31/03/2026
Aspirin in Primary Prevention of ASCVD
General Principle
• Aspirin is NO longer routinely recommended for primary prevention of cardiovascular disease.
• Use is individualized, balancing:
• ASCVD risk reduction
• Bleeding risk
Guideline Positions
National Institute for Health and Care Excellence (NICE)
• NICE does NOT recommend routine aspirin for primary prevention of cardiovascular disease.
• Aspirin is not offered for primary prevention in people without established CVD.
• Focus is on:
• Statin therapy
• Risk factor modification (BP, smoking, diabetes, lipids)
NICE explicitly avoids aspirin for primary prevention due to lack of net benefit.
American College of Cardiology / American Heart Association (ACC/AHA)
• Aspirin may be considered in selected adults 40–70 years:
• With high ASCVD risk
• And low bleeding risk
• Should not be used routinely
• Emphasis on individualized decision-making
Criteria Favoring Use
Aspirin may be considered (selective use) if ALL are present:
• Elevated 10-year ASCVD risk (commonly ≥10%)
• Low bleeding risk
• Age typically:
• 40–70 years (ACC/AHA selective population)
• Patient agrees after shared decision-making
When to Avoid Aspirin
Avoid or generally do NOT initiate if:
• Routine use for primary prevention (per NICE: not recommended)
• Increased bleeding risk:
• History of GI bleed or peptic ulcer
• Concurrent anticoagulants / dual antiplatelet therapy
• Chronic kidney disease with bleeding tendency
• Uncontrolled hypertension
• Liver disease or coagulopathy
• Low or borderline ASCVD risk
