The role of aspirin in the primary prevention of atherosclerotic cardiovascular disease (ASCVD) is being redefined towards a more individualized, risk-based approach.^[1] Current guidelines support selective use of aspirin. United States Preventive Services Task Force (USPSTF) recommends it for adults aged 40–59 years with ≥10% 10-year risk, European Society of Cardiology (ESC) for high-risk patients with diabetes, and American College of Cardiology/ American Heart Association (ACC/AHA) for adults aged 40–70 years with high ASCVD risk and low bleeding risk.^[2]

India’s CV risk landscape is different from that of the Western world. In India, myocardial infarctions (MIs) occur 10 years earlier vs in the West (age 53 vs. 58 years)^[3], with one-third of events occurring before age 50. The 10-year risk scores often underestimate ASCVD risk in Indians prompting a shift toward lifetime risk models for better assessment.^[4]

A 2025 global analysis showed that five risk factors namely hypertension (HT), type 2 diabetes (T2D), dyslipidemia, smoking, and high body mass index (BMI) account for ~50% of CVD burden, with midlife blood pressure (BP) and smoking control offering the biggest survival gains.^[5] Risk factor control is poor, and only 7% meet targets for glucose, BP, lipids, supporting the consideration for aggressive steps like aspirin.^[6]  

In individuals with elevated lipoprotein(a) [Lp(a)], aspirin lowered ASCVD mortality by 52%.^[7]Risk-benefit balance is crucial. Tools like the Aspirin-Guide app help refine decisions.

Consider a 55-year-old man with HT, dyslipidemia (total cholesterol 220 mg/dL, HDL cholesterol 40 mg/dL), sedentary lifestyle with BMI 26 kg/m² (modifiable risk factor), and family history of premature coronary heart disease (CHD) (non-modifiable risk factor), non-smoker, with no history of GI bleed or NSAID use—high ASCVD risk and clinically assessed low bleeding risk;  fitting Diabetes, Cardiorenal, and Metabolic Diseases (DCRM) 2.0 (2024) criteria for considering low-dose aspirin (75–100 mg/day). In high CV risk and low-bleeding risk patients, aspirin may be considered for primary prevention when appropriately indicated.

Reference

1.      Zheng SL, et al. Association of aspirin use for primary prevention with cardiovascular events and bleeding events: a systematic review and meta-analysis. JAMA. 2019;321(3):277-87.

2.      Della Bona R, et al. Aspirin in Primary prevention: looking for those who enjoy it. J Clin Med. 2024;13(14):4148.

3.      Puri R, et al. Lipid Association of India 2023 update on cardiovascular risk assessment and lipid management in Indian patients: Consensus statement IV. J Clin Lipidol. 2024;18(3):e351-e373.

4.      Kalra A, et al. The burgeoning cardiovascular disease epidemic in Indians - perspectives on contextual factors and potential solutions. Lancet Reg Health Southeast Asia. 2023:12:100156.

5.      Global Cardiovascular Risk Consortium; Magnussen C, et al. Global effect of cardiovascular risk factors on lifetime estimates. N Engl J Med. 2025 Mar 30.

6.      Ranjit Mohan Anjana, et al; ICMR-INDIAB Collaborative Study Group. Metabolic non-communicable disease health report of India: the ICMR-INDIAB national cross-sectional study (ICMR-INDIAB-17). Lancet Diabetes Endocrinol. 2023;11(7):474-89.

7.      Razavi AC, et al. Aspirin use for primary prevention among US adults with and without elevated Lipoprotein(a). Am J Prev Cardiol. 2024;18:100674.