Article    Table of Contents                    Abstract of this article Free    PDF of this article (PDFs free after 6 months)    Summary for Patients    Summary for Patients (PDF)    Figures/Tables List    Related articles in Annals    Articles citing this article  Services    Send comment/rapid response letter    Notify a friend about this article    Alert me when this article is cited    Add to Personal Archive    Download to Citation Manager    ACP Search                            Get Permissions  Google Scholar    Search for Related Content  PubMed    Related Articles in PubMed    PubMed Citation    PubMed

CLINICAL GUIDELINES

Aspirin for the Primary Prevention of Cardiovascular Events: Recommendation and Rationale

U.S. Preventive Services Task Force*

15 January 2002 | Volume 136 Issue 2 | Pages 157-160

This statement summarizes the recommendation of the third U.S. Preventive Services Task Force (USPSTF) for aspirin for the primary prevention of cardiovascular events, as well as the supporting scientific evidence. The complete information on which this statement is based, including evidence tables and references, can be found in a companion article in this issue. Copies of this document, the summary of the evidence, and the systematic evidence review can be obtained through the USPSTF Web site (http://www.ahrq.gov/clinic/uspstfix.htm) and in print through the Agency for Healthcare Research and Quality Publications Clearinghouse (800-358-9295).

*For a list of the members of the U.S. Preventive Services Task Force, see the Appendix.

Summary of the Recommendation

The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians discuss aspirin chemoprevention with adults who are at increased risk for coronary heart disease (see Clinical Considerations). Discussions with patients should address both the potential benefits and harms of aspirin therapy. This is a grade A recommendation. (See Appendix Table 1 for a description of the USPSTF classification of recommendations.)

View this table: [in this window] [in a new window]   Appendix Table 1. U.S. Preventive Services Task Force Grades and Recommendations

 
The USPSTF found good evidence that aspirin decreases the incidence of coronary heart disease in adults who are at increased risk for heart disease. It also found good evidence that aspirin increases the incidence of gastrointestinal bleeding and fair evidence that aspirin increases the incidence of hemorrhagic strokes. (See Appendix Table 2 for a description of the USPSTF classification of levels of evidence.) The USPSTF concluded that the balance of benefits and harms is most favorable in patients at high risk for coronary heart disease (those with a 5-year risk 3%) but is also influenced by patient preferences.

View this table: [in this window] [in a new window]   Appendix Table 2. U.S. Preventive Services Task Force Grades for Strength of Overall Evidence

 

Clinical Considerations

Decisions about aspirin therapy should take into account overall risk for coronary heart disease. Risk assessment should include asking about the presence and severity of the following risk factors: age, sex, diabetes, elevated total cholesterol levels, low levels of high-density lipoprotein cholesterol, elevated blood pressure, family history (in younger adults), and smoking. Tools that incorporate specific information on multiple risk factors provide more accurate estimation of cardiovascular risk than categorizations based simply on counting the numbers of risk factors (http://www.med-decisions.com) (1).

Men older than 40 years of age, postmenopausal women, and younger persons with risk factors for coronary heart disease (for example, hypertension, diabetes, or smoking) are at increased risk for heart disease and may wish to consider aspirin therapy. The Table shows how estimates of the type and magnitude of benefits and harms associated with aspirin therapy vary with an individual's underlying risk for coronary heart disease. Although balance of benefits and harms is most favorable in high-risk persons (those with a 5-year risk 3%), some persons at lower risk may consider the potential benefits of aspirin to outweigh the potential harms.

View this table: [in this window] [in a new window]   Table. Estimates of Benefits and Harms of Aspirin Given for 5 Years to 1000 Persons with Various Levels of Baseline Risk for Coronary Heart Disease

 

Discussions about aspirin therapy should focus on potential coronary heart disease benefits, such as prevention of myocardial infarction, and potential harms, such as gastrointestinal and intracranial bleeding. Discussions should take into account individual preferences and risk aversions concerning myocardial infarction, stroke, and gastrointestinal bleeding. Although the optimal timing and frequency of discussions related to aspirin therapy are unknown, reasonable options include every 5 years in middle-aged and older persons or when other cardiovascular risk factors are detected.

