You might have read several headlines about aspirin recently and wondered how they applied to you. I have had a few patients recently ask me about whether they still need to take their aspirin. So I thought this would be a great opportunity to review where we stand on the evidence for aspirin.
To cut the long story short –
If you have had a heart attack in the past or have known blockages in your coronary arteries (coronary artery disease) or have stents in your heart – Continue following your doctor’s orders for aspirin.
If you do not meet the criteria above, and do not have known heart disease, but are taking aspirin only to prevent heart disease – Have a conversation about whether you can discontinue aspirin with your doctor
For some background –
Aspirin has been around for several decades. Its use to prevent clotting for prevention of cardiovascular disease became widespread in the 1990s after emerging evidence for its benefit. In a large collaborative meta-analysis of available trial evidence of antiplatelet agents up to 1997, aspirin reduced the risk of repeat heart attacks among patients who had just had heart attacks by about 20%, with a slightly increased risk of bleeding. As such, aspirin has been used widely for prevention of heart disease given the net overall benefit derived from reduction in cardiovascular morbidity and mortality despite a slightly increased risk of bleeding.
Given that aspirin performed so well among patients who had had heart attacks, it was believed that it would also prevent heart attacks among patients who have not had them yet, but were at high risk. This is what we call ‘primary prevention’. But like many other phenomena in life, this assumption did not bear out when scientifically tested. Even though aspirin has been used widely for primary prevention for more than 2 decades now, we have learnt in the last couple years that we may have got that wrong. In an analysis of all the recent studies about aspirin, the benefit from taking a daily low-dose aspirin was offset by the danger of internal bleeding. Overall, about 250 people needed to take aspirin for 10 years to prevent one adverse event related to the heart. Meanwhile, during that time, there was about one major bleeding episode for about every 201 people treated (like bleeding in the brain or in the gastrointestinal tract). Overall, the increase in major bleeding incidents was slightly higher than the decrease in heart-related events.
This was rightly adopted into several scientific guidelines including new primary prevention guidelines by the American College of Cardiology and the American Heart Association last month. For those without cardiovascular disease, they demoted aspirin to something that might be reasonable (but is not being recommended) for people 40 to 70 years old and is considered something to be avoided (potentially harmful and should not be used) by those who are older than 70 years old or at increased risk of bleeding. And for those with other reasons to take aspirin, you should not confuse these recommendations for people without cardiovascular disease (including stroke) for those that are for people who have heart disease, heart procedures, or other reasons to take aspirin. In any case, it is important to touch base with your doctor before discontinuing any medication. Some other recommendations from this group included:
- For patients with type 2 diabetes and other cardiovascular risk factors, metformin is the first-line treatment. Some newer drugs like GLP-1R agonists and SGLT-2 inhibitors may now be considered to help reduce risk of heart disease. If you have diabetes, talk to your doctor about this.
- Adults should aim to get at least 150 minutes of moderate or 75 minutes of vigorous physical activity a week, which is consistent with prior guidance.
- Statins are recommended with lifestyle changes for patients with elevated LDL cholesterol levels (at or above 190 mg/dL), type 2 diabetes, or other cardiovascular risk factors.
Finally, the decision about aspirin for patients without known cardiovascular disease should be made in an informed share way between the patient and physician. For most patients – less will be more.
If you have any questions about how these recommendations may apply to you, or anything else about your heart at all, click here.