases are the leading causes of death and disability worldwide and Portugal is no exception. Despite the progress achieved in recent decades in the knowledge and control of cardiovascular risk factors and risk-facilitating factors, much remains to be done and actions of the entire community are needed to better prevent these diseases. High cholesterol, tobacco consumption, arterial hypertension, diabetes, obesity, and sedentary lifestyle are cardiovascular risk factors . Inflammatory diseases, personal and social fragility, mental illness, air pollution, among others, are factors that facilitate risk . Most of these factors are preventable or modifiable . For example, an estimated 90% of the risk for stroke is explained only by modifiable risk factors. After a first event: secondary prevention Atherosclerosis is a chronic inflammation of the arteries that is at the origin of many cases of cardiovascular and cerebrovascular diseases. It has acute complications with the formation of thrombi that occlude the arteries, causing: Myocardial infarctio n, in the case of coronary arteries, which supply blood to the heart muscle; Ischemic stroke , in the case of cerebral arteries. After a first event – either a myocardial infarction or a stroke – to take a small daily dose of aspirin is part of the standard chronic therapy to prevent future events. This therapy is justified by the effect of aspirin to counteract the formation of thrombus (antithrombotic effect). In specific cases, aspirin is replaced by drugs with equivalent properties. Just after the acute episode, when there is greater vulnerability and risk, another drug can be added to increase the effect. Initiating anticoagulant therapy may also be indicated when certain arrhythmias are detected. Taking preventive medication after a first event of any nature to prevent its recurrence is part of what is called secondary prevention . And primary prevention? The issue of primary prevention with antithrombotic medication in people who have never had a stroke or a myocardial infarction is not so certain, it has changed over the years and there is still no consensus in the medical community. Some older recommendations, based on a pharmacological rationale and on small studies, were subsequently replaced by more robust studies that evaluated, in chronic patients, the balance between potential benefits and risks. In fact, antithrombotic drugs are associated with a risk of bleeding , often mediated by direct aggression to the upper digestive tract, which increases with the age of patients. When thrombotic risk exists but is relatively low, the associated bleeding risk does not favor the use of aspirin or similar drugs in many situations. Nevertheless, in patients at higher thrombotic risk, primary prevention may be warranted. For example, in peripheral arterial disease (such as obstructive disease of the arteries of the lower limbs), in aortic aneurysms and in carotid disease, there are individual indications for taking aspirin. Current recommendations Considering the different opinions, the fundamentals that support it, and in line with the most recent recommendations (2022) that take into account those from the American College of Cardiology of 2019 and from the European Society of Cardiology of 2021, we defend the following: Secondary prevention Aspirin (or an equivalent drug proposed by the physician in an individual based decision) should be taken by all people undergoing secondary prevention (patients who have already suffered a myocardial infarction or ischemic stroke). Exceptions are patients with ischemic stroke associated with atrial fibrillation, for whom another class of antithrombotic drugs is indicated, namely anticoagulants. Primary prevention In primary prevention, the rule is not to recommend the use of aspirin . Nonetheless: In patients aged 40-59 years with very high cardiovascular risk (>10%) its use may be justified; In those over 60 years of age, in most cases, it is still not recommended to start aspirin in primary prevention; However, the potential benefits of using aspirin in preventing other conditions, such as colorectal cancer, support that the final decision is made for all patients on a strictly individual basis. In the future, the use of diagnostic laboratory tests, such as the aggregation test, may help to make better decisions on the medication for primary prevention. However, first of all, the control of other risk factors must be optimized and healthy lifestyle habits practiced . In short Taking aspirin preventively: yes or no? In secondary prevention, yes, in most cases; In primary prevention, no, except in particular situations evaluated on a case-by-case basis by a physician with adequate training in cardiovascular risk. Sources Dehmer SP, O’Keefe LR, Evans CV, Guirguis-Blake JM, Perdue LA, Maciosek MV. Aspirin use to prevent cardiovascular disease and colorectal cancer: Updated modeling study for the US preventive services task force . JAMA 2022;327:1598–1607. Berger JS. Aspirin for primary prevention: Time to rethink our approach . JAMA Netw Open 2022;5:e2210144. Meet the cardiology and neurology clinical team from Hospital da Luz network. The content published in the Health Guide is intended for the general public and is provided for informational and educational purposes only. It does not replace individual medical assessment, diagnosis, or personalized clinical advice from a qualified healthcare professional. The content is produced or reviewed by physicians and other healthcare professionals at Hospital da Luz and is based on the knowledge available at the time of publication or the most recent update, as indicated at the beginning of each item.