Most participants in the primary prevention trials of aspirin therapy have been men between 40 and 75 years of age. Current estimates of benefits and harms may not be as reliable for women and older men. Although older patients may derive greater benefits because they are at higher risk for coronary heart disease and stroke, their risk for bleeding may be higher. Uncontrolled hypertension may attenuate the benefits of aspirin in reducing coronary heart disease.

The optimum dose of aspirin for chemoprevention is not known. Primary and secondary prevention trials have demonstrated benefits with a variety of regimens, including 75 mg/d, 100 mg/d, and 325 mg every other day. Dosages of approximately 75 mg/d seem to be as effective as higher doses; whether dosages below 75 mg/d are effective has not been established. Enteric-coated or buffered preparations do not clearly reduce adverse gastrointestinal effects of aspirin. Uncontrolled hypertension and concomitant use of other nonsteroidal anti-inflammatory agents or anticoagulants increase risk for serious bleeding.

Scientific Evidence

Epidemiology and Clinical Background

Cardiovascular disease, including ischemic coronary heart disease, stroke, and peripheral vascular disease, is the leading cause of death in the United States (3). Yearly, over 1 million Americans experience new or recurrent myocardial infarction or fatal coronary heart disease. Most events occur in older persons and those with recognized risk factors for cardiovascular disease, including high cholesterol level, high blood pressure, diabetes, or a history of smoking. The early-documented and clear success of aspirin in preventing further clinical disease in some patients with known heart disease (secondary prevention) raised interest in aspirin as a potential primary preventive intervention in men and women without known heart disease (4). Two early randomized trials of aspirin had conflicting results, however, and lacked sufficient power to estimate major harms, such as gastrointestinal bleeding and hemorrhagic stroke (5, 6). Thus, the role of aspirin in primary prevention has remained controversial. The new USPSTF recommendation incorporates additional data from three recent trials and provides more reliable estimates of both benefits and harms of aspirin in patients without known heart disease.

Efficacy of Chemoprevention

Five trials have examined the effects of daily or every-other-day aspirin for the primary prevention of cardiovascular events over periods of 4 to 7 years (7-9). Most participants were men older than 50 years of age. Meta-analysis of pooled data from all of the studies showed that aspirin therapy reduced the risk for coronary heart disease by 28% (summary odds ratio, 0.72 [95% CI, 0.60 to 0.87]). Summary estimates showed no significant effects of aspirin on total mortality (odds ratio, 0.93 [CI, 0.84 to 1.02]) and stroke (odds ratio, 1.02 [CI, 0.85 to 1.23]).

Harms of Chemoprevention

These five primary prevention trials, and a larger number of randomized, controlled trials of secondary prevention that enrolled patients with heart disease or stroke, demonstrate that aspirin increases rates of gastrointestinal bleeding. Estimated rates of major gastrointestinal bleeding episodes are approximately 2 to 4 per 1000 middle-aged persons (4 to 12 per 1000 for older persons) given aspirin for 5 years (10-12).

These controlled trials in primary and secondary prevention settings also suggest that aspirin increases rates of hemorrhagic strokes by a small amount (0 to 2 per 1000 persons given aspirin for 5 years) (5-7). Such estimates are less reliable than those of gastrointestinal bleeding because few strokes were reported in the trials.

