**6. Role of aspirin in CVD**

Efforts were being done for decades to prevent and treat cardiovascular disease (CVD). By the twentieth century, CVD had become a major cause of mortality and morbidity, and many efforts were being made to prevent it worldwide [51–53].

Given the prevalence of CVD, several strategies are being considered for its prevention, including lifestyle changes as well as strict management of cardiovascular risk factors such as hypertension, diabetes, hyperlipidemia, and metabolic syndrome. In addition to traditional methods, other alternative methods have also been studied for its prevention. Along with this, some exploiters have used aspirin for the prevention of CVD, and with some controversy, it is believed that aspirin is beneficial in the primary prevention of CVD [54, 55].

Today aspirin is widely used for the primary prevention of CVD. In the United States alone, 40% of adults over the age of 50 are using aspirin for the prevention of CVD [56]. Aspirin is an irreversible and nonselective cyclo-oxygenase (COX) inhibitor class of drug, whose work is to reduce thromboxane A2 production and inhibit platelet aggregation and vasoconstriction. The ability to prevent platelet aggregation provides the potential to reduce arterial thrombosis, and when used at low doses, it is beneficial in preventing myocardial infarction (MI) and stroke. On the other hand, aspirin also inhibits the production of prostaglandin as well as reducing the side effects of GI bleeding by inhibiting COX 1 and protecting the gastrointestinal (GI) mucosa [57]. It has been assessed through successive clinical trials that aspirin is effective in the prevention of CVD. A number of tests have been performed to demonstrate its efficacy and it has been found that it is beneficial in secondary prevention of CVD even in patients with previous MI or ischemic stroke and at high risk [58].

#### **7. Risk factors**

Recently, the publication of a number of studies has raised doubts about the benefits of using aspirin as a primary prevention for patients with moderate cardiovascular risk. Three of the trials were published in 2018, A Study of Cardiovascular Events in Diabetes (ASCEND), Aspirin in Reducing Events in the Elderly (ASPREE), and ARRIVE.

The ASCEND study assessed the effectiveness and safety of aspirin use by arbitrarily assigning 14,480 diabetic patients into 100 mg aspirin or placebo teams and observing them for a median of 7.4 years. Internal hemorrhage has emerged as a haul within the safety assessment. All major bleeding during this study was 29% higher with the aspirin administration cluster and a high risk of bleeding was seen in patients with a high risk of vascular events. This study has concluded that aspirin use prevented serious vascular events in patients who had diabetes and no previous CVD, however this absolute profit was for the most part balanced by the same rate of bleeding hazard [59].

In the ASPREE trial, old patients aged 70 or above who did not have CVD, dementia or disability were randomized and given 100 mg aspirin or placebo at a median of 4.7 years of follow-up. Contrary to other studies that established the incidence of CVD as the primary endpoint, ASPREE evaluated all causes of death, dementia, and chronic physical incapacity as primary endpoints. Moreover, apart from other studies, the ASPREE study evaluated the cause of mortality. Death from any cause was 12.7 per 1000 person within the aspirin group and 11.1 per 1000 people within the placebo group with a considerably accrued risk in the aspirin cluster. However, the incidence of CVD was 10.7 within the aspirin and 11.3 within the placebo teams per 1000 person-years, which indicated there was no distinction between trial groups. They completed that once aspirin was taken for the first purpose of preventing CVD in healthy old subjects without CVD, there was no profit, but the risk of bleeding was larger and also the death rate was higher. Thus, the study has proposed that aspirin is not a significant prescribing agent as a practice in order to prevent CVD for healthy old individuals. The fascinating purpose of this study is that they enclosed insanity as a primary and secondary outcome as a result of there have been some previous suggestions that aspirin will scale back vascular insanity or physical inactivity by decreasing cerebral events [60, 61].

