{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T05:00:15Z","timestamp":1785474015432,"version":"3.56.0"},"reference-count":37,"publisher":"MDPI AG","issue":"15","license":[{"start":{"date-parts":[[2026,7,29]],"date-time":"2026-07-29T00:00:00Z","timestamp":1785283200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100004326","name":"Bayer","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100004326","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Cardiovascular disease (CVD) remains the leading global cause of morbidity and mortality. While low-dose aspirin is well established for secondary prevention, its role in primary prevention is controversial because modest benefits in cardiovascular benefits must be balanced against increased bleeding risk, as highlighted by recent large trials. Current guidelines recommend restricting aspirin use to individuals at higher cardiovascular risk without elevated bleeding risk, yet significant heterogeneity persists in defining these thresholds. Evidence from randomized trials, guidelines, cohort and modeling analyses, and post hoc or observational subgroup studies suggests that selected patients with advanced subclinical atherosclerosis or specific high-risk markers may have a more favorable risk\u2013benefit profile, although the certainty and directness of evidence vary across subgroups. This narrative review and pragmatic clinical guide presents an illustrative tiered framework based on clinical, imaging, and biomarker markers\u2014such as coronary artery calcium score, carotid plaque score, and lipoprotein(a)\u2014to support individualized discussion of preventive aspirin therapy. The framework is not a validated risk calculator or standalone treatment algorithm, and decisions should balance absolute cardiovascular risk, major bleeding risk, evidence certainty, and patient preferences.<\/jats:p>","DOI":"10.3390\/jcm15155936","type":"journal-article","created":{"date-parts":[[2026,7,29]],"date-time":"2026-07-29T17:01:46Z","timestamp":1785344506000},"page":"5936","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Aspirin in Primary Prevention of CVD: A Pragmatic Outline and Advice for Treatment Personalization"],"prefix":"10.3390","volume":"15","author":[{"given":"Francesca","family":"Santilli","sequence":"first","affiliation":[{"name":"Department of Medicine and Aging and Center for Advanced Studies and Technology, University of Chieti-Pescara, Via Luigi Polacchi 11, 66100 Chieti, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dirk","family":"Sibbing","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Ludwig-Maximilians-Universit\u00e4t (LMU) M\u00fcnchen, Geschwister-Scholl-Platz 1, 80539 M\u00fcnich, Germany"},{"name":"Privatklinik Lauterbacher M\u00fchle am Ostersee, Unterlauterbach 1, 82402 Seeshaupt, Germany"},{"name":"3DZHK (German Center for Cardiovascular Research), Partner Site M\u00fcnich Heart Alliance, Lazarettstra\u00dfe 36, 80636 M\u00fcnich, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Augusto Maria Lavalle","family":"Cobo","sequence":"additional","affiliation":[{"name":"Cardiology Department, Sanatorio Otamendi, Ciudad Autonoma de Buenos Aires C1007ABJ, Argentina"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,29]]},"reference":[{"key":"ref_1","unstructured":"World Health Organization (2026, June 23). Available online: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/cardiovascular-diseases-(cvds)."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"100456","DOI":"10.1016\/j.ajpc.2022.100456","article-title":"Advanced subclinical atherosclerosis: A novel category within the cardiovascular risk continuum with distinct treatment implications","volume":"13","author":"Blaha","year":"2023","journal-title":"Am. J. Prev. Cardiol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1016\/j.ahj.2017.12.006","article-title":"ASCEND: A Study of Cardiovascular Events iN Diabetes: Characteristics of a randomized trial of aspirin and of omega-3 fatty acid supplementation in 15,480 people with diabetes","volume":"198","author":"Bowman","year":"2018","journal-title":"Am. Heart J."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1519","DOI":"10.1056\/NEJMoa1803955","article-title":"Effect of aspirin on all-cause mortality in the healthy elderly","volume":"379","author":"McNeil","year":"2018","journal-title":"N. Engl. J. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1036","DOI":"10.1016\/S0140-6736(18)31924-X","article-title":"Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): A randomised, double-blind, placebo-controlled trial","volume":"392","author":"Gaziano","year":"2018","journal-title":"Lancet"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1376","DOI":"10.1016\/j.jacc.2019.03.009","article-title":"2019 ACC\/AHA guideline on the primary prevention of cardiovascular disease: Executive summary: A report of the American College of Cardiology\/American Heart Association Task Force on Clinical Practice Guidelines","volume":"74","author":"Arnett","year":"2019","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"3227","DOI":"10.1093\/eurheartj\/ehab484","article-title":"2021 ESC Guidelines on cardiovascular disease prevention in clinical practice","volume":"42","author":"Visseren","year":"2021","journal-title":"Eur. Heart J."