The Lancet has recently debated the traditional approach to stroke prevention, which requires screening and stratification for risk of disease, is complex, expensive, and only modestly successful (Feigin et al, 2013). New strategies for primary and secondary prevention of stroke and cardiovascular disease, such as an effective polypill and/or aspirin, require further discussion, especially from a public-health perspective. Why?
Polypill
- First, no evidence is available for the effectiveness of the polypill in people at low risk of cardiovascular disease; hence, polypill use in such people is not scientifically grounded. In an individual-participant data
meta analysis of three large randomised controlled trials, the mean 10-year risk of cardiovascular disease was 17·7%, suggesting that participants were largely at intermediate risk. - Second, most of the participants included in the three trials were 45 years or older (mean 63·0 years) and, as noted by Yusuf and Pinto in The Lancet, the preventive effect was more pronounced in people aged 55 years or older.
- Third, Yusuf and Pinto have suggested that aspirin should be one of the components of the polypill for both primary and secondary stroke prevention. However, a large randomised controlled trial of primary cardiovascular prevention was stopped prematurely due to the significant (38%) increase of major bleeding complications in the aspirin group, compared with placebo.
Other concerns with the polypill include its side-effects and drug interactions, potential overtreatment, cost (particularly in low-income countries), and the potential requirement of laboratory tests before the initiation of treatment.
Aspirin
CV disease
Therefore, the guidelines of the American Heart Association do not recommend routine use of aspirin for primary prevention of cardiovascular disease, especially in adults older than 70 years and adults of any age who are at increased risk of bleeding. There is also a low level of evidence to recommend the use of low-dose aspirin (ie, 75–100 mg per day taken orally) in adults 40–70 years of age who are at high risk and are free from cardiovascular disease.
Stroke
Aspirin for secondary stroke prevention should be limited to people after an ischaemic stroke or transient ischaemic attack, and special considerations are required for patients who are taking oral anticoagulants or other antiplatelet agents or who have had a haemorrhagic stroke.
