Aspirin in the primary prevention of cardiovascular disease and cancer
- Frederick A Spencer, MD
Frederick A Spencer, MD
- Professor of Medicine
- McMaster University
- Gordon Guyatt, MD
Gordon Guyatt, MD
- Professor of Clinical Epidemiology and Biostatistics and Medicine
- McMaster University
- Section Editors
- Joann G Elmore, MD, MPH
Joann G Elmore, MD, MPH
- Editor-in-Chief — Primary Care (Adult)
- Section Editor — General Medicine
- Professor of Medicine, Adjunct Professor of Epidemiology
- University of Washington School of Medicine
- Christopher P Cannon, MD
Christopher P Cannon, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Harvard Medical School
Cardiovascular disease (CVD) and cancer are the leading causes of morbidity and mortality worldwide, representing 24 and 13 percent of all deaths, respectively [1,2]. Aspirin produces statistically significant and important reductions in cardiovascular events in survivors of a wide range of occlusive CVD events, including coronary heart disease (CHD); its net benefit (reduction in cardiovascular events versus an increase in major bleeding events) warrants its use as secondary prevention.
On the other hand, aspirin use for primary prevention in apparently healthy people (without either known CHD or moderate to high risk for CHD) is less clear. With a lower incidence of cardiovascular events in this population, the ratio of benefit to risk is lower. (See "Benefits and risks of aspirin in secondary and primary prevention of cardiovascular disease", section on 'Estimating the benefit to risk ratio'.)
Historically, only the potential cardiovascular benefits of aspirin, including reductions in the rates of cardiovascular death, myocardial infarction, or stroke, have been considered when making decisions about its use for primary prevention. Some data suggest aspirin may also have a favorable impact on cancer incidence, metastasis, and mortality, particularly colorectal cancer. These effects of aspirin on the development of cancer and subsequent adverse outcomes might alter recommendations for the use of aspirin for primary prevention. A personalized approach to the decision whether or not to advise aspirin use for primary prevention, factoring an individual's health risks and personal values, is likely to be optimal [3,4].
This topic summarizes the evidence from clinical trials and observational studies regarding the potential benefits and risks of aspirin for primary prophylaxis. We will provide estimates of benefit and risks of aspirin for apparently healthy individuals at varying risk for both cardiovascular and colorectal cancer outcomes. These summaries are intended to facilitate discussions between clinicians and patients regarding use of aspirin as primary prophylaxis.
Discussion of the role of aspirin in secondary and primary prevention of CVD (not considering cancer prevention), including individuals at moderate to high risk for CVD, is presented separately. The role of nonsteroidal antiinflammatory drugs (NSAIDs) and aspirin in the prevention of colorectal cancer (not considering cardiovascular disease) is discussed separately as well. (See "Benefits and risks of aspirin in secondary and primary prevention of cardiovascular disease" and "NSAIDs (including aspirin): Role in prevention of colorectal cancer".)
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- MECHANISM OF ACTION
- PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE
- PRIMARY PREVENTION OF CANCER
- Aspirin and cancer incidence
- - Colorectal cancer
- - Other cancers
- Aspirin and cancer mortality
- Colorectal cancer mortality
- Any cancer mortality
- TOTAL MORTALITY
- ADVERSE EFFECTS OF ASPIRIN
- - Rates
- - Risk factors for aspirin-associated bleeding
- - Primary prevention of aspirin-induced GI bleeding
- Aspirin sensitivity
- Prevention of cardiovascular events
- Prevention of cancer events
- RECOMMENDATIONS FOR PRIMARY PREVENTION
- Estimating benefits and risks
- Individualizing decisions for aspirin prophylaxis
- Recommendations of others
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS