When are aspirin (acetylsalicylic acid) and atorvastatin (Lipitor) prescribed for patients with a history of cardiovascular events or those at high risk of developing cardiovascular disease, such as those with diabetes, hypertension, or hyperlipidemia?

When Aspirin and Atorvastatin Are Prescribed

Aspirin (75-162 mg daily) and atorvastatin are given together in patients with established cardiovascular disease (secondary prevention) and in high-risk primary prevention patients, specifically those with diabetes aged ≥50 years who have additional cardiovascular risk factors such as hypertension or dyslipidemia. 1, 2

Secondary Prevention (Established Cardiovascular Disease)

In patients with known CVD, ACE inhibitor, aspirin, and statin therapy should be used together to reduce cardiovascular events. 1

This includes patients with:

• History of myocardial infarction 2, 3
• Prior stroke or TIA 4
• History of coronary revascularization 2
• Documented coronary artery disease on imaging 2
• Peripheral arterial disease 1

Aspirin dose: 75-162 mg daily (most commonly 81 mg in the US) 1, 2, 3

Atorvastatin dosing varies by indication:

• Stable coronary disease: 10-80 mg daily 5
• Acute coronary syndrome: 80 mg daily provides greater benefit than lower doses 5
• Post-MI with high-risk factors: 80 mg daily superior to moderate-dose pravastatin 5

Primary Prevention in High-Risk Patients

Diabetes with Additional Risk Factors

Aspirin (75-162 mg/day) and statin therapy should be used in diabetic patients ≥40 years with at least one additional cardiovascular risk factor (hypertension, family history of premature CVD, dyslipidemia, smoking, or albuminuria). 1, 2

The 2019 ESC guidelines specify that aspirin for primary prevention may be considered in diabetic patients at very high/high cardiovascular risk but is not recommended in those at moderate risk. 1

Hypertension with Diabetes

In hypertensive diabetic patients aged ≥50 years with controlled blood pressure (<150/90 mmHg) and presence of target organ damage, both low-dose aspirin (75-81 mg daily) and statin therapy are recommended. 2

The HOT trial demonstrated that aspirin 75 mg daily reduced cardiovascular events by 15% and MI by 36% in well-controlled hypertensive patients with diabetes. 2

10-Year CVD Risk ≥10%

For patients aged 40-75 years with a 10-year cardiovascular disease risk ≥10%, both aspirin and statin therapy are recommended. 1, 3, 6

The USPSTF recommends statins (B recommendation) for this population, while aspirin should be offered selectively (C recommendation) after weighing bleeding risks. 6, 7

Important Contraindications and Cautions

Aspirin Should NOT Be Given:

• Age ≥60 years for primary prevention (bleeding risks outweigh benefits) 3, 7
• Active bleeding or recent gastrointestinal bleeding 1, 2
• Known aspirin allergy 1
• Concurrent anticoagulation therapy 1
• Bleeding disorders or clinically active hepatic disease 1
• Age <21 years (risk of Reye syndrome) 1, 2
• Uncontrolled hypertension 2

Alternative: Clopidogrel 75 mg daily for patients with documented aspirin allergy requiring antiplatelet therapy. 1, 2

Atorvastatin Cautions:

• Contraindicated in acute liver failure or decompensated cirrhosis 8
• Risk of myopathy/rhabdomyolysis increases with age ≥65 years, renal impairment, hypothyroidism, and drug interactions (especially cyclosporine, gemfibrozil, certain antivirals) 8
• Avoid concomitant use with >1.2 liters daily of grapefruit juice 8
• Increased hemorrhagic stroke risk with 80 mg dose in patients with recent stroke/TIA 8

Dosing Algorithm

For secondary prevention:

• Aspirin 75-100 mg daily indefinitely 2, 3, 9
• Atorvastatin 10-80 mg daily (higher doses for acute coronary syndrome or very high-risk patients) 5

For primary prevention in diabetes with hypertension:

• Aspirin 75-81 mg daily if age 40-59 years, controlled BP, and ≥1 additional risk factor 2
• Atorvastatin dose based on LDL-C targets: aim for <1.8 mmol/L (<70 mg/dL) in high-risk or <1.4 mmol/L (<55 mg/dL) in very high-risk patients 1

For primary prevention based on 10-year CVD risk:

• Risk ≥10%: Both aspirin and statin recommended 1, 6
• Risk 7.5-10%: Statin recommended, aspirin selective 6, 7
• Risk <7.5%: Statin may be considered if other risk factors present; aspirin not recommended 7

Common Pitfalls

Do not prescribe aspirin for primary prevention in patients ≥60 years - the 2022 USPSTF guidelines explicitly recommend against this due to bleeding risks exceeding benefits. 7

Do not use atorvastatin 80 mg in patients with recent hemorrhagic stroke - post-hoc analysis of the SPARCL trial showed 68% increased risk of recurrent hemorrhagic stroke. 8

Monitor for bleeding risk factors - major bleeding occurs at approximately 2-5 per 1,000 patients per year with aspirin, with risk doubling in those with uncontrolled hypertension or concurrent NSAID use. 2, 3, 9

Consider alternative statins in diabetic patients with low HDL-cholesterol - atorvastatin has minimal effect on raising HDL-cholesterol, which may be disadvantageous in metabolic syndrome. 5