May 2021The purpose of this document is to keep a working list of European guidelines with information on aspirin. The guidelines themselves should be read for further information.Primary prevention of cardiovascular diseaseKey Message: “Antiplatelet therapy is not recommended in individuals free from CVD, due to the increased risk of major bleeding.” European Society of Cardiology (ESC) 2016 The 2016 European guidelines on CVD prevention review the evidence for antiplatelet therapy in individuals without CVD and conclude that current evidence does not support the use of aspirin in those without CVD due to the risk of a major bleed. For more information see:https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/CVD-Prevention-in-clinical-practice-European-Guidelines-onThe ESC 2019 guidelines on diabetes (DM), pre-diabetes, and cardiovascular disease state:

• “Patients with DM and symptomatic CVD should be treated no differently to patients without DM
• In patients with DM at moderate CV risk, aspirin for primary prevention is not recommended
• In patients with DM at high/very high risk, aspirin may be considered in primary prevention

For more information see:https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Diabetes-Pre-Diabetes-and-Cardiovascular-Diseases-developed-with-the-EASDIn addition, the ESC 2019 diabetes guidelines identify the following gaps in the evidence relating to platelet use in people with diabetes:

• Type 1 diabetes and CVD prevention [in vivo platelet activation has been reported]
• Body mass and antiplatelet responsiveness especially in those with diabetes and obesity where higher dose strategies need investigation
• Are antithrombotic effects similar in pre-DM and DM?

The ESC does not recommend aspirin for healthy people over 70 following results of the ASPREE trial.https://www.escardio.org/The-ESC/Press-Office/Press-releases/aspirin-should-not-be-recommended-for-healthy-people-over-70The ESC state in a press release following results of ARRIVE that the benefits of aspirin in primary prevention remain unclear.https://www.escardio.org/Congresses-&-Events/ESC-Congress/Congress-resources/Congress-news/benefit-of-aspirin-for-primary-prevention-of-cardiovascular-events-remains-unclear-arrive-trial-resultsIn another press release following the ASCEND trial the ESC state that the bleeds and benefits are balanced in people with diabetes using aspirin for primary CVD prevention and that no cancer benefit was found in this study.https://www.escardio.org/The-ESC/Press-Office/Press-releases/bleeds-and-benefit-with-aspirin-balanced-in-patients-with-diabetes-and-no-effect-on-cancerSecondary prevention of cardiovascular diseaseThe 2020 ESC guidelines for the management of acute coronary syndromes, in patients presenting without persistent ST-segment elevation, recommends that people [without atrial fibrillation] undergoing percutaneous coronary intervention are given aspirin, unless contraindicated, at a loading dose of 150-300 mg once daily and a maintenance dose of 75-100 mg once daily. They recommend a P2Y12 receptor inhibitor is given in addition to low-dose aspirin for the first 12 months For further information see:https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-Coronary-Syndromes-ACS-in-patients-presenting-without-persistent-ST-segmThe 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes recommended aspirin for CVD event prevention at a dose of 75-100 mg daily in patients with previous MI or revascularization. In addition, aspirin 75-100 mg daily can also be considered for people without a history of MI or revascularization but where there is evidence of coronary artery disease using imaging tests. For further information see:https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Chronic-Coronary-SyndromesThe 2016 European Guidelines for CVD prevention in clinical practice make the following recommendations for antiplatelet therapy (see table below). This is a based on a careful appraisal of risks versus benefits of aspirin or other antiplatelet therapy. The guidelines state that there is a gap in the evidence concerning new antiplatelet drugs in patients with stable coronary artery disease as well as a gap in the understanding about the use of new antiplatelet drugs used in combination with anticoagulation treatment.