Editing Aspirin (section)

===Heart attacks and strokes===
Aspirin is an important part of the treatment of those who have had a [[myocardial infarction|heart attack]].<ref>{{cite book | title = Myocardial infarction with ST-segment elevation: the acute management of myocardial infarction with ST-segment elevation [Internet] | series = NICE Clinical Guidelines | issue = 167 | date = July 2013 | pmid = 25340241 | chapter-url = https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0071000/ | url-status = live | archive-url = https://web.archive.org/web/20151231192814/http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0071000/ | archive-date = 31 December 2015 | at = 17.2 Aspirin | author1 = National Clinical Guideline Centre (UK) | chapter = Adjunctive pharmacotherapy and associated NICE guidance | publisher = Royal College of Physicians (UK) }}</ref> It is generally not recommended for routine use by people with no other health problems, including those over the age of 70.<ref name="Arnett-2019">{{cite journal | vauthors = Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC, Virani SS, Williams KA, Yeboah J, Ziaeian B | title = 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines | journal = Journal of the American College of Cardiology | volume = 74 | issue = 10 | pages = e177–e232 | date = September 2019 | pmid = 30894318 | pmc = 7685565 | doi = 10.1016/j.jacc.2019.03.010 | doi-access = free | title-link = doi }}</ref>

The 2009 Antithrombotic Trialists' Collaboration published in Lancet evaluated the efficacy and safety of low dose aspirin in secondary prevention. In those with prior ischaemic stroke or acute myocardial infarction, daily low dose aspirin was associated with a 19% relative risk reduction of serious cardiovascular events (non-fatal myocardial infarction, non-fatal stroke, or vascular death). This did come at the expense of a 0.19% absolute risk increase in gastrointestinal bleeding; however, the benefits outweigh the hazard risk in this case.{{citation needed|date=April 2023}} Data from previous trials have suggested that weight-based dosing of aspirin has greater benefits in primary prevention of cardiovascular outcomes.<ref name="Lancet2018Dose"/> However, more recent trials were not able to replicate similar outcomes using low dose aspirin in low body weight (<70&nbsp;kg) in specific subset of population studied i.e. elderly and diabetic population, and more evidence is required to study the effect of high dose aspirin in high body weight (≥70&nbsp;kg).<ref>{{cite journal | vauthors = Bowman L, Mafham M, Wallendszus K, Stevens W, Buck G, Barton J, Murphy K, Aung T, Haynes R, Cox J, Murawska A, Young A, Lay M, Chen F, Sammons E, Waters E, Adler A, Bodansky J, Farmer A, McPherson R, Neil A, Simpson D, Peto R, Baigent C, Collins R, Parish S, Armitage J | title = Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus | journal = The New England Journal of Medicine | volume = 379 | issue = 16 | pages = 1529–1539 | date = October 2018 | pmid = 30146931 | doi = 10.1056/NEJMoa1804988 | doi-access = free | title-link = doi }}</ref><ref>{{cite journal | vauthors = McNeil JJ, Wolfe R, Woods RL, Tonkin AM, Donnan GA, Nelson MR, Reid CM, Lockery JE, Kirpach B, Storey E, Shah RC, Williamson JD, Margolis KL, Ernst ME, Abhayaratna WP, Stocks N, Fitzgerald SM, Orchard SG, Trevaks RE, Beilin LJ, Johnston CI, Ryan J, Radziszewska B, Jelinek M, Malik M, Eaton CB, Brauer D, Cloud G, Wood EM, Mahady SE, Satterfield S, Grimm R, Murray AM | title = Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly | journal = The New England Journal of Medicine | volume = 379 | issue = 16 | pages = 1509–1518 | date = October 2018 | pmid = 30221597 | doi = 10.1056/NEJMoa1805819 | pmc = 6289056 | doi-access = free | title-link = doi }}</ref><ref>{{cite journal | vauthors = Woods RL, Polekhina G, Wolfe R, Nelson MR, Ernst ME, Reid CM, Shah RC, Lockery JE, Orchard SG, Murray AM, McNeil JJ | title = No Modulation of the Effect of Aspirin by Body Weight in Healthy Older Men and Women | journal = Circulation | volume = 141 | issue = 13 | pages = 1110–1112 | date = March 2020 | pmid = 32223674 | doi = 10.1161/CIRCULATIONAHA.119.044142 | pmc = 7286412 | doi-access = free | title-link = doi }}</ref>