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"100363","DOI":"10.1016\/j.ajpc.2022.100363","article-title":"Implications of the heterogeneity between guideline recommendations for the use of low dose aspirin in primary prevention of cardiovascular disease","volume":"11","author":"Li","year":"2022","journal-title":"Am. J. Prev. Cardiol."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Rodgers, J.L., Jones, J., Bolleddu, S.I., Vanthenapalli, S., Rodgers, L.E., Shah, K., Karia, K., and Panguluri, S.K. (2019). Cardiovascular risks associated with gender and aging. J. Cardiovasc. Dev. Dis., 6.","DOI":"10.3390\/jcdd6020019"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"4410","DOI":"10.1093\/eurheartj\/ehaf514","article-title":"Aspirin, cardiovascular events, and major bleeding in older adults: Extended follow-up of the ASPREE trial","volume":"46","author":"Wolfe","year":"2025","journal-title":"Eur. Heart J."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"458","DOI":"10.1177\/17407745251324866","article-title":"Aspirin in primary prevention: Undue reliance on an uninformative trial led to misinformed clinical guidelines","volume":"22","author":"Wittes","year":"2025","journal-title":"Clin. Trials"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"722","DOI":"10.1161\/CIRCULATIONAHA.123.065420","article-title":"Outcomes after aspirin discontinuation among baseline users in contemporary primary prevention aspirin trials: A meta-analysis","volume":"149","author":"Campbell","year":"2024","journal-title":"Circulation"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"434","DOI":"10.1016\/j.jacc.2018.05.027","article-title":"Coronary Calcium Score and Cardiovascular Risk","volume":"72","author":"Greenland","year":"2018","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1001\/jamacardio.2020.4939","article-title":"Value of coronary artery calcium scanning in association with the net benefit of aspirin in primary prevention of atherosclerotic cardiovascular disease","volume":"6","author":"Ajufo","year":"2021","journal-title":"JAMA Cardiol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"849","DOI":"10.1161\/CIRCULATIONAHA.115.018524","article-title":"Role of coronary artery calcium score of zero and other negative risk markers for cardiovascular disease: The Multi-Ethnic Study of Atherosclerosis (MESA)","volume":"133","author":"Blaha","year":"2016","journal-title":"Circulation"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e034718","DOI":"10.1161\/JAHA.123.034718","article-title":"Carotid ultrasound-based plaque score for the allocation of aspirin for the primary prevention of cardiovascular disease events: The Multi-Ethnic Study of Atherosclerosis and the Atherosclerosis Risk in Communities Study","volume":"13","author":"Dzaye","year":"2024","journal-title":"J. Am. Heart Assoc."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e033562","DOI":"10.1161\/JAHA.123.033562","article-title":"Aspirin and cardiovascular risk in individuals with elevated lipoprotein(a): The Multi-Ethnic Study of Atherosclerosis","volume":"13","author":"Bhatia","year":"2024","journal-title":"J. Am. Heart Assoc."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"100674","DOI":"10.1016\/j.ajpc.2024.100674","article-title":"Aspirin use for primary prevention among US adults with and without elevated lipoprotein(a)","volume":"18","author":"Razavi","year":"2024","journal-title":"Am. J. Prev. Cardiol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"101855","DOI":"10.1016\/j.jacadv.2025.101855","article-title":"Advanced subclinical atherosclerosis and low-dose aspirin: Guideline-based extension into asymptomatic chronic coronary syndromes","volume":"4","author":"Blaha","year":"2025","journal-title":"JACC Adv."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"3823","DOI":"10.1093\/eurheartj\/ehaf517","article-title":"Cardiovascular biomarkers for risk stratification in primary prevention","volume":"46","author":"Neumann","year":"2025","journal-title":"Eur. Heart J."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Emerging Risk Factors Collaboration, Sarwar, N., Gao, P., Kondapally Seshasai, S.R., Gobin, R., Kaptoge, S., Di Angelantonio, E., Ingelsson, E., Lawlor, D.A., and Selvin, E. (2010). Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: A collaborative meta-analysis of 102 prospective studies. Lancet, 375, 2215\u20132222.","DOI":"10.1016\/S0140-6736(10)60484-9"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1246","DOI":"10.4239\/wjd.v6.i13.1246","article-title":"Diabetes and cardiovascular disease: Epidemiology, biological mechanisms, treatment recommendations and future research","volume":"6","author":"Leon","year":"2015","journal-title":"World J. Diabetes"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"418","DOI":"10.1186\/s12933-025-02966-4","article-title":"Hunting for a coronary artery disease diagnosis in asymptomatic patients with diabetes mellitus: If, how and when","volume":"24","author":"Santilli","year":"2025","journal-title":"Cardiovasc. Diabetol."