Aspirin remains one of medicine's most fascinating paradoxes.
It is lifesaving in secondary prevention after myocardial infarction and ischemic stroke, and remains a cornerstone of acute coronary syndrome management.
In primary prevention, however, routine use has largely fallen out of favor because modest cardiovascular benefit is often offset by GI and intracranial bleeding. Patient selection is everything.
The oncology story is becoming more compelling. Large cohort studies and recent meta analyses suggest lower colorectal cancer incidence, reduced metastatic spread, and lower cancer mortality, likely through platelet inhibition, COX-1/COX-2 modulation, and improved immune surveillance. The signal is strongest for colorectal cancer, but causality for routine prevention remains unproven. (ScienceDirect)
For athletes, the evidence is surprisingly reassuring. There is no convincing human evidence that low dose aspirin (75 to 100 mg/day) reduces muscle hypertrophy, strength, or recovery. Concerns about impaired adaptation originate mainly from higher dose NSAIDs, not cardioprotective aspirin doses. Bleeding risk, however, may become more relevant in contact sports and endurance events. (JAMA Network)
The real question is no longer "Is aspirin good or bad?" but can biomarkers identify those who gain meaningful anticancer and cardiovascular benefit while avoiding unnecessary bleeding?
Sources: NEJM, JAMA, JAMA Oncology, Journal of the American College of Cardiology (JACC), Public Health (2025 meta-analysis), USPSTF Evidence Review.