The shifting sands on aspirin use

Since I last wrote about this topic, important data was added to our understanding about using aspirin to help prevent cardiovascular events in otherwise healthy individuals. Believe it or not, despite the fact that aspirin has been around for over a hundred years, this issue has remained controversial.

Here’s what’s NOT in dispute:

If you have documented coronary artery disease, peripheral artery disease, history of stroke or TIA, aspirin use makes sense and has been shown to reduce the risk of subsequent cardiovascular problems.

Where it gets muddy is if you don’t have a history of ANY of these. Then, the data has been less clear about what to do. But as people get older, physicians have been more likely to recommend that they start prophylactic daily aspirin “just in case”, especially if they have risk factors for heart disease (like high cholesterol or a history of smoking).

The logic behind this is as follows: the chance that you have SOME plaque build-up somewhere in your body increases with increasing age. Meaning, we may not know it – yet – but coronary artery disease, peripheral vascular disease, cerebrovascular disease – is likely already lurking inside of you, especially as you move into your 60s and 70s. It has therefore seemed logical to put people on aspirin as they get older - as a little extra insurance against potentially devastating health events related to plaque build-up - like heart attack and stroke.  

But even “baby aspirin” is a drug and can cause serious bleeding (after all, that’s the point of taking it – to thin the blood). And the question has remained - does benefit outweigh harm in otherwise “healthy” older individuals? 

A new study provides the answer. Researchers took nearly 20 thousand individuals 65 years of age or older WITHOUT documented cardiovascular disease, randomized them to receive either a low dose daily aspirin or placebo, and followed them for nearly 5 years. What they found was that there was NO significant cardiovascular benefit from prophylactic aspirin use. In fact, the group that took low dose aspirin did WORSE – with higher rates of serious bleeding – in the digestive tract and in the brain.

Other recently published trials have shown that prophylactic aspirin use in younger individuals without documented cardiovascular disease failed to reduce risk. And even in diabetics, where a cardiovascular benefit was noted, that benefit was counterbalanced by an increased risk of serious bleeding in aspirin users.

Overall, it is becoming more and more apparent that individuals without known heart or vascular disease do not benefit from prophylactic aspirin use, regardless of age or underlying risk profile. So if you don’t have a history of heart attack, stroke, peripheral vascular disease, or otherwise documented atherosclerosis by studies such as coronary calcium CT scan or carotid ultrasound, check with your physician whether you should still be on that daily aspirin.

NOTE: We NEVER advocate you stop any medication without first speaking with your healthcare provider. Not every study result applies to every patient. Your personal physician is always in the best position to determine what makes sense for your particular health situation.

And don't forget, the data on food and prevention of heart disease is vast and consistent.  The sands have never shifted when it comes to the importance of what we eat.

References:

McNeil JJ, Woods RL, Nelson MR, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on Disability-free Survival in the Healthy Elderly. N Engl J Med 2018;Sep 16:[Epub ahead of print].

McNeil JJ, Nelson MR, Woods RL, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med 2018;Sep 16:[Epub ahead of print].

McNeil JJ, Wolfe R, Woods RL, et al., on behalf of the ASPREE Investigator Group. Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly. N Engl J Med 2018;Sep 16:[Epub ahead of print].