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Many people have the impression that all middle-age individuals should be on low-dose aspirin. Not true.
The U.S. Preventive Services Task Force policy for the preventive use of aspirin (usually “baby aspirin,” 81 milligrams) is relevant only to “primary prevention” of cardiovascular disease, not “secondary prevention” (preventing a second cardiovascular event). The secondary preventive benefits of aspirin are strongly established.
Although USPSTF recommendations are felt to be the gold standards for prevention, the group’s policies for aspirin are rapidly becoming out of date.
The primary preventive use of aspirin has been based on cardiovascular risk factors balanced with the risk of hemorrhage, which can be heightened with aspirin. Specific risk factors for cardiovascular disease include hypertension, diabetes, smoking and high cholesterol. Risk factors for hemorrhage include a history of ulcers, bleeding disorders, renal failure and liver disease.
The current USPSTF recommendations, written in 2016, are as follows:
◗ Initiate low-dose aspirin use for the primary prevention of cardiovascular disease in adults age 50 to 59 who have a 10% or greater 10-year CVD event risk (calculated by evaluating risk factors), are not at increased risk for bleeding, and have a life expectancy of at least 10 years.
◗ The decision to initiate low-dose aspirin use for the primary prevention of CVD in adults age 60 to 69 who have a 10% or greater 10-year CVD risk should be an individual one. Hemorrhage risk is increased in this older age group, lessening overall benefit.
◗ The current evidence is insufficient to assess the overall primary prevention benefits versus harms of aspirin in adults 70 or older.
Clearly, not all middle-age men and women are currently recommended by the USPSTF policy to be on aspirin, especially those of low or average cardiovascular risk. However, recent studies discourage its use even further.
Several large, newer studies have cast doubt almost completely on aspirin’s primary prevention value.
In one study, patients over 70 receiving aspirin received no benefit in reducing cardiovascular disease, disability or mortality but did have an increased risk of major hemorrhage. A second study demonstrated no decrease in cardiovascular or cerebrovascular events but did show an increase in gastrointestinal bleeding in people with multiple cardiovascular risk factors who had not actually suffered a stroke or heart attack. A third study found a 12% decrease in cardiovascular events in diabetics but a 29% increase in major bleeding events, greatly outweighing any benefits.
Additionally, there have been two meta-analysis studies (a study combining the results of many studies). The first meta-analysis found no overall benefit of aspirin therapy. Although cardiovascular events decreased 11%, this benefit was counterbalanced with an increase in major hemorrhagic events.
In the second meta-analysis, those taking aspirin had no decrease in all-cause and cardiovascular mortality as well as stroke, but heart attacks decreased 18%.
So, study results vary, but the prevailing feeling is that aspirin should no longer be routinely recommended for primary prevention of cardiovascular disease and should be a case-by-case decision based on cardiovascular and bleeding risks. Remaining unresolved is aspirin use in high-risk patients who have demonstrated vascular disease but have not had a cardiovascular event. Remember, aspirin definitely remains the cornerstone of secondary prevention.
Seek advice from your health care provider before initiating or terminating preventive aspirin use.•
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