Aspirin at 120: Retiring, recombining, or repurposing?

During the past 20 years, we have witnessed the following trends in aspirin usage: (i) a "dropping" trend, characterized by the early discontinuation of low-dose aspirin from dual antiplatelet therapy or triple antithrombotic therapy (oral anticoagulation plus dual antiplatelet therapy in patients with atrial fibrillation) following an acute coronary syndrome or after percutaneous coronary intervention; (ii) a "combinatorial" trend, featuring the addition of a lower dose of a P2Y12 inhibitor or direct oral anticoagulant drug to low-dose aspirin for the long-term treatment of stable patients with atherosclerotic cardiovascular disease; and (iii) a "repurposing" trend, characterized by growing interest in the oncologic community to assess the chemopreventive effect of aspirin against certain types of cancers (particularly of the gastrointestinal tract), both as primary prevention and adjuvant therapy. The aim of this review is to present the mechanistic rationale underlying these trends, discuss the design and findings of trials testing novel treatments or new therapeutic applications of aspirin, and report on the ISTH Congress results on this topic.