Aspirin for Primary Prevention of Cardiovascular Events in People With Diabetes

A position statement of the American Diabetes Association, a scientific statement of the American Heart Association, and an expert consensus document of the American College of Cardiology Foundation

  1. M. Sue Kirkman, MD10
  1. 1Department of Medicine, University of North Carolina, Chapel Hill, North Carolina;
  2. 2Department of Neurology, Northwestern University, Chicago, Illinois;
  3. 3Division of Endocrinology, Diabetes, and Medical Genetics (Emeritus), Medical University of South Carolina, Charleston, South Carolina;
  4. 4Department of Medicine, University of Vermont, Burlington, Vermont;
  5. 5Section of Endocrinology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut;
  6. 6Division of Cardiovascular Medicine, Department of Medicine, Texas Tech University, Paul Foster School of Medicine, El Paso, Texas;
  7. 7Mount Sinai Heart, Mount Sinai School of Medicine, New York, New York;
  8. 8College of Pharmacy, Oregon State University and Oregon Health and Science University, Portland, Oregon;
  9. 9Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia;
  10. 10American Diabetes Association, Alexandria, Virginia.
  1. Corresponding author: M. Sue Kirkman, skirkman{at}diabetes.org.

The burden of cardiovascular disease (CVD) among patients with diabetes is substantial. Individuals with diabetes are at two- to fourfold increased risk of cardiovascular events compared with age- and sex-matched individuals without diabetes. In diabetic patients over the age of 65 years, 68% of deaths are from coronary heart disease (CHD) and 16% are from stroke (1). A number of mechanisms for the increased cardiovascular risk with diabetes have been proposed, including increased tendency toward intracoronary thrombus formation (2), increased platelet reactivity (3), and worsened endothelial dysfunction (4).

The increased risk for cardiovascular events and mortality in patients with diabetes has led to considerable interest in identifying effective means for cardiovascular risk reduction. Aspirin has been shown to be effective in reducing cardiovascular morbidity and mortality in high-risk patients with myocardial infarction (MI) or stroke (secondary prevention) (5). The Food and Drug Administration has not approved aspirin for use in primary prevention, and its net benefit among patients with no previous cardiovascular events is more controversial, for both patients with and without a history of diabetes (5). The U.S. Preventive Services Task Force recently updated its recommendation about aspirin use for primary prevention. The Task Force recommended encouraging aspirin use in men age 45–79 years and women age 55–79 years and not encouraging aspirin use in younger adults. They did not differentiate their recommendations based on the presence or absence of diabetes (6,7).

In 2007, the American Diabetes Association (ADA) and the American Heart Association (AHA) jointly recommended that aspirin therapy (75–162 mg/day) be used as a primary prevention strategy in those with diabetes at increased cardiovascular risk, including those who are over 40 years of age or who have additional risk factors (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria) (8). These recommendations were …

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