After [[percutaneous coronary intervention]]s (PCIs), such as the placement of a [[coronary artery]] [[stent]], a U.S. [[Agency for Healthcare Research and Quality]] guideline recommends that aspirin be taken indefinitely.<ref>{{cite web | author = National Guideline Clearinghouse (NGC) |title=2011 ACCF/AHA/SCAI guideline for percutaneous coronary artery intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions |url=http://www.guideline.gov/content.aspx?id=34980 |url-status=dead |archive-url=https://web.archive.org/web/20120813064712/http://www.guideline.gov/content.aspx?id=34980 |archive-date=13 August 2012 |access-date=28 August 2012 |publisher=United States [[Agency for Healthcare Research and Quality]] (AHRQ)}}</ref> Frequently, aspirin is combined with an [[ADP receptor inhibitor]], such as [[clopidogrel]], [[prasugrel]], or [[ticagrelor]] to prevent [[Thrombosis|blood clots]]. This is called dual antiplatelet therapy (DAPT). Duration of DAPT was advised in the United States and European Union guidelines after the CURE<ref>{{cite journal |vauthors=Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK |date=August 2001 |title=Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation |url=http://real.mtak.hu/12922/1/1277670.pdf |journal=The New England Journal of Medicine |volume=345 |issue=7 |pages=494–502 |doi=10.1056/nejmoa010746 |pmid=11519503|s2cid=15459216 }}</ref> and PRODIGY<ref>{{cite journal |vauthors=Costa F, Vranckx P, Leonardi S, Moscarella E, Ando G, Calabro P, Oreto G, Zijlstra F, Valgimigli M |date=May 2015 |title=Impact of clinical presentation on ischaemic and bleeding outcomes in patients receiving 6- or 24-month duration of dual-antiplatelet therapy after stent implantation: a pre-specified analysis from the PRODIGY (Prolonging Dual-Antiplatelet Treatment After Grading Stent-Induced Intimal Hyperplasia) trial |journal=European Heart Journal |volume=36 |issue=20 |pages=1242–51 |doi=10.1016/s0735-1097(15)61590-x |pmid=25718355 |doi-access=free |title-link=doi}}</ref> studies. In 2020, the systematic review and network meta-analysis from Khan et al.<ref>{{cite journal |vauthors=Khan SU, Singh M, Valavoor S, Khan MU, Lone AN, Khan MZ, Khan MS, Mani P, Kapadia SR, Michos ED, Stone GW, Kalra A, Bhatt DL |date=October 2020 |title=Dual Antiplatelet Therapy After Percutaneous Coronary Intervention and Drug-Eluting Stents: A Systematic Review and Network Meta-Analysis |journal=Circulation |volume=142 |issue=15 |pages=1425–1436 |doi=10.1161/CIRCULATIONAHA.120.046308 |pmc=7547897 |pmid=32795096}}</ref> showed promising benefits of short-term (< 6 months) DAPT followed by P2Y12 inhibitors in selected patients, as well as the benefits of extended-term (> 12 months) DAPT in high risk patients. In conclusion, the optimal duration of DAPT after PCIs should be personalized after outweighing each patient's risks of ischemic events and risks of bleeding events with consideration of multiple patient-related and procedure-related factors. Moreover, aspirin should be continued indefinitely after DAPT is complete.<ref>{{cite journal |vauthors=Capodanno D, Alfonso F, Levine GN, Valgimigli M, Angiolillo DJ |date=December 2018 |title=ACC/AHA Versus ESC Guidelines on Dual Antiplatelet Therapy: JACC Guideline Comparison |journal=Journal of the American College of Cardiology |volume=72 |issue=23 Pt A |pages=2915–2931 |doi=10.1016/j.jacc.2018.09.057 |pmid=30522654 |doi-access=free |title-link=doi}}</ref><ref>{{cite journal |vauthors=Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, Granger CB, Lange RA, Mack MJ, Mauri L, Mehran R, Mukherjee D, Newby LK, O'Gara PT, Sabatine MS, Smith PK, Smith SC |date=September 