Recommendations of Other Organizations

In 1994, the Canadian Task Force on Preventive Health Care concluded that the evidence was not strong enough to recommend for or against use of aspirin for primary prevention of heart disease in men or women and recommended that physicians and patients balance the reduced rate of nonfatal myocardial infarction against potential adverse effects (13). In 2000, the American Diabetes Association recommended that clinicians consider aspirin for primary prevention of heart disease in diabetic patients who are older than 30 years of age or have risk factors for cardiovascular disease and no contraindications to aspirin therapy (14). In 1997, the American Heart Association concluded that aspirin may be warranted for patients at high risk for myocardial infarction but that health care providers must consider a patient's particular cardiovascular risk profile, the demonstrated benefits of aspirin on reducing risk for a first myocardial infarction, and known and unknown side effects of aspirin (15). In 1998, the European Society of Cardiology recommended low-dose aspirin (75 mg) for patients with well-controlled hypertension and men at "particularly" high risk for coronary heart disease, but not for all persons at high risk (16).

Appendix

Members of the U.S. Preventive Services Task Force are Alfred O. Berg, MD, MPH, Chair (University of Washington, Seattle, Washington); Janet D. Allan, PhD, RN, CS, Vice-Chair (University of Texas Health Science Center, San Antonio, Texas); Paul S. Frame, MD (Tri-County Family Medicine, Cohocton, New York, and University of Rochester, Rochester, New York); Charles J. Homer, MD, MPH (National Initiative for Children's Healthcare Quality, Boston, Massachusetts); Mark S. Johnson, MD, MPH (University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, New Jersey); Jonathan D. Klein, MD, MPH (University of Rochester School of Medicine, Rochester, New York); Tracy A. Lieu, MD, MPH (Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massachusetts); Cynthia D. Mulrow, MD, MSc (University of Texas Health Science Center at San Antonio, Audie L. Murphy Memorial Veterans Hospital, San Antonio, Texas); C. Tracy Orleans, PhD (The Robert Wood Johnson Foundation, Princeton, New Jersey); Jeffrey F. Peipert, MD, MPH (Women and Infants' Hospital, Providence, Rhode Island); Nola J. Pender, PhD, RN (University of Michigan, Ann Arbor, Michigan); Albert L. Siu, MD, MSPH (Mount Sinai School of Medicine and The Mount Sinai Medical Center, New York, New York); Steven M. Teutsch, MD, MPH (Merck & Co., Inc., West Point, Pennsylvania); Carolyn Westhoff, MD, MSc (Columbia University College of Physicians and Surgeons, New York, New York); and Steven H. Woolf, MD, MPH (Medical College of Virginia, Virginia Commonwealth University, Fairfax, Virginia).

Author and Article Information

Top Author & Article Info References

From the U.S. Preventive Services Task Force, Agency for Healthcare Research and Quality, Rockville, Maryland.

Requests for Single Reprints: Reprints are available from the USPSTF Web site (http://www.ahrq.gov/clinic/uspstfix.htm) and in print through the Agency for Healthcare Research and Quality Publications Clearinghouse (800-358-9295).

References

Top Author & Article Info References

1. Wilson PW, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories Circulation. 1998;97:1837-47. [PMID: 9603539].[Abstract/Free Full Text]

2. Hayden M, Pignone M, Phillips C, Mulrow C. Aspirin for the primary prevention of cardiovascular events: a summary of the evidence for the U.S. Preventive Services Task Force Ann Intern Med. 2002;136:161-71.[Abstract/Free Full Text]

3. Hoyert DL, Kochanek KD, Murphy SL. Deaths: Final Data for 1997. National Vital Statistics Reports. Hyattsville, MD: National Center for Health Statistics; 1999.

4. Collaborative overview of randomised trials of antiplatelet therapy—I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists' Collaboration BMJ. 1994;308:81-106. [PMID: 8298418].[Abstract/Free Full Text]

5. Final report on the aspirin component of the ongoing Physicians' Health Study Steering Committee of the Physicians' Health Study Research Group N Engl J Med. 1989;321:129-35. [PMID: 2664509].[Abstract]

6. Peto R, Gray R, Collins R, Wheatley K, Hennekens C, Jamrozik K, et al. Randomised trial of prophylactic daily aspirin in British male doctors Br Med J (Clin Res Ed). 1988;296:313-6. [PMID: 3125882].

