Aspirin, who is really needed to prevent heart attack and stroke (and when)

For secondary prevention, that is, after a first event such as heart attack or stroke, there is no doubt. Acetylsalicylic acid is a sort of “milestone” to reduce the risk of new episodes, thanks to its antiplatelet activity. But in primary prevention, when that event has not yet occurred, how do you choose who can benefit most from the drug without running excessive risks of bleeding or actual bleeding? At the moment the choice is mainly based on the cardiovascular risk of the individual, which guides the approach. But in the future, it will be necessary to define a real “phenotype”, that is the characteristics of the individual subject, to define who can really benefit, with minimal risks, from treatment with aspirin in primary prevention. To design this path, which could represent a turning point in personalized antiplatelet prophylaxis, is Jeffrey S. Bergerof NYU Grossman School of Medicine, through an editorial on Jama Network Open.

Aspirin to prevent heart attacks and strokes: the US goes back. “Needed, but made to measure”

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The solution to the question can only come from specific studies for the most appropriate use of acetylsalicylic acid in primary prevention that go beyond the simple concept of global cardiovascular risk (therefore in practice a sum of the “weight” of the various factors that endanger the heart, from overweight to smoking up to diabetes and hypercholesterolemia), to better define the specific profile of the subject in terms of blood coagulation.

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How to precisely identify who can benefit most from this approach? According to the expert, in the future, thanks to specific tests such as the analysis of the platelet transcriptome, it will be possible to identify the subjects who may be most sensitive to having reactions, with consequent personalization of the treatment. But at the moment for the diffusion of this technique which is based on blood tests, as well as for the light transmission aggregometry, a specific test to measure the function of platelets, thinking of a large-scale use is premature. Therefore, specific studies will be needed – some are already underway – to limit the potential side effects as much as possible and optimize the effect that reduces the dangers of forming aggregates capable of clogging the arteries.

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All this should lead to a sort of genetic “signature” that will allow to identify subjects with particularly “reactive” platelets or with diseases mediated by these units of the blood to balance the benefits and risks of low-dose aspirin treatment from the beginning. In short, we are moving towards tailor-made prevention. “I believe that understanding these genetic patterns of platelet hyperactivity will ultimately guide the choice of optimal antiplatelet therapies to prevent cardiovascular events – concludes the expert”. To date, the guidelines on the use of aspirin in primary prevention seek to characterize as best as possible who in the population could benefit the most from prophylactic treatment. All this, obviously, on the basis of the doctor’s evaluation of the individual patient and the doctor-patient relationship.

American recommendations

The American College of Cardiology and the American Heart Association recommend that the use of low-dose aspirin may be considered for primary prevention of cardiovascular disease related to atherosclerosis among selected adults aged 40 to 70 at higher risk but not at increased risk of bleeding. On the other hand, they do not provide for use for the primary prevention of cardiovascular diseases in over-70s and in those who have a greater risk of bleeding.

But Europe disagrees

The ESC, European Society of Cardiology, suggests that among individuals at very high cardiovascular risk, low-dose aspirin can also be evaluated in primary prevention. “Thinking of an accurate personalization on the basis of specific tests for the use of acetylsalicylic acid at low doses in primary prevention is premature: certainly this approach is fundamental in cardiovascular prevention – he underlines Massimo Volpe, President of the Italian Society of Cardiovascular Prevention (Siprec) – but there are many aspects that need to be clarified by specific studies: just think of those who discover that they have atherosclerotic plaques, perhaps without symptoms, during a CT scan performed for other reasons. In this case, the prophylactic use of acetylsalicylic acid certainly has significance for the patient, even if it is not “sanctioned” in the guidelines. In this condition, in Italy alone, there are hundreds of thousands of people. The doctor-patient relationship and the doctor’s knowledge must always be given priority. There are cases in which, even regardless of the guidelines, it is necessary to follow the treatment alongside therapies for the other risk factors. All this while waiting for tests to personalize the therapy as much as possible “.

Heart door

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