Is aspirin (acetylsalicylic acid) still prescribed for primary prevention of cardiovascular disease?

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Last updated: May 14, 2025 • View editorial policy

From the Guidelines

Aspirin is no longer routinely recommended for primary prevention of cardiovascular disease for most people, and its use should be carefully considered based on individual risk factors and bleeding risk. Current guidelines suggest that low-dose aspirin (typically 81-100 mg daily) should only be considered for select individuals aged 40-70 who have a high risk of cardiovascular disease and low bleeding risk, as evidenced by the ASCEND trial 1. For adults over 70, aspirin is generally not recommended for primary prevention due to increased bleeding risks that outweigh potential benefits. The shift away from widespread aspirin use for primary prevention occurred because research showed that while aspirin can reduce heart attack and stroke risk, this benefit is often offset by increased risk of gastrointestinal bleeding and hemorrhagic stroke, as seen in the Antithrombotic Trialists’ Collaboration meta-analysis 1.

Some key points to consider when deciding on aspirin use for primary prevention include:

  • Age: aspirin is generally not recommended for primary prevention in adults over 70 due to increased bleeding risks 1
  • Cardiovascular risk factors: individuals with high cardiovascular risk and low bleeding risk may benefit from aspirin therapy 1
  • Bleeding risk: aspirin should be used with caution in individuals with high bleeding risk, as the potential benefits may be outweighed by the risks 1
  • Overall health status: primary prevention decisions should be individualized through shared decision-making between patients and healthcare providers, considering factors like age, cardiovascular risk factors, bleeding risk, and overall health status 1.

It's worth noting that aspirin remains strongly recommended for secondary prevention in people who have already experienced a heart attack, stroke, or have established cardiovascular disease, as the benefits of aspirin therapy in these cases far outweigh the risks 1. In contrast, older guidelines, such as those from 2014 2, recommended aspirin therapy for primary prevention in individuals with diabetes at increased cardiovascular risk, but these recommendations have been updated to reflect the more nuanced understanding of aspirin's benefits and risks.

From the Research

Aspirin Prescription for Primary Prevention

  • Aspirin is no longer widely prescribed for primary prevention of cardiovascular disease due to uncertain net clinical benefits and increased risk of bleeding 3, 4.
  • Recent randomized trials have shown either no benefit or modest benefit on combined ischemic end points, without any impact on hard cardiovascular events such as myocardial infarction or stroke, accompanied by an increased risk of bleeding 4, 5.
  • The use of aspirin for primary prevention is still debated because of uncertain data regarding the risk-benefit ratio, and most patients without established atherosclerotic cardiovascular disease should not be prescribed aspirin 3, 6.
  • A tailored approach to find the proper patient category to treat with aspirin in primary prevention is proposed, considering individual cardiovascular risk and bleeding risk 6.
  • Patients with intermediate-high cardiovascular risk (10-year MACE risk >10%) without a prohibitive bleeding risk may represent the target population for aspirin therapy in primary prevention 6.

Key Considerations

  • Aggressive management of comorbidities tailored to the expected cardiovascular risk needs to be emphasized, rather than aspirin prescription 3.
  • Informed shared decision making between clinicians and patients regarding the use of aspirin for primary prevention of cardiovascular events is a suitable approach 3, 5.
  • The results of net clinical benefit analysis of aspirin therapy suggest that benefits and risks associated with aspirin are related to 10-year risk of major adverse cardiovascular events (MACEs) 6.

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Research

Aspirin in Primary Prevention of Cardiovascular Events.

Clinical medicine & research, 2020

Research

[Aspirin in primary cardiovascular prevention - a 2022 update].

Giornale italiano di cardiologia (2006), 2022

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.