7. Thrombosis prevention trial: randomised trial of low-intensity oral anticoagulation with warfarin and low-dose aspirin in the primary prevention of ischaemic heart disease in men at increased risk. The Medical Research Council's General Practice Research Framework Lancet. 1998;351:233-41. [PMID: 9457092].[Medline]

8. Hansson L, Zanchetti A, Carruthers SG, Dahlöf B, Elmfeldt D, Julius S, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group Lancet. 1998;351:1755-62. [PMID: 9635947].[Medline]

9. Low-dose aspirin and vitamin E in people at cardiovascular risk: a randomised trial in general practice. Collaborative Group of the Primary Prevention Project Lancet. 2001;357:89-95. [PMID: 11197445].[Medline]

10. Roderick PJ, Wilkes HC, Meade TW. The gastrointestinal toxicity of aspirin: an overview of randomised controlled trials Br J Clin Pharmacol. 1993;35:219-26. [PMID: 8471398].[Medline]

11. Dickinson JP, Prentice CR. Aspirin: benefit and risk in thromboprophylaxis QJM. 1998;91:523-38. [PMID: 9893756].[Abstract/Free Full Text]

12. Stalnikowicz-Darvasi R. Gastrointestinal bleeding during low-dose aspirin administration for prevention of arterial occlusive events. A critical analysis J Clin Gastroenterol. 1995;21:13-6. [PMID: 7560825].[Medline]

13. Anderson G. Acetylsalicylic acid and the primary prevention of cardiovascular disease. In: Canadian Task Force on the Periodic Health Examination. Ottawa, Canada: Health Canada; 1994:680-90.

14. Aspirin therapy in diabetes. American Diabetes Association. Diabetes Care. 2001; 24(Suppl 10):S62-S63. Available at http://www.diabetes.org/clinicalrecommendations/Supplement101/S62.htm.

15. Hennekens CH, Dyken ML, Fuster V. Aspirin as a therapeutic agent in cardiovascular disease: a statement for healthcare professionals from the American Heart Association Circulation. 1997;96:2751-3. [PMID: 9355934].[Free Full Text]

16. Prevention of coronary heart disease in clinical practice. Recommendations of the Second Joint Task Force of European and other Societies on coronary prevention Eur Heart J. 1998;19:1434-503. [PMID: 9820987].[Free Full Text]

Related articles in Annals:

Editorials
Disease Prevention Guidelines from the U.S. Preventive Services Task Force
Harold C. Sox

Annals 2002 136: 155-156. [Full Text]  

Clinical Guidelines
Aspirin for the Primary Prevention of Cardiovascular Events: A Summary of the Evidence for the U.S. Preventive Services Task Force
Michael Hayden, Michael Pignone, Christopher Phillips, AND Cynthia Mulrow

Annals 2002 136: 161-172. [ABSTRACT][SUMMARY][Full Text]  

Summaries for Patients
Aspirin for the Prevention of Heart Attacks in People without Previous Cardiovascular Events: Recommendations from the United States Preventive Services Task Force

Annals 2002 136: I55. [Full Text]  

Letters
Aspirin for the Primary Prevention of Cardiovascular Events
George E. McLaughlin

Annals 2002 137: 622-623. [Full Text]  

This article has been cited by other articles:

				I. B. Hirsch, S. E. Inzucchi, and M. S. Kirkman Standards of Medical Care in Diabetes--2008: Response to Dora, Kramer, and Canani Diabetes Care, May 1, 2008; 31(5): e45 - e45. [Full Text] [PDF]

				C. Patrono and B. Rocca Aspirin: Promise and Resistance in the New Millennium Arterioscler. Thromb. Vasc. Biol., March 1, 2008; 28(3): s25 - s32. [Abstract] [Full Text] [PDF]

				American Diabetes Association Standards of Medical Care in Diabetes--2008 Diabetes Care, January 1, 2008; 31(Supplement_1): S12 - S54. [Full Text] [PDF]