The ARRIVE was a randomized sort of trial, conducted with 12,545 patients of 55 years (men) or 60 years (women) and older people (mean age 63.9); who had a median cardiac risk to receive 100 mg aspirin or placebo for 60 months of followup. They restricted the patients who were at high risk of bleeding and diabetes. The first terminus (MI, stroke, cardiovascular death, unstable angina or TIA) occurred in 4.29% of patients within the aspirin cluster versus 4.48% of patients within the placebo teams. One of the significant the protocols to note within the ARRIVE trial is that the genuine cardiovascular event rate was less than the anticipated cardiovascular rate. This implies that the cluster concerned within the ARRIVE trials managed the CVD risk issue higher than within the former trials [62].

Thirteen randomized controlled trials comprising 164,225 patients were observed. The danger of all-cause and cardiovascular mortality was similar for both aspirin and control teams. Aspirin reduced the relative risk (RRR) of major adverse cardiovascular events (MACE) by 9%, myocardial infraction by 14%, and cerebrovascular accident by 10 percent, however was related to a 46% relative risk increase of major bleeding events as compared with controls. Aspirin use did not transform into a net clinical profit adjusted for event connected with mortality risk. There was associate degree interaction for aspirin impact in 3 patient subgroups: (i) in patients with statin drug treatment, aspirin was related to a 12% RRR of MACE and this impact was lacking within the no-statin group; (ii) in nonsmokers, aspirin was related to a 10% RRR of MACE and this impact was not observed in smokers; and (iii) in males, aspirin resulted in a 11% RRR of MACE with a nonsignificant impact in females. Aspirin use does not scale back all-cause of cardio vascular mortality associated with insufficient profit risk quantitative relation for CVD prevention. Nonsmokers, patients treated with statins, and males had the best risk reduction of MACE across subgroups. Systematic review registration: PROSPERO CRD42019118474 [63].

A systematic search of PubMed and Embase was conducted with the assistance of Antithrombotic Trialists' (ATT). A set of thirteen trials randomizing 164,225 participants with 1,050,511 participant-years of follow-up were enclosed. The median age of trial participants was 62 years, 19 had diabetes along with the

**33**

aspirin [66].

*Risk-Benefit Events Associated with the Use of Aspirin for Primary Prevention…*

median baseline risk of the primary cardiovascular outcome was 9.2%. Aspirin use was related to important reductions within the composite cardiac outcome compared with no aspirin (57.1 per 10,000 participant-years with aspirin and 61.4 per 10,000 participant-years with no aspirin). Aspirin use was related to elevated degree accrued risk of major bleeding events compared with no aspirin (23.1 per 10,000 participant-years with aspirin and 16.4 per 10,000 participantyears with no aspirin). The administration of aspirin in without cardiovascular disease was related to a lower risk of cardiovascular events associated with an accrued risk of major bleeding. This data may be helpful to aware the patients concerning aspirin use for primary prevention of cardiovascular events and

Another meta-analysis was performed in concurrence with the well-liked coverage things for Systematic Reviews and Meta-Analyses (PRISMA) tips. Electronic databases were explored for randomized trials that compared aspirin vs. placebo (or control) in subjects while not established atherosclerotic disease. The first efficaciousness outcome was all-cause mortality, whereas the first safety outcome was major bleeding. Outline estimates were reported employing a Der Simonian and Laird random effects model. A set of 11 trials with 157,248 volunteers were enclosed. At a mean follow-up of 6.6 years, aspirin was not related to a lower incidence of all-cause mortality. However, aspirin was related to high degree accrued incidence of major bleeding and intracranial bleeding. The same impact on all-cause mortality and major hemorrhage was incontestable in diabetic and high cardiovascular risk patients (i.e. 10-year risk >7.5%). Aspirin was related to a lower incidence of cardiac muscle infarction; but, this outcome was characterized by extensive heterogeneousness, and this impact was not evident upon limiting the analysis to the more modern trials. Trial ordered analysis confirmed the shortage of good thing about aspirin for all-cause mortality up to a relative risk reduction of 5%. Aspirin use among healthy people while known arterial sclerosis seems to be related to accrued damage and lack of mortality benefit. During this setting, aspirin is probably related to a considerable reduction in MI risk; but, this comes at a value of accrued major bleeding and together with intracranial hemorrhage. The routine use of aspirin for primary prevention has to