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"American Diabetes Association Professional Practice Committee (2024). 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes\u20142024. Diabetes Care, 47, S179\u2013S218.","DOI":"10.2337\/dc24-S010"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"255","DOI":"10.1093\/eurheartj\/ehz486","article-title":"2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD","volume":"41","author":"Cosentino","year":"2020","journal-title":"Eur. Heart J."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1007\/s40256-024-00630-y","article-title":"Aspirin for the primary prevention of cardiovascular diseases in patients with chronic kidney disease: An updated meta-analysis","volume":"24","author":"Bellos","year":"2024","journal-title":"Am. J. Cardiovasc. Drugs"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1953","DOI":"10.1093\/eurjpc\/zwab132","article-title":"Aspirin for the primary prevention of cardiovascular disease in individuals with chronic kidney disease: A systematic review and meta-analysis","volume":"28","author":"Pallikadavath","year":"2021","journal-title":"Eur. J. Prev. Cardiol."},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"(2024). Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int., 105, S117\u2013S314.","DOI":"10.1016\/j.kint.2023.10.018"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"920","DOI":"10.1001\/jama.2024.1215","article-title":"Aspirin for metabolic dysfunction\u2013associated steatotic liver disease without cirrhosis: A randomized clinical trial","volume":"331","author":"Simon","year":"2024","journal-title":"JAMA"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"508","DOI":"10.1001\/jama.2024.11617","article-title":"Low-dose aspirin and hepatic fat quantity in patients with MASLD","volume":"332","author":"Tu","year":"2024","journal-title":"JAMA"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"102065","DOI":"10.1016\/j.eclinm.2023.102065","article-title":"Daily aspirin associated with a reduced risk of hepatocellular carcinoma in patients with non-alcoholic fatty liver disease: A population-based cohort study","volume":"61","author":"Lee","year":"2023","journal-title":"eClinicalMedicine"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"845","DOI":"10.1038\/s41569-023-00892-0","article-title":"International Atherosclerosis Society guidance for implementing best practice in the care of familial hypercholesterolaemia","volume":"20","author":"Watts","year":"2023","journal-title":"Nat. Rev. Cardiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"619","DOI":"10.1111\/j.1365-2125.2011.03943.x","article-title":"Anti-platelet therapy: Cyclo-oxygenase inhibition and the use of aspirin with particular regard to dual anti-platelet therapy","volume":"72","author":"Warner","year":"2011","journal-title":"Br. J. Clin. Pharmacol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"357","DOI":"10.7326\/M18-2808","article-title":"Predicting bleeding risk to guide aspirin use for the primary prevention of cardiovascular disease: A cohort study","volume":"170","author":"Selak","year":"2019","journal-title":"Ann. Intern. Med."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"231","DOI":"10.1016\/S2468-1253(18)30037-2","article-title":"Effects of gastroprotectant drugs for the prevention and treatment of peptic ulcer disease and its complications: A meta-analysis of randomised trials","volume":"3","author":"Scally","year":"2018","journal-title":"Lancet Gastroenterol. Hepatol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1597","DOI":"10.1016\/S0140-6736(22)01843-8","article-title":"Helicobacter pylori eradication for primary prevention of peptic ulcer bleeding in older patients prescribed aspirin in primary care (HEAT): A randomised, double-blind, placebo-controlled trial","volume":"400","author":"Hawkey","year":"2022","journal-title":"Lancet"},{"key":"ref_37","unstructured":"Guirguis-Blake, J.M., Evans, C.V., Perdue, L.A., Bean, S.I., and Senger, C.A. (2022). Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: An Evidence Update for the U.S. Preventive Services Task Force Evidence Synthesis No. 211. AHRQ Publication No. 21-05283-EF-1."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/15\/5936\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T04:35:55Z","timestamp":1785472555000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/15\/5936"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,29]]},"references-count":37,"journal-issue":{"issue":"15","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["jcm15155936"],"URL":"https:\/\/doi.org\/10.3390\/jcm15155936","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,29]]}}}