Background The use of aspirin in the primary prevention of cardiovascular events remains controversial. We aimed to assess the efficacy and safety of aspirin versus placebo in patients with a moderate estimated risk of a first cardiovascular event. Methods ARRIVE is a randomised, double-blind, placebo-controlled, multicentre study done in seven countries. Eligible patients were aged 55 years (men) or 60 years (women) and older and had an average cardiovascular risk, deemed to be moderate on the basis of the number of specific risk factors. We excluded patients at high risk of gastrointestinal bleeding or other bleeding, or diabetes. Patients were randomly assigned (1:1) with a computer-generated randomisation code to receive enteric-coated aspirin tablets (100 mg) or placebo tablets, once daily. Patients, investigators, and others involved in treatment or data analysis were masked to treatment allocation. The primary efficacy endpoint was a composite outcome of time to first occurrence of cardiovascular death, myocardial infarction, unstable angina, stroke, or transient ischaemic attack. Safety endpoints were haemorrhagic events and incidence of other adverse events, and were analysed in the intention-to-treat population. This study is registered with Clinical Trials. gov, number NCT00501059. Findings Between July 5, 2007, and Nov 15, 2016, 12546 patients were enrolled and randomly assigned to receive aspirin (n=6270) or placebo (n=6276) at 501 study sites. Median follow-up was 60 months. In the intention-to-treat analysis, the primary endpoint occurred in 269 (4.29%) patients in the aspirin group versus 281 (4-48%) patients in the placebo group (hazard ratio [HR] 0.96; 95% CI 0.81-1.13; p=0.6038). Gastrointestinal bleeding events (mostly mild) occurred in 61 (0.97%) patients in the aspirin group versus 29 (0.46%) in the placebo group (HR 2.11; 95% CI 1.36-3.28; 1:0-0007). The overall incidence rate of serious adverse events was similar in both treatment groups (n=1266 [20.19%] in the aspirin group vs n=1311 [20.89%] in the placebo group. The overall incidence of adverse events was similar in both treatment groups (n=5142 [82.01%] vs n=5129 [81.72%] in the placebo group). The overall incidence of treatment-related adverse events was low (n=1050 [16.75%] vs n=850 [13.54%] in the placebo group; p<0.0001). There were 321 documented deaths in the intention-to-treat population (n=160 [2.55%] vs n=161 [2.57%] of 6276 patients in the placebo group). Interpretation The event rate was much lower than expected, which is probably reflective of contemporary risk management strategies, making the study more representative of a low-risk population. The role of aspirin in primary prevention among patients at moderate risk could therefore not be addressed. Nonetheless, the findings with respect to aspirin's effects are consistent with those observed in the previously published low-risk primary prevention studies.