In Reply: We appreciate Dr Colwell's comments
on our work. We agree with Dr Boissel's1
editorial, that each individual patient should be evaluated regarding his
or her risk and potential benefit from long-term aspirin therapy.Our meta-analysis
has demonstrated that aspirin therapy reduces risk of myocardial infarction
and ischemic stroke, but increases risk of hemorrhagic stroke. In patients
with prior cardiovascular disease, including myocardial infarction, unstable
angina, chronic stable angina, ischemic stroke, and transient ischemic attacks,
the benefits of aspirin use outweigh the potential for adverse effects, and
aspirin therapy should be recommended for all such patients.2
However, in patients without prior cardiovascular disease, the decision to
start aspirin therapy should be individualized based on the risk-benefit ratio.
Patients with diabetes are at increased risk of cardiovascular disease, mainly
myocardial infarction. Therefore, the ADA has wisely recommended aspirin therapy
as a primary prevention strategy in diabetic patients with additional risk
factors for cardiovascular disease.3 Because
most of the trials included in our meta-analysis were not conducted in diabetic
patients, the risk of hemorrhagic stroke related to aspirin therapy in this
population could not be estimated. However, based on the high absolute risk
of myocardial infarction and ischemic stroke in diabetic patients, the benefit
should outweigh the risk.