Cardiovascular disease
Aspirin is recommended for the prevention and treatment of various aspects of cardiovascular disease in management guidelines published in the UK and Europe (see European Society of Cardiology, www.escardio.org; National Institute for Health and Clinical Excellence, www.nice.org.uk; and Scottish InterCollegiates Network, www.sign.ac.uk). Although details may differ, these guidelines broadly agree on the indications and contraindications for aspirin.

• Expert Consensus Document on the Use of Antiplatelet Agents, 2004 (www.escardio.org/NR/rdonlyres/408F3F49-5C2B-4450-A3B2-BF11FC5A90FB/0/guidelines_Antiplatelets_FT_2004.pdf)

• Aspirin Foundation Position Papers:
Alternate-day dosing
Duration of therapy with medium-dose aspirin following a vascular event
Interaction between aspirin and NSAIDs
Peri-operative use of aspirin
Prevention of deep vein thrombosis associated with flying

In general, aspirin is recommended when an individual's risk of an ischaemic event (such as a myocardial infarction, MI) exceeds a certain threshold. Nine risk factors determine 90 percent of an individual's total risk: smoking, history of hypertension or diabetes, waist:hip ratio (a measure of overweight), dietary pattern, physical activity, alcohol consumption, blood lipids and psychosocial factors. People who have already had a heart attack or ischaemic stroke, or who have heart failure, are at high risk of having another event by virtue of this history in addition to these risk factors.

Cardiovascular risk can be estimated using various evidence-based models derived from studies of the incidence of events in large populations. These models all have advantages and disadvantages for specific groups of people - for example, they may be inaccurate for individuals who were not adequately represented in the population on which the models are based. Risk is estimated using computerised tools (or, less accurately, printed graphs) based on these models.

• For clinical guidance, see Risk estimation and the prevention of cardiovascular disease (www.sign.ac.uk/pdf/sign97.pdf).

It is now recognised that people who have peripheral vascular disease (intermittent claudication, or leg pain on walking that is relieved by rest) are also at increased risk of cardiovascular events. This is because their condition shares the underlying pathology of coronary heart disease - the impairment of arterial blood flow due to atheromatous plaques. It is recommended that affected individuals should take measures to reduce risk similar to those indicated for people with coronary heart disease.

• Diagnosis and management of peripheral arterial disease, 2006 (www.sign.ac.uk/pdf/sign89.pdf)
• Vascular disease - clopidogrel and dipyridamole, 2005 (http://guidance.nice.org.uk/TA90/?c=91497).

Aspirin is recommended only for people at increased risk because long-term use is associated with a small but nonetheless significant risk of adverse effects. Its use is indicated when its benefits outweigh the possible risk of adverse effects. The most important concerns associated with long-term aspirin use are its gastrointestinal safety and the risk of haemorrhagic stroke.

• Aspirin Foundation Position Papers:
Aspirin and the risk of haemorrhagic stroke
Gastric safety and tolerability of aspirin


The indications for aspirin are conventionally divided into three categories:

1. Acute treatment - use during a current event (e.g. taking a tablet of aspirin when experiencing chest pain probably due to a heart attack)

• Acute coronary syndromes - clopidogrel, 2004 (http://guidance.nice.org.uk/TA80/?c=91497) (review expected July 2007)

• Acute coronary syndromes, 2007 (www.sign.ac.uk/pdf/sign93.pdf)

2. Primary prevention - use of aspirin by individuals who are at increased risk of a cardiovascular event, but have not yet had one, to reduce their risk

• Risk estimation and the prevention of cardiovascular disease (www.sign.ac.uk/pdf/sign97.pdf)

• Expert Consensus Document on the Use of Antiplatelet Agents, 2004 (www.escardio.org/NR/rdonlyres/408F3F49-5C2B-4450-A3B2-BF11FC5A90FB/0/guidelines_Antiplatelets_FT_2004.pdf)

• Management of stable angina, 2007 (www.sign.ac.uk/pdf/sign96.pdf)

• Guidelines on the management of stable angina pectoris, 2006 (www.escardio.org/NR/rdonlyres/19F7C64E-B1B4-4E5D-9FE2-310D3568B351/0/Guidelines_Angina_ES_finalpaginated_2006.pdf)

• Guidelines on diabetes, prediabetes and cardiovascular diseases, 2007 (www.escardio.org/NR/rdonlyres/C1073F34-7F1A-48AA-8B3D-EB6AC273B790/0/Guidelines_Diabetes_ES_2007.pdf)

• Type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and adults, 2004 (http://guidance.nice.org.uk/CG15/niceguidance/pdf/English)

• Chronic heart failure 2003 (http://guidance.nice.org.uk/CG5/niceguidance/pdf/English)

• Aspirin Foundation Position Paper:
Primary prevention of coronary heart disease

.Secondary prevention - use of aspirin by individuals who have had a cardiovascular event to reduce their risk of subsequent events

• Myocardial infarction: secondary prevention, 2007 (http://guidance.nice.org.uk/CG48/?c=91497)
• Expert Consensus Document on the Use of Antiplatelet Agents, 2004 (www.escardio.org/NR/rdonlyres/408F3F49-5C2B-4450-A3B2-BF11FC5A90FB/0/guidelines_Antiplatelets_FT_2004.pdf)

• Guidelines on diabetes, prediabetes and cardiovascular diseases, 2007 (www.escardio.org/NR/rdonlyres/C1073F34-7F1A-48AA-8B3D-EB6AC273B790/0/Guidelines_Diabetes_ES_2007.pdf)

• Aspirin Foundation Position Paper:
Aspirin in secondary prevention