				R. J. Glynn, P. M Ridker, S. Z. Goldhaber, and J. E. Buring Effect of Low-Dose Aspirin on the Occurrence of Venous Thromboembolism: A Randomized Trial Ann Intern Med, October 16, 2007; 147(8): 525 - 533. [Abstract] [Full Text] [PDF]

				J. L. Anderson, C. D. Adams, E. M. Antman, C. R. Bridges, R. M. Califf, D. E. Casey Jr, W. E. Chavey II, F. M. Fesmire, J. S. Hochman, T. N. Levin, et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine J. Am. Coll. Cardiol., August 14, 2007; 50(7): e1 - e157. [Full Text] [PDF]

				S. Ardoin, C. Sandborg, and L. Schanberg Review: Management of dyslipidemia in children and adolescents with systemic lupus erythematosus Lupus, August 1, 2007; 16(8): 618 - 626. [Abstract] [PDF]

				E. M. Hylek, C. Evans-Molina, C. Shea, L. E. Henault, and S. Regan Major Hemorrhage and Tolerability of Warfarin in the First Year of Therapy Among Elderly Patients With Atrial Fibrillation Circulation, May 29, 2007; 115(21): 2689 - 2696. [Abstract] [Full Text] [PDF]

				J. T. Cohen and P. J. Neumann What's More Dangerous, Your Aspirin Or Your Car? Thinking Rationally About Drug Risks (And Benefits) Health Aff., May 1, 2007; 26(3): 636 - 646. [Abstract] [Full Text] [PDF]

				E. J. Jacobs, M. J. Thun, E. B. Bain, C. Rodriguez, S. J. Henley, and E. E. Calle A Large Cohort Study of Long-Term Daily Use of Adult-Strength Aspirin and Cancer Incidence J Natl Cancer Inst, April 18, 2007; 99(8): 608 - 615. [Abstract] [Full Text] [PDF]

				J. M. Rippe, T. J. Angelopoulos, and L. Zukley Lifestyle Medicine Strategies for Risk Factor Reduction, Prevention, and Treatment of Coronary Heart Disease: Part II American Journal of Lifestyle Medicine, March 1, 2007; 1(2): 79 - 90. [Abstract] [PDF]

				American Diabetes Association Standards of Medical Care in Diabetes--2007 Diabetes Care, January 1, 2007; 30(suppl_1): S4 - S41. [Full Text] [PDF]

				T. D. Sequist, R. Marshall, S. Lampert, E. J. Buechler, and T. H. Lee Missed opportunities in the primary care management of early acute ischemic heart disease. Arch Intern Med, November 13, 2006; 166(20): 2237 - 2243. [Abstract] [Full Text] [PDF]

				N. O'Kennedy, L. Crosbie, S. Whelan, V. Luther, G. Horgan, J. I Broom, D. J Webb, and A. K Duttaroy Effects of tomato extract on platelet function: a double-blinded crossover study in healthy humans. Am. J. Clinical Nutrition, September 1, 2006; 84(3): 561 - 569. [Abstract] [Full Text] [PDF]

				C. H. Hennekens, O. Sechenova, D. Hollar, and V. L. Serebruany Dose of Aspirin in the Treatment and Prevention of Cardiovascular Disease: Current and Future Directions. Journal of Cardiovascular Pharmacology and Therapeutics, September 1, 2006; 11(3): 170 - 176. [Abstract] [PDF]

				C. Hur, A. T Chan, A. C Tramontano, and G S. Gazelle Coxibs Versus Combination NSAID and PPI Therapy for Chronic Pain: An Exploration of the Risks, Benefits, and Costs Ann. Pharmacother., June 1, 2006; 40(6): 1052 - 1063. [Abstract] [Full Text] [PDF]

