Why we should not skip aspirin in cardiovascular prevention

Summary

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 syndroms (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 thrombembolism).

Zusammenfassung

Acetylsalizylsäure (ASS) ist seit über 20 Jahren zugelassene und bewährte Antiplättchenmedikation zur kardiovaskulären Prävention. Dies beruht pharmakologisch auf dem besonderen Wirkmechanismus, den keine andere Antiplättchensubstanz aufweist: Hemmung der Plättchen-COX-1 und der nachfolgenden Thromboxansynthese bei fast jedem Patienten. ASS wirkt synergistisch mit ADP-Rezeptorantagonisten in der dualen Antiplättchentherapie des akuten Koronarsyndroms (ACS) sowie bei perkutanen Koronarinterventionen (PCI) und ist Langzeitmedikation der ersten Wahl in der Sekundärprävention der Atherothrombose. Patienten mit Vorhofflimmern sind eine Besonderheit und profitieren mehr von einer Antikoagulation. Nach Einführung der neuen oralen Antikoagulantien (NOACs), direkten Inhibitoren von Faktor Xa oder Thrombin, wurde diskutiert, ob nicht auf eine zusätzliche duale Antiplättchentherapie verzichtet werden kann und eventuell eine Anti-plättchensubstanz, genügt, d. h., ob z. B. ASS durch einen ADP-Antagonisten ersetzt werden kann. Die vorhandenen Daten sind unzureichend und erlauben zurzeit keine klare Aussage über das Nutzen/Risikoverhältnis, insbesondere das Blutungsrisiko. Mehr Forschung zu ASS ist erforderlich und erfolgt in mehreren Studien und Patientenpopulationen. Dazu gehören insbesondere Personen mit einem erhöhten Risiko für Gefäßthrombosen (Diabetes mellitus, Präeklampsie, idiopathische venöse Thromboembolie).

Keywords

Aspirin - antiplatelet agents - thrombin - acute coronary syndrome - primary prevention - secondary prevention

Schlüsselwörter

Acetylsalizylsäure - Antiplättchensubstanzen - Thrombin - akutes Koronarsyndrom - primäre Prävention - sekundäre Prävention

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