For secondary cardiovascular prevention, the net benefits of adding aspirin to other preventive measures would substantially exceed the bleeding hazards, irrespective of age and gender.

In contrast, for many people without pre-existing vascular disease, the cardiovascular benefits of adding long-term aspirin to other, safer, forms of primary prevention (e.g. statins and antihypertensive drugs) are likely to be of similar magnitude as the hazards.

Four ongoing primary prevention trials may help assess the benefit/risk profile of low-dose aspirin in preventing multiple outcomes (including dementia and cancer) in ?50 000 participants at somewhat higher cardiovascular risk than in the earlier trials, because of diabetes mellitus (ASCEND and ACCEPT-D), advanced age (ASPREE),or a cluster of risk factors (ARRIVE).

Hence, the currently available trial results do not seem to justify general guidelines advocating or discouraging the routine use of aspirin in all apparently healthy individuals above a moderate level of coronary risk, unless additional long-term benefits of aspirin therapy become firmly established.

In the meantime, clinical judgement as well as adequate knowledge of the available data may help the doctor–patient relationship in making a personalized choice after considering the different components of a complex equation that includes the patient’s preferences and values.

G Mohan.