aspirin less effective than P2Y12 inhibitors for secondary prevention

For decades routine medical advice has endorsed aspirin for the prevention of cardiovascular disease. Recent research has consistently chipped away at the justification for that advice. And now new research damages aspirin’s reputation even further.

New Canadian Heart and Stroke guidelines have brought Canada into line with the United States and current European advice by no longer recommending low-dose aspirin for the prevention of primary—that is first time—atherosclerotic cardiovascular disease (ASCVD). They have also questioned Aspirin’s value for secondary prevention and “lower[ed] the confidence of the recommendation to take aspirin for the prevention of ASCVD even in people at higher risk.”

The new Canadian guidelines no longer recommend aspirin for people without a prior history of cardiovascular events. And, though they do continue to recommend it for people with a history of cardiovascular, cerebrovascular or peripheral artery disease, they no longer recommend it for prevention of a first vascular event even if you have vascular risk factors.

And now a just published systematic review and meta-analysis even further erodes aspirin’s value for even secondary prevention, that is for people who have existing cardiovascular disease or who have already suffered a prior event.

The new study looked at all the previous studies that compared aspirin to a P2Y12 inhibitor for secondary prevention in people with existing cerebrovascular, coronary, or peripheral artery disease. P2Y12 inhibitors are another class of antiplatelet drugs. It included nine studies of 42,108 people.

People who got the P2Y12 inhibitors had a borderline 19% reduction for the risk of myocardial infarction compared with those who received aspirin. Neither treatment had a benefit over the other for risk of stroke, vascular death of death from any cause. The risk of major bleeding was the same for both treatments.

That means that aspirin is a worse choice than P2Y12 inhibitors for the secondary prevention of cardiovascular disease. But P2Y12 inhibitors are not a much better choice either: you would need to treat 244 people to prevent one extra heart attack. For that reason, the researchers concluded that P2Y12 inhibitors’ benefit over aspirin “is of debatable clinical relevance, in view of the high number needed to treat to prevent a myocardial infarction and the absence of any effect on all-cause and vascular mortality.”

This new study further erodes confidence in the recommendation of aspirin even for secondary prevention of cardiovascular disease.


Lancet 2020;395(10235):1487-95


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