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Aspirin for Primary Prevention of Cardiovascular Events in People With Diabetes. A Position Statement of the American Diabetes Association, a Scientific Statement of the American Heart Association, and an Expert Consensus Document of the American College of Cardiology Foundation
2010 circ.ahajournals.(pdf)

How Can We Integrate Potential Benefits and Harms of Aspirin to Determine Which Patients With Diabetes Should or Should not Receive Aspirin for the Primary Prevention of CV Events?

On the basis of the currently available evidence, aspirin appears to have a modest effect on cardiovascular events (RR reduction of 10%), with the absolute decrease in events depending on the underlying CVD risk (those with higher baseline risk should have greater absolute benefit).The main adverse effects appear to be an increased risk of gastrointestinal bleeding.The excess risk may be as high as 1–5 per 1000 per year in real-world settings.In adults with CVD risk greater than 1% per year, the number of CVD events prevented will be similar to or greater than the number of bleeding events induced, although the events considered (MI, stroke, and gastrointestinal bleeding) do not have equal effects on long-term health.34 We have developed recommendations based on these data.

The effect of aspirin for primary prevention of CVD events in adults with diabetes is currently unclear.Trials to date have reached mixed results, but overall suggest that aspirin modestly reduces risk of cardiovascular events.More research is needed to better define the specific effects of aspirin in diabetes, including any sex-specific differences.

For now, we recommend the following:
●Low-dose (75–162 mg/d) aspirin use for prevention is reasonable for adults with diabetes and no previous history of vascular disease who are at increased CVD risk (10 year risk of CVD events over 10%) and who are not at increased risk for bleeding (based on a history of previous gastrointestinal bleeding or peptic ulcer disease or concurrent use of other medications that increase bleeding risk, such as NSAIDS or warfarin).Those adults with diabetes at increased CVD risk include most men over age 50 years and women over age 60 years who have 1 or more of the following additional major risk factors: smoking, hypertension, dyslipidemia, family history of premature CVD, and albuminuria.(ACCF/AHA Class IIa, Level of Evidence: B) (ADA Level of Evidence: C)

● Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk (men under age 50 years and women under 60 years with no major additional CVD risk factors; 10-year CVD risk under 5%) as the potential adverse effects from bleeding offset the potential benefits.
(ACCF/AHA Class III, Level of Evidence: C) (ADA Level of Evidence: C)

● Low-dose (75–162 mg/d) aspirin use for prevention might be considered for those with diabetes at intermediate CVD risk (younger patients with 1 or more risk factors, or older patients with no risk factors, or patients with 10-year CVD risk of 5–10%) until further research is available.(ACCF/AHA Class IIb, Level of Evidence: C) (ADA Level of Evidence: E)


Cardiovascular Risk Assessment
These recommendations depend on the accurate assessment of cardiovascular risk as part of the decision-making process about aspirin use.All patients with diabetes do not have high cardiovascular risk, despite the assumptions of some previous guidelines. We have provided treatment guidance based on either a combination of age, sex, and other risk factors or on an estimate of absolute cardiovascular risk.An important consideration is that patients may acquire additional risk factors over time, which would necessitate a reassessment of their overall risk profile.


The absolute risk-based recommendations require the use of a risk prediction tool.
Tools that can be used in patients with diabetes are available from several sources, for example: 1.
UKPDS Risk Engine: http://www.dtu.ox.ac.uk/riskengine/ index.php 2.
ARIC CHD Risk Calculator: http://www.aricnews.net/ riskcalc/html/RC1.html 3.
American Diabetes Association Risk Assessment Tool, Diabetes PHD: http://www.diabetes.org/phd