Primary Prevention of Cardiovascular Events With Low-Dose Aspirin and Vitamin E in Type 2 Diabetic Patients

Results of the Primary Prevention Project (PPP) trial

  1. Michele Sacco, MD1,
  2. Fabio Pellegrini, MS1,
  3. Maria C. Roncaglioni, MSC, BIOLS2,
  4. Fausto Avanzini, MD2,
  5. Gianni Tognoni, MD2,
  6. Antonio Nicolucci, MD1 and
  7. on behalf of the PPP Collaborative Group*
  1. 1Department of Clinical Pharmacology and Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri, Consorzio Mario Negri Sud, S. Maria Imbaro (CH), Italy
  2. 2Department of Cardiovascular Research, Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
  1. Address correspondence and reprint requests to Antonio Nicolucci, MD, Department of Clinical Pharmacology and Epidemiology, Consorzio Mario Negri Sud Via Nazionale, 66030 S. Maria Imbaro (CH), Italy. E-mail: nicolucc{at}


OBJECTIVE—We investigated in general practice the efficacy of antiplatelets and antioxidants in primary prevention of cardiovascular events in people with type 2 diabetes.

RESEARCH DESIGN AND METHODS—The Primary Prevention Project (PPP) is a randomized, open trial with a two-by-two factorial design aimed to investigate low-dose aspirin (100 mg/day) and vitamin E (300 mg/day) in the prevention of cardiovascular events in patients with one or more cardiovascular risk factors. The primary end point was a composite end point of cardiovascular death, stroke, or myocardial infarction. A total of 1,031 people with diabetes in the PPP, aged ≥50 years, without a previous cardiovascular event were enrolled by 316 general practitioners and 14 diabetes outpatient clinics.

RESULTS—The PPP trial was prematurely stopped (after a median of 3.7 years) by the independent data safety and monitoring board because of a consistent benefit of aspirin compared with the control group in a population of 4,495 patients with one or more major cardiovascular risk factors. In diabetic patients, aspirin treatment was associated with a nonsignificant reduction in the main end point (relative risk [RR] = 0.90, 95% CI 0.50–1.62) and in total cardiovascular events (0.89, 0.62–1.26) and with a nonsignificant increase in cardiovascular deaths (1.23, 0.69–2.19). In nondiabetic subjects, RRs for the main end point, total cardiovascular events, and cardiovascular deaths were 0.59 (0.37–0.94), 0.69 (0.53–0.90), and 0.32 (0.14–0.72), respectively. No significant reduction in any of the end points considered could be found with vitamin E in either diabetic or nondiabetic subjects.

CONCLUSIONS—Our data suggest a lower effect of primary prevention of cardiovascular disease (CVD) with low-dose aspirin in diabetic patients as opposed to subjects with other cardiovascular risk factors. If confirmed, these findings might indicate that the antiplatelet effects of aspirin in diabetic patients are overwhelmed by aspirin-insensitive mechanisms of platelet activation and thrombus formation, thus making the balance between benefits and harms of aspirin treatment unfavorable. Further large-scale trials investigating the role of aspirin in the primary prevention of CVD in diabetic patients are urgently needed.


  • * Members of the Primary Prevention Project (PPP) Collaborative Group are listed in the appendix.

  • A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

    See accompanying editorial, p. 3349.

    • Accepted July 30, 2003.
    • Received April 2, 2003.
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