2016 |title=2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines |journal=Journal of the American College of Cardiology |volume=68 |issue=10 |pages=1082–115 |doi=10.1016/j.jacc.2016.03.513 |pmid=27036918 |doi-access=free |title-link=doi}}</ref><ref>{{cite journal |vauthors=Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A, Jüni P, Kastrati A, Kolh P, Mauri L, Montalescot G, Neumann FJ, Petricevic M, Roffi M, Steg PG, Windecker S, Zamorano JL, Levine GN |date=January 2018 |title=2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS) |journal=European Heart Journal |volume=39 |issue=3 |pages=213–260 |doi=10.1093/eurheartj/ehx419 |pmid=28886622 |doi-access=free |title-link=doi}}</ref>

The status of the use of aspirin for the primary prevention in cardiovascular disease is conflicting and inconsistent, with recent changes from previously recommending it widely decades ago, and that some referenced newer trials in clinical guidelines show less of benefit of adding aspirin alongside other anti-hypertensive and cholesterol lowering therapies.<ref name="Arnett-2019" /><ref name="Visseren-2021">{{cite journal | vauthors = Visseren FL, Mach F, Smulders YM, Carballo D, Koskinas KC, Bäck M, Benetos A, Biffi A, Boavida JM, Capodanno D, Cosyns B, Crawford C, Davos CH, Desormais I, Di Angelantonio E, Franco OH, Halvorsen S, Hobbs FD, Hollander M, Jankowska EA, Michal M, Sacco S, Sattar N, Tokgozoglu L, Tonstad S, Tsioufis KP, van Dis I, van Gelder IC, Wanner C, Williams B | title = 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice | journal = European Heart Journal | volume = 42 | issue = 34 | pages = 3227–3337 | date = September 2021 | pmid = 34458905 | doi = 10.1093/eurheartj/ehab484 | doi-access = free }}</ref> The ASCEND study demonstrated that in high-bleeding risk diabetics with no prior cardiovascular disease, there is no overall clinical benefit (12% decrease in risk of ischaemic events v/s 29% increase in GI bleeding) of low dose aspirin in preventing the serious vascular events over a period of 7.4 years. Similarly, the results of the ARRIVE study also showed no benefit of same dose of aspirin in reducing the time to first cardiovascular outcome in patients with moderate risk of cardiovascular disease over a period of five years. Aspirin has also been suggested as a component of a [[polypill]] for prevention of cardiovascular disease.<ref name="pmid16100022">{{cite journal |vauthors=Norris JW |date=September 2005 |title=Antiplatelet agents in secondary prevention of stroke: a perspective |journal=Stroke |volume=36 |issue=9 |pages=2034–6 |doi=10.1161/01.STR.0000177887.14339.46 |pmid=16100022 |doi-access=free |title-link=doi}}</ref><ref name="pmid16603580">{{cite journal |vauthors=Sleight P, Pouleur H, Zannad F |date=July 2006 |title=Benefits, challenges, and registerability of the polypill |journal=European Heart Journal |volume=27 |issue=14 |pages=1651–6 |doi=10.1093/eurheartj/ehi841 |pmid=16603580 |doi-access=free |title-link=doi}}</ref> Complicating the use of aspirin for prevention is the phenomenon of aspirin resistance.<ref name="pmid16364973">{{cite journal |vauthors=Wang TH, Bhatt DL, Topol EJ |date=March 2006 |title=Aspirin and clopidogrel resistance: an emerging clinical entity |journal=European Heart Journal |volume=27 |issue=6 |pages=647–54 |doi=10.1093/eurheartj/ehi684 |pmid=16364973 |doi-access=free |title-link=doi}}</ref><ref name="pmid20944898">{{cite journal |vauthors=Oliveira DC, Silva RF, Silva DJ, Lima VC |date=September 2010 |title=Aspirin resistance: fact or fiction? |journal=Arquivos Brasileiros de Cardiologia |volume=95 |issue=3 |pages=e91-4 |doi=10.1590/S0066-782X2010001300024 |pmid=20944898 |doi-access=free |title-link=doi}}</ref> For people who are resistant, aspirin's efficacy is reduced.<ref name="pmid21306212">{{cite journal |vauthors=Topçuoglu MA, Arsava EM, Ay H |date=February 2011 |title=Antiplatelet resistance in stroke |journal=Expert Review of Neurotherapeutics |volume=11 |issue=2 |pages=251–63 |doi=10.1586/ern.10.203 |pmc=3086673 |pmid=21306212}}</ref> Some authors have suggested testing regimens to identify people who are resistant to aspirin.<ref name="pmid19576352">{{cite journal |vauthors=Ben-Dor I, Kleiman NS, Lev E |date=July 2009 |title=Assessment, mechanisms, and clinical implication of variability in platelet response to aspirin and clopidogrel therapy |journal=The American Journal of Cardiology |volume=104 |issue=2 |pages=227–33 |doi=10.1016/j.amjcard.2009.03.022 |pmid=19576352}}</ref>

