title: A Critical Appraisal of Aspirin in Secondary Prevention: Is Less More?
abstract: Aspirin represents the sine qua non for antiplatelet pharmacotherapy in patients with cardiovascular diseases because of its well-established role in secondary prevention and its widespread availability and affordability. Historical studies, conducted in an era that bears little resemblance to contemporary clinical practice, demonstrated large reductions in thrombotic risk when aspirin was compared with placebo, thus forming the evidence base promulgated in practice guidelines and recommendations. P2Y12inhibitors have mostly been studied in addition to aspirin; dual-antiplatelet therapy proved superiority compared with aspirin monotherapy for the prevention of ischemic events, despite increased bleeding risks. An alternative approach currently under investigation includes evaluation of single-antiplatelet therapy with P2Y12inhibitors alone versus dual-antiplatelet therapy after acute coronary syndromes or coronary stent implantation. As the availability of more effective antiplatelet agents increases, it is time to revisit the existing and long-standing paradigm supporting aspirin use for secondary prevention of atherothrombotic events. Ongoing trials will provide new evidence whether the less-is-more strategy is justified.
authors.affiliation: From Department of Cardiology, Bern University Hospital, University of Bern, Switzerland (G.G., S.W., M.V.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (G.G.); Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Belgium (P.V.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M.); and Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands (M.V.).
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Gargiulo
authors.affiliation: From Department of Cardiology, Bern University Hospital, University of Bern, Switzerland (G.G., S.W., M.V.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (G.G.); Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Belgium (P.V.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M.); and Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands (M.V.).
authors.forename: Stephan
authors.initials: S
authors.lastname: Windecker
authors.affiliation: From Department of Cardiology, Bern University Hospital, University of Bern, Switzerland (G.G., S.W., M.V.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (G.G.); Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Belgium (P.V.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M.); and Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands (M.V.).
authors.forename: Pascal
authors.initials: P
authors.lastname: Vranckx
authors.affiliation: From Department of Cardiology, Bern University Hospital, University of Bern, Switzerland (G.G., S.W., M.V.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (G.G.); Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Belgium (P.V.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M.); and Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands (M.V.).
authors.forename: Charles Michael
authors.initials: CM
authors.lastname: Gibson
authors.affiliation: From Department of Cardiology, Bern University Hospital, University of Bern, Switzerland (G.G., S.W., M.V.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (G.G.); Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Belgium (P.V.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M.); and Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands (M.V.).
authors.forename: Roxana
authors.initials: R
authors.lastname: Mehran
authors.affiliation: From Department of Cardiology, Bern University Hospital, University of Bern, Switzerland (G.G., S.W., M.V.); Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (G.G.); Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Belgium (P.V.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M.); and Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands (M.V.). marco.valgimigli@insel.ch.
authors.forename: Marco
authors.initials: M
authors.lastname: Valgimigli
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy; D001241:Aspirin / Q000627:therapeutic use*; D004359:Drug Therapy, Combination; D006801:Humans; D009203:Myocardial Infarction / Q000517:prevention & control*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D058921:Purinergic P2Y Receptor Antagonists / Q000627:therapeutic use; D055502:Secondary Prevention
chemical_list: D010975:Platelet Aggregation Inhibitors; D058921:Purinergic P2Y Receptor Antagonists; D001241:Aspirin
keywords: aspirin; percutaneous coronary intervention; platelet aggregation inhibitors; purinergic P2Y receptor antagonists; secondary prevention