Acetylsalicylic acid in the primary prevention of vascular complications in patients without clinically apparent atherosclerosis: how to balance risk and benefit?

Abstract

Antiplatelet agents are an integral part of the treatment of patients with various presentations of atherothrombosis. Among all drugs in this group, acetylsalicylic acid has the broadest evidence base. This review is devoted to the prescription of acetylsalicylic acid for the primary prevention of vascular complications in patients without clinically apparent atherosclerosis. Current approaches to the risk stratification of ischemic events and determination of indications for such treatment are discussed. Primary prevention trials have been focused on the risk assessment scales, the prognostic value of which raises many questions. In this context, besides the traditional (classical) factors underlying these scales, it is reasonable to take into account the so-called “risk modifiers” that can affect the likelihood of CVC. The coronary artery calcium score is one of the strongest risk modifiers. The characteristics of key primary prevention trials, which included patients of different ages with various risk factors, are provided. In accordance with the current guidelines of European and Russian expert communities, the acetylsalicylic acid may be prescribed to individuals with a high risk of vascular complications, among which the best evidence base is available for patients with diabetes mellitus. The positive effects of antiplatelet treatment have been demonstrated to be maintained in the settings of modern therapy with a proven positive effect on the prognosis. A particular focus has been placed on minimizing bleeding. The correct assessment and correction of modifiable hemorrhagic risk factors, the use of drugs to protect the stomach, and the appointment of acetylsalicylic acid in the minimum effective dosage of 75 mg per day are called upon to increase the safety of treatment. A preference in favour of uncoated forms that are absorbed in the stomach for obese and diabetic patients may be discussed.