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More than 50 million US adults take aspirin regularly for long-term prevention of cardiovascular disease (CVD) and mortality, typically 81 or 325 mg/d. But while aspirin is still the most widely studied antiplatelet drug in the world, controversy remains regarding the most appropriate long-term daily dose and whether the drug has a role in primary prevention.

A meta-analysis published earlier this year in the 

 is the latest in a series of inquiries that compare CVD risk reduction against elevated risk of bleeding to assess the net benefit of aspirin prophylaxis in primary and secondary prevention.

 The results corroborate existing data that suggest the principal cardiovascular effect of aspirin in primary prevention is on nonfatal MI with no real benefit with regard to fatal MI, stroke, or CVD death. Even these benefits are considerably offset by an elevated risk of bleeding.

• What does this analysis add to our understanding of the interplay of aspirin dosing, efficacy, and safety?
• How do risks and benefits of aspirin prophylaxis differ in primary and secondary prevention?
• How should primary care clinicians approach the aspirin versus statin question with patients who are at risk, but low risk, for CVD?

Here to put this issue into perspective are Drs Christopher Cannon and Payal Kohli. Dr Cannon, a senior investigator with the TIMI Study Group, is Editor-in-Chief of 

. He is also Professor of Medicine at Harvard Medical School and Associate Physician in the Cardiovascular Division of Brigham and Women’s Hospital in Boston. Dr Kohli graduated from Harvard Medical School, completed her internal medicine training in Boston, and is currently a fellow in cardiovascular medicine at the University of California San Francisco.

a. In high-risk patients (Framingham Risk Score ≥10%) and anyone with established coronary disease, aspirin 81 mg/d should be used
b. In borderline-risk patients (Framingham Risk Score = 5% to 10%), decisions should be individually tailored and aspirin should be used if the benefit outweighs the risk of bleeding
c. In low-risk patients (Framingham Risk Score <5%), using aspirin for primary prevention can actually result in more bleeding than benefit. These very low-risk patients should be taken off aspirin and lifestyle modification should be encouraged instead.

2. Aspirin in secondary prevention: In anyone with established coronary disease (included those who have been instrumented), 81 mg/d of aspirin should be used instead of 325 mg/d.

3. Unlike statins, aspirin is not disease-modifying and exerts its beneficial effect via antithrombotic mechanisms on a ruptured plaque. Therefore, it is less effective in patients who may not have significant plaque burden.

 Seshasai SRK, Wijesuriya S, Sivakumaran R, et al. Effect of aspirin on vascular and nonvascular outcome: Meta-analysis of randomized controlled trials. 

Peters RJG, Mehta SR, Fox KAA, et al, for the CURE trial investigators. Effects of aspirin dose when used alone or in combination with clopidogrel in patients with acute coronary syndromes: Observations from the clopidogrel in unstable angina to prevent recurrent events (CURE) study. 

 Campbell CL, Smyth S, Montalescot G, Steinhubl SR. Aspirin dose for the prevention of cardiovascular disease: A systematic review. 

Antithrombotic Trialists’ (ATT) Collaboration. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. 

Mehta SR, Bassand JP, Chrolavicius S, et al. Dose comparisons of clopidogrel and aspirin in acute coronary syndromes. 

Use of aspirin in primary prevention of cardiovascular disease must be based on individual risk-benefit analysis and is not appropriate for patients at low risk.

Antiplatelet Therapy With Aspirin: What Dose in Primary and Secondary Prevention?

The European Society of Cardiology just weighed in on the 3 new alternatives to warfarin for oral anticoagulation. The response is tempered enthusiasm.

In a position paper, published in the April 17 issue the 

Journal of the American College of Cardiology

-the ESC finds favor with results of clinical trials in the prevention of stroke in atrial fibrillation but has some concerns about efficacy and safety of the agents in prevention after acute coronary syndromes.

The 3 agents discussed are the direct thrombin inhibitor dabigatran (Pradaxa); and the 2 direct factor Xa inhibitors apixaban (Eliquis) and rivaroxaban (Xarelto).

Advantages of all 3 versus warfarin include ease of use and lower rates of intracranial hemorrhage with less or comparable rates of bleeding. All are given in fixed doses and do not require that patients monitor INR.

Dabigatran is in the only agent that has been used in clinical practice, and for approximately 1 year. But they have all made popular headlines and you may get questions from your patients.

• How do these, and similar agents still in development, rank in terms of reducing the risk of primary cardiovascular endpoints?
• Do they have a role as alternatives to antiplatelet therapy?
• Should we be thinking about switching our patients on warfarin?

Here to put this issue into perspective are Drs. Christopher Cannon and Payal Kohli. Dr Cannon, a senior investigator with the TIMI Study Group, is editor-in-chief of Cardiosource Science and Quality. He is also Professor of Medicine at Harvard Medical School and Associate Physician in the Cardiovascular Division of Brigham and Woman’s Hospital in Boston. Dr. Kohli graduated from Harvard Medical School and completed her internal medicine training in Boston and is scheduled to start her fellowship in cardiovascular medicine at the University of California San Francisco in June 2012.

The New Oral Anticoagulants: Benefits, Risks, Patient Selection

In many patients, episodic migraines increase in frequency and transform into a refractory pattern. What strategies can you employ to help avoid-or even reverse-this transformation?

 Here, Dr Susan Hutchinson, outlines 6 simple and effective steps you can take to help your patients combat chronic migraine. Dr Hutchinson is a headache specialist and family physician who practices in Orange County, California. She is the Founder of the Orange County Migraine Headache Center in Irvine.

Migraine-6 Steps to Counter Refractory Headaches

In many patients, episodic migraines increase in frequency and transform into a refractory pattern.

Podcast: Migraine-6 Steps to Counter Refractory Headaches

What are the factors that underlie the transformation of episodic migraine to refractory migraine?

Here to explain is headache specialist and family physician, Dr Susan Hutchinson, who practices in Orange County, California. Dr Hutchinson is founder of the Orange County Migraine and Headache Center in Irvine, California.

Migraine: When the Headaches Keep on Coming

What are the factors that underlie the transformation of episodic migraine to refractory migraine? Dr Susan Hutchinson explains.

Podcast: Migraine-When the Headaches Keep on Coming

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