				M. Pignone, S. Earnshaw, J. A. Tice, and M. J. Pletcher Aspirin, statins, or both drugs for the primary prevention of coronary heart disease events in men: a cost-utility analysis. Ann Intern Med, March 7, 2006; 144(5): 326 - 336. [Abstract] [Full Text] [PDF]

				J. S. Berger, M. C. Roncaglioni, F. Avanzini, I. Pangrazzi, G. Tognoni, and D. L. Brown Aspirin for the Primary Prevention of Cardiovascular Events in Women and Men: A Sex-Specific Meta-analysis of Randomized Controlled Trials JAMA, January 18, 2006; 295(3): 306 - 313. [Abstract] [Full Text] [PDF]

				D. L. Bhatt, P. G. Steg, E. M. Ohman, A. T. Hirsch, Y. Ikeda, J.-L. Mas, S. Goto, C.-S. Liau, A. J. Richard, J. Rother, et al. International Prevalence, Recognition, and Treatment of Cardiovascular Risk Factors in Outpatients With Atherothrombosis JAMA, January 11, 2006; 295(2): 180 - 189. [Abstract] [Full Text] [PDF]

				A Blann Antiplatelet therapy and the vascular tree Heart, January 1, 2006; 92(1): 3 - 4. [Full Text] [PDF]

				American Diabetes Association Standards of Medical Care in Diabetes-2006 Diabetes Care, January 1, 2006; 29(suppl_1): S4 - S42. [Full Text] [PDF]

				Prepared by: British Cardiac Society, British Hype JBS 2: Joint British Societies' guidelines on prevention of cardiovascular disease in clinical practice Heart, December 1, 2005; 91(suppl_5): v1 - v52. [Full Text] [PDF]

				F. C. Hall and N. Dalbeth Disease modification and cardiovascular risk reduction: two sides of the same coin? Rheumatology, December 1, 2005; 44(12): 1473 - 1482. [Abstract] [Full Text] [PDF]

				J. W Eikelboom Warfarin was not more effective than aspirin and increased adverse events in symptomatic intracranial arterial stenosis Evid. Based Med., October 1, 2005; 10(5): 136 - 136. [Full Text] [PDF]

				J. W Eikelboom Low dose aspirin lowered stroke risk but not risks of MI or cardiovascular deaths in women Evid. Based Med., October 1, 2005; 10(5): 137 - 137. [Full Text] [PDF]

				S. Chen Low-dose aspirin: Major benefits, minimal cost Am. J. Health Syst. Pharm., July 1, 2005; 62(13): 1357 - 1357. [Full Text] [PDF]

				J. J. Saseen ASHP Therapeutic Position Statement on the Daily Use of Aspirin for Preventing Cardiovascular Events Am. J. Health Syst. Pharm., July 1, 2005; 62(13): 1398 - 1405. [Full Text] [PDF]

				P. M Ridker, N. R. Cook, I-M. Lee, D. Gordon, J. M. Gaziano, J. E. Manson, C. H. Hennekens, and J. E. Buring A Randomized Trial of Low-Dose Aspirin in the Primary Prevention of Cardiovascular Disease in Women N. Engl. J. Med., March 31, 2005; 352(13): 1293 - 1304. [Abstract] [Full Text] [PDF]

				C. Hur, L. S Simon, and G S. Gazelle Analysis of Aspirin-Associated Risks in Healthy Individuals Ann. Pharmacother., January 1, 2005; 39(1): 51 - 57. [Abstract] [Full Text] [PDF]

				American Diabetes Association Standards of Medical Care in Diabetes Diabetes Care, January 1, 2005; 28(suppl_1): S4 - S36. [Full Text] [PDF]

				S. D. Persell and D. W. Baker Aspirin Use Among Adults With Diabetes: Recent Trends and Emerging Sex Disparities Arch Intern Med, December 13, 2004; 164(22): 2492 - 2499. [Abstract] [Full Text] [PDF]

