Interview with PD Dr. med. Caroline Kleinecke, cardiologist

The key points at a glance

  • In secondary prevention after a heart attack, stroke or stent implantation, aspirin or clopidogrel remains a central component of treatment.
  • Aspirin is no longer routinely recommended in primary prevention today.
  • The potential benefit must be weighed against the individual bleeding risk.
  • Current guidelines recommend an individualised decision in selected high-risk patients.
  • The most effective preventive measures remain LDL cholesterol lowering, blood pressure control, stopping smoking, exercise and weight reduction.
  • In secondary prevention after a heart attack, stroke or stent implantation, aspirin or clopidogrel remains a central component of treatment.

Dr. Kleinecke, aspirin has been regarded as "heart protection" for decades. Does that still hold true today?

Yes, although one must now distinguish very clearly between primary and secondary prevention. In secondary prevention, aspirin, or clopidogrel in certain situations, remains one of the most important treatments in modern cardiology. In coronary heart disease and after a heart attack, stroke or stent implantation, antiplatelet therapy clearly reduces the risk of further cardiovascular events and improves the prognosis. The situation is different in primary prevention, meaning people with no known cardiovascular disease.

Why is aspirin viewed more critically in primary prevention today?

The reason is the comparatively small absolute risk reduction alongside an existing bleeding risk. Aspirin can slightly reduce heart attacks and ischaemic strokes in certain risk groups, but at the same time it increases the risk of relevant bleeding complications.

Which studies have shaped this development in particular?

Above all the 2018 ARRIVE, ASPREE and ASCEND trials. Overall, these large randomised trials could not demonstrate a convincing net clinical benefit of routine aspirin therapy in primary prevention.

Does that mean aspirin is no longer recommended in primary prevention at all today?

No. The decision must be made individually. Current European guidelines do not recommend routine aspirin therapy in people at low or moderate cardiovascular risk. In selected high-risk patients with a low bleeding risk, treatment can be discussed in individual cases.

Which factors play a role in this decision?

We always look at the overall risk. This includes age, blood pressure, LDL cholesterol, diabetes mellitus, smoking, kidney function, family history and the individual bleeding risk.

Many patients today are given aspirin once coronary calcium has been detected. Does that make sense?

Not automatically. The detection of coronary calcium or non-obstructive coronary sclerosis does not necessarily mean that aspirin is required. Consistent treatment of risk factors is often far more important. Effective LDL cholesterol lowering in particular has a much stronger influence on long-term risk.

Which preventive measures are especially important today?

Evidence is strongest for stopping smoking, regular physical activity, a Mediterranean diet, consistent blood pressure control, effective LDL cholesterol lowering, optimal diabetes control and weight reduction.

Your personal conclusion?

In primary prevention, aspirin is no longer a general standard therapy today. What matters is an individual risk-benefit assessment. At the same time, antiplatelet therapy with aspirin or clopidogrel remains a central pillar of modern cardiology in secondary prevention.