As of {{as of|2022|April|lc=n|alt=|bare=yes}}, the [[United States Preventive Services Task Force]] (USPSTF) determined that there was a "small net benefit" for patients aged 40–59 with a 10% or greater 10-year cardiovascular disease (CVD) risk, and "no net benefit" for patients aged over 60.<ref>{{citation-attribution|{{cite web | title=Recommendation: Aspirin Use to Prevent Cardiovascular Disease: Preventive Medication | website=United States Preventive Services Taskforce | date=23 November 2020 | url=https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/aspirin-to-prevent-cardiovascular-disease-preventive-medication | access-date=5 May 2022}}}}</ref><ref>{{cite journal | vauthors = Davidson KW, Barry MJ, Mangione CM, Cabana M, Chelmow D, Coker TR, Davis EM, Donahue KE, Jaén CR, Krist AH, Kubik M, Li L, Ogedegbe G, Pbert L, Ruiz JM, Stevermer J, Tseng CW, Wong JB | title = Aspirin Use to Prevent Cardiovascular Disease: US Preventive Services Task Force Recommendation Statement | journal = JAMA | volume = 327 | issue = 16 | pages = 1577–1584 | date = April 2022 | pmid = 35471505 | doi = 10.1001/jama.2022.4983 | title-link = doi | doi-access = free }}</ref><ref>{{cite news | vauthors = Aubrey A, Stone W |date=26 April 2022 |title=Older adults shouldn't start a routine of daily aspirin, task force says |website=[[NPR]] |url=https://www.npr.org/sections/health-shots/2022/04/26/1094881056/older-adults-shouldnt-start-a-routine-of-daily-aspirin-task-force-says}}</ref> Determining the net benefit was based on balancing the risk reduction of taking aspirin for heart attacks and ischaemic strokes, with the increased risk of [[gastrointestinal bleeding]], [[Intracranial hemorrhage|intracranial bleeding]], and [[hemorrhagic stroke]]s. Their recommendations state that age changes the risk of the medicine, with the magnitude of the benefit of aspirin coming from starting at a younger age, while the risk of bleeding, while small, increases with age, particular for adults over 60, and can be compounded by other risk factors such as [[diabetes]] and a history of gastrointestinal bleeding. As a result, the USPSTF suggests that "people ages 40 to 59 who are at higher risk for CVD should decide with their clinician whether to start taking aspirin; people 60 or older should not start taking aspirin to prevent a first heart attack or stroke." Primary prevention guidelines from {{as of|2019|September|lc=n|alt=|bare=yes}} made by the [[American College of Cardiology]] and the [[American Heart Association]] state they might consider aspirin for patients aged 40–69 with a higher risk of atherosclerotic CVD, without an increased bleeding risk, while stating they would not recommend aspirin for patients aged over 70 or adults of any age with an increased bleeding risk.<ref name="Arnett-2019" /> They state a CVD risk estimation and a risk discussion should be done before starting on aspirin, while stating aspirin should be used "infrequently in the routine primary prevention of (atherosclerotic CVD) because of lack of net benefit". As of {{as of|2021|August|lc=n|alt=|bare=yes}}, the [[European Society of Cardiology]] made similar recommendations; considering aspirin specifically to patients aged less than 70 at high or very high CVD risk, without any clear contraindications, on a case-by-case basis considering both ischemic risk and bleeding risk.<ref name="Visseren-2021" />