				C. Patrono, B. Coller, G. A. FitzGerald, J. Hirsh, and G. Roth Platelet-Active Drugs: The Relationships Among Dose, Effectiveness, and Side Effects: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest, September 1, 2004; 126(3_suppl): 234S - 264S. [Abstract] [Full Text] [PDF]

				E. R. Cox, M. Frisse, A. Behm, and K. A. Fairman Over-the-Counter Pain Reliever and Aspirin Use Within a Sample of Long-term Cyclooxygenase 2 Users Arch Intern Med, June 14, 2004; 164(11): 1243 - 1246. [Full Text] [PDF]

				P. A. Howard and P. Delafontaine Nonsteroidal Anti-Inflammatory drugs and cardiovascular risk J. Am. Coll. Cardiol., February 18, 2004; 43(4): 519 - 525. [Abstract] [Full Text] [PDF]

				C. Hur, N. S. Nishioka, and G. S. Gazelle Cost-Effectiveness of Aspirin Chemoprevention for Barrett's Esophagus J Natl Cancer Inst, February 18, 2004; 96(4): 316 - 325. [Abstract] [Full Text] [PDF]

				A. T. Chan, E. L. Giovannucci, E. S. Schernhammer, G. A. Colditz, D. J. Hunter, W. C. Willett, and C. S. Fuchs A Prospective Study of Aspirin Use and the Risk for Colorectal Adenoma Ann Intern Med, February 3, 2004; 140(3): 157 - 166. [Abstract] [Full Text] [PDF]

				Standards of Medical Care in Diabetes Diabetes Care, January 1, 2004; 27(90001): s15 - 35. [Full Text] [PDF]

				Aspirin Therapy in Diabetes Diabetes Care, January 1, 2004; 27(90001): s72 - 73. [Full Text] [PDF]

				M. Sacco, F. Pellegrini, M. C. Roncaglioni, F. Avanzini, G. Tognoni, and A. Nicolucci Primary Prevention of Cardiovascular Events With Low-Dose Aspirin and Vitamin E in Type 2 Diabetic Patients: Results of the Primary Prevention Project (PPP) trial Diabetes Care, December 1, 2003; 26(12): 3264 - 3272. [Abstract] [Full Text] [PDF]

				J. A. Colwell Aspirin for Primary Prevention of Cardiovascular Events in Diabetes Diabetes Care, December 1, 2003; 26(12): 3349 - 3350. [Full Text] [PDF]

				J. E Shaw Chemoprophylaxis with aspirin (81 mg daily) reduced the incidence of colorectal adenomas in people at risk Evid. Based Med., November 1, 2003; 8(6): 178 - 179. [Full Text] [PDF]

				J. E Shaw Aspirin prevented new colorectal adenomas in patients with previous colorectal cancer Evid. Based Med., November 1, 2003; 8(6): 179 - 179. [Full Text] [PDF]

				R. S. Eidelman, P. R. Hebert, S. M. Weisman, and C. H. Hennekens An Update on Aspirin in the Primary Prevention of Cardiovascular Disease Arch Intern Med, September 22, 2003; 163(17): 2006 - 2010. [Abstract] [Full Text] [PDF]

				J. G. Canto and A. E. Iskandrian Major Risk Factors for Cardiovascular Disease: Debunking the "Only 50%" Myth JAMA, August 20, 2003; 290(7): 947 - 949. [Full Text] [PDF]

				B. M.R. Spiegel, L. Targownik, G. S. Dulai, and I. M. Gralnek The Cost-Effectiveness of Cyclooxygenase-2 Selective Inhibitors in the Management of Chronic Arthritis Ann Intern Med, May 20, 2003; 138(10): 795 - 806. [Abstract] [Full Text] [PDF]

				K. Przyklenk and G. Heusch Late preconditioning against myocardial stunning: Does aspirin close the "second window" of endogenous cardioprotection? J. Am. Coll. Cardiol., April 2, 2003; 41(7): 1195 - 1197. [Full Text] [PDF]