Snehal Bhatt, PharmD, AACC, BCPS, FASHP, professor of pharmacy practice at Massachusetts College of Pharmacy and Health Sciences, explores the varied and evolving role of aspirin in the management of cardiovascular diseases. He explains that aspirin's strongest indication is in cryptogenic strokes and large arterial thrombosis, while in cardioembolic strokes, anticoagulation is preferred over antiplatelet therapy like aspirin. In peripheral arterial disease, aspirin remains a recommended option, including in combination with low-dose rivaroxaban. However, in chronic coronary disease, recent studies suggest that discontinuing aspirin in favor of P2Y12 inhibitor monotherapy may offer a better safety profile without compromising efficacy.
**Pharmacy Times:** What is the current role in aspirin for stroke, peripheral arterial disease, and chronic coronary disease?
**Snehal Bhatt:** That's a really good question. It really varies across that spectrum, as we try to talk about cardiovascular disease is pretty broad, so we have everything from your typical myocardial infarction, chronic coronary disease through into things you mentioned, like peripheral arterial disease and stroke. The role of aspirin is really different based on any of those etiologies, right? So the strongest role for aspirin is definitely in the cryptogenic stroke rate or the large Arterial thrombosis types of strokes. Strokes that are thought to be due to cardioembolic causes. As we presented, there's a number of studies that validated anticoagulation therapy as being superior to antiplatelet therapy, which included aspirin. So in cardioembolic strokes, there really isn't a role for aspirin or any antiplatelet therapy. For the other types of strokes, there's a very strong role for aspirin as a part either of short course, of combined dual antiplatelet therapy, or aspirin monotherapy. Within peripheral arterial disease, aspirin is still a class 1a recommendation for primary prevention, and as the disease progresses, there is a role for aspirin in combination therapy, most recently with very low-dose rivaroxaban, which is FDA approved for peripheral arterial disease patients, either with or without, revascularization. The chronic coronary disease part is a really fascinating story. Historically, aspirin has been used as the sole antiplatelet agent. As we deescalate from dual antiplatelet therapy to single antiplatelet therapy. That's now coming into question a lot more and a lot of recent studies have suggested that when we deescalate from dual antiplatelet therapy rather than dropping the P2Y12 inhibitor there appears to be a number of data that suggests that there's more safety without lack of efficacy by actually discontinuing aspirin and continuing P2Y12 inhibitor monotherapy.
**Pharmacy Times:** How does the risk of bleeding vary between different populations, and how does aspirin help manage this?
**Bhatt:** Having patient specific awareness of their disease and any other comorbidities that can enhance the risk of bleeding is really important for us as pharmacists because aspirin does have bleeding risk. It's just unavoidable, and so aspirin doesn't necessarily help with this particular aspect, but knowing how to safely and effectively use aspirin and when to safely discontinue aspirin for patients who are at high bleed risk is really the more recent focus.
**Pharmacy Times:** What are the benefits of using aspirin, and are there any limitations of the therapy?
**Bhatt:** The benefits historically have been very strong because we had no other antiplatelet agent. So aspirin has been a workhorse. One could argue that at one time, aspirin was really a life saving medication. As we continue to evolve in our management of the entire spectrum of cardiovascular disease, we're now getting a lot more thoughtful with regards to the true risk benefit ratios of aspirin, just because it was used as default is we had no other options, doesn't mean that's the best in 2024 and 2025.
**Pharmacy Times:** How can pharmacists address patient concerns and manage potential adverse events?
**Bhatt:** So that's a really good question, and that whole area continues to evolve. We do know that there is a protection with antiplatelet therapy as part of secondary prevention. Historically, that's always been aspirin. More recent data has and more recent guidelines have suggested that P2Y12 inhibitor monotherapy may strike a better balance between still protecting patients from future cardiovascular events while having slightly less bleeding rates compared to aspirin-based therapy.