Why we should not skip aspirin in cardiovascular prevention.

Since more than 20 years, aspirin is an approved and established first-line antiplatelet medication in cardiovascular prevention. This is partially due to ist unique mode of action which is not shared with any other antiplatelet agent as well by the reliability of its pharmacological efficacy: inhibition of platelet COX-1 and subsequent thromboxane formation in almost every patient. Aspirin acts synergistic with ADP-antagonists in dual antiplatelet therapy of acute coronary syndromes (ACS) and percutaneous coronary interventions (PCI) and is also approved for long-term secondary prevention. Patients with atrial fibrillation are an exception and benefit more from anticoagulants. After the introduction of the new oral anticoagulants (NOACs), i.e. direct inhibitors of factor Xa or thrombin formation, there is a renewed discussion about the role of antiplatelet agents, specifically if additional dual antiplatelet treatment is still necessary for an optimum clinical effect or whether one component, such as aspirin might be skipped in favor of other classes of oral antiplatelet agents, such as ADP-antagonists. The available data are insufficient to recommend this because of a low number of studies and a still uncertain benefit/risk (bleeding) ratio. More research on aspirin as a chemopreventive appears also to be necessary and is going on, in particular in individuals at high-risk for vascular thrombotic diseases (diabetics, preeclampsia, venous thromboembolism).