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Aspirin for primary prevention of cardiovascular disease in diabetes mellitus

Abstract

Aspirin is effective for the prevention of cardiovascular events in patients with a history of vascular disease, as so-called secondary prevention. In general populations with no history of previous myocardial infarction or stroke, aspirin also seems useful for primary prevention of cardiovascular events, although the absolute benefits are smaller than those seen in patients with previous cardiovascular disease. Patients with diabetes mellitus are at an increased risk of cardiovascular events, but new trials have raised questions about the benefit of aspirin for primary prevention in patients with this disorder. This Review comprehensively examines the basic pharmacology of aspirin and provides an overview of the randomized, controlled trials of aspirin therapy that have included patients with diabetes mellitus. On the basis of currently available evidence from primary prevention trials, aspirin is estimated to reduce the relative risk of myocardial infarction and stroke by about 10% in patients with diabetes mellitus; however, aspirin also increases the risk of gastrointestinal bleeding. As such, low-dose aspirin therapy (75–162 mg) is reasonable for patients with diabetes mellitus and a 10-year risk of cardiovascular events >10%. Results from upcoming large trials will help clarify the effects of aspirin with greater precision, including whether the benefits differ between men and women.

Key Points

  • Patients with diabetes mellitus exhibit increased platelet reactivity

  • Randomized trials of aspirin for the primary prevention of cardiovascular events in patients with diabetes mellitus have studied heterogeneous populations and exhibit heterogeneous results

  • Aspirin (75–162 mg daily) for primary prevention is reasonable for patients with diabetes mellitus and moderate or high cardiovascular disease risk (10-year risk >10%) that are not at high risk of gastrointestinal bleeding

  • Patients with low cardiovascular disease risk (10-year risk <5%) should not use aspirin as a preventive measure

  • Ongoing trials of aspirin therapy in patients with diabetes mellitus will help to provide more definitive conclusions

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Figure 1: Overview of platelet activation and its inhibition by antiplatelet drugs.

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M. Pignone and C. D. Williams researched the data for the article and provided a substantial contribution to discussions of the content. Both authors contributed equally to writing the article and reviewed and/or edited the manuscript before submission.

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Correspondence to Michael Pignone.

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Pignone, M., Williams, C. Aspirin for primary prevention of cardiovascular disease in diabetes mellitus. Nat Rev Endocrinol 6, 619–628 (2010). https://doi.org/10.1038/nrendo.2010.169

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