Aspirin for primary prevention

To the Editor: I greatly appreciated the review by Drs. Schenone and Lincoff about aspirin for primary prevention in your May 2020 issue.¹

I wanted to note that the statement in green on page 303, “Statins may dilute the potential benefit of aspirin,” conflicts with what I have read regarding statins’ ability to improve aspirin resistance.²

Moreover, as I interpret a meta-analysis performed by the Antithrombotic Trialists’ Collaboration,³ statins may halve the risk of coronary heart disease, but when aspirin is added, hypothetically the added benefit of the aspirin is marginal, given the increased risk of bleeding. Ultimately it would be the aspirin theoretically diluting the benefit of the statin because of bleeding risk. The authors of the meta-analysis note: “If the risk of occlusive vascular disease is already approximately halved by statins or other measures, then the further absolute benefit of adding aspirin could well be only about half as large as was suggested by these primary prevention trials, but the main bleeding hazards could well remain. In that case, the benefits and hazards of adding long-term aspirin in people without preexisting disease might be of approximately similar magnitude.”

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