Revisiting Aspirin in Primary Prevention: Still Useful in Selected Patients?

초록

For decades, aspirin has been a standard therapy for the primary prevention of cardiovascular disease (CVD). However, recent large-scale randomized controlled trials, including ASPREE, ASCEND, and ARRIVE, have questioned its net benefit by highlighting a significant risk of major bleeding that often offsets its modest preventive effects. Consequently, major guidelines, such as those from the USPSTF and ACC/AHA, no longer recommend the routine initiation of aspirin for primary prevention in most adults, particularly the elderly. As the "aspirin for all" paradigm fades, this presentation aims to review the current landscape and explore future strategies for identifying "selected patients" who may still derive a net benefit from aspirin therapy. While guideline shifts have focused on initiation, two critical clinical dilemmas remain: the potential harm of discontinuation in existing users, as suggested by observational data and recent meta-analyses, and the challenge of selection. Traditional CVD risk scores are insufficient to pinpoint individuals whose benefits outweigh the bleeding risks. A promising new strategy involves a "platelet-guided approach," utilizing biomarkers relevant to aspirin's mechanism of action, such as identifying a hyperreactive platelet phenotype through aggregometry or transcriptomics. Ultimately, the broad use of aspirin in primary prevention is declining, underscoring the necessity of shared decision-making based on a granular assessment of individual bleeding and cardiovascular risks. This precision medicine approach, leveraging novel biomarkers like platelet phenotype, may hold the key to maximizing the utility of aspirin in the modern era.