In 1997, the American Diabetes Association (ADA) recommended low-dose aspirin therapy as a secondary prevention strategy in people with diabetes (1,2). There was nothing that was unique in this policy. It simply formalized recommendations that were supported by meta-analyses of all secondary prevention antiplatelet trials before 1994 (3). The ADA, however, agreed that this sole strategy was not sufficient for people with diabetes. Cardiovascular events are increased at least two- to fourfold in diabetes, and the major mode of death is a cardiovascular event. The cardiovascular risk for a person with type 2 diabetes who has not had a recognized myocardial infarction is the same as a non-diabetic individual who has already had a heart attack (4). People with diabetes have platelets that are hypersensitive to aggregating agents in vitro, and there is increased platelet thromboxane synthesis that is blocked by low doses of aspirin (5). It is generally accepted that the antithrombotic effect of aspirin is mediated by its inhibition of thromboxane synthesis. Results from primary and secondary prevention trials in people with diabetes support the final recommendation that adult (>30 years of age) diabetic individuals at high risk for vascular disease should be treated with 81-325 mg enteric-coated aspirin daily (1,2).

The definition of high vascular risk is of obvious importance. The ADA recommended that the presence of at least one of the following cardiovascular risk factors in a patient with diabetes confers …