The most significant approach to forestall atherosclerotic vascular malady, cardiovascular breakdown, and atrial fibrillation is to advance healthy routine all through life. A group based consideration approach is a compelling technique for the avoidance of cardiovascular malady. Clinicians ought to assess the social determinants of wellbeing that influence people to advise treatment choices. Grown-ups who are 40–75 years old and are being assessed for cardiovascular illness prevention ought to experience 10-year atherosclerotic cardiovascular disease (ASCVD) hazard estimation and have a clinician–patient risk conversation before beginning on pharmacological treatment, for example, antihypertensive treatment, a statin, or

To adjust the advantages and dangers, earlier US guidelines have suggested prophylactic aspirin medicine just in the setting of raised ASCVD risk (eg, as determined estimators like the PCE (Personal Care Evaluation) or dependent on the nearness of explicit ASCVD risk elements). Meta-relapse investigations of recorded trials show that watched ASCVD chance tracks sensibly well with standard assessed ASCVD hazard. Interestingly, noticed bleeding risk on aspirin medicine is less very

*DOI: http://dx.doi.org/10.5772/intechopen.93286*

bleeding [64].

be reconsidered [65].

**8. Guideline for prevention of CVD**

#### *Risk-Benefit Events Associated with the Use of Aspirin for Primary Prevention… DOI: http://dx.doi.org/10.5772/intechopen.93286*

median baseline risk of the primary cardiovascular outcome was 9.2%. Aspirin use was related to important reductions within the composite cardiac outcome compared with no aspirin (57.1 per 10,000 participant-years with aspirin and 61.4 per 10,000 participant-years with no aspirin). Aspirin use was related to elevated degree accrued risk of major bleeding events compared with no aspirin (23.1 per 10,000 participant-years with aspirin and 16.4 per 10,000 participantyears with no aspirin). The administration of aspirin in without cardiovascular disease was related to a lower risk of cardiovascular events associated with an accrued risk of major bleeding. This data may be helpful to aware the patients concerning aspirin use for primary prevention of cardiovascular events and bleeding [64].

Another meta-analysis was performed in concurrence with the well-liked coverage things for Systematic Reviews and Meta-Analyses (PRISMA) tips. Electronic databases were explored for randomized trials that compared aspirin vs. placebo (or control) in subjects while not established atherosclerotic disease. The first efficaciousness outcome was all-cause mortality, whereas the first safety outcome was major bleeding. Outline estimates were reported employing a Der Simonian and Laird random effects model. A set of 11 trials with 157,248 volunteers were enclosed. At a mean follow-up of 6.6 years, aspirin was not related to a lower incidence of all-cause mortality. However, aspirin was related to high degree accrued incidence of major bleeding and intracranial bleeding. The same impact on all-cause mortality and major hemorrhage was incontestable in diabetic and high cardiovascular risk patients (i.e. 10-year risk >7.5%). Aspirin was related to a lower incidence of cardiac muscle infarction; but, this outcome was characterized by extensive heterogeneousness, and this impact was not evident upon limiting the analysis to the more modern trials. Trial ordered analysis confirmed the shortage of good thing about aspirin for all-cause mortality up to a relative risk reduction of 5%. Aspirin use among healthy people while known arterial sclerosis seems to be related to accrued damage and lack of mortality benefit. During this setting, aspirin is probably related to a considerable reduction in MI risk; but, this comes at a value of accrued major bleeding and together with intracranial hemorrhage. The routine use of aspirin for primary prevention has to be reconsidered [65].
