Who should – and who shouldn’t – take daily aspirin
Recent clinical trials have updated recommendations for aspirin use to reduce cardiovascular disease risk
For decades aspirin has been universally used to prevent repeat heart attack and stroke, and also to prevent the initial occurrence of these events in high-risk people
Based on new research, the United States Preventive Services Task Force (USPSTF) has updated its 2016 recommendations on the use of aspirin for prevention of cardiovascular disease.
Here is a summary of the updated USPSTF guidance from Ezra A. Amsterdam, distinguished professor of cardiology at UC Davis Health.
How aspirin works
Aspirin reduces the ability of blood platelets to clump and form clots that block arteries that supply blood to vital organs such as heart muscle and brain, thereby reducing the risk of heart attack and stroke.
Who should take aspirin?
Aspirin remains central to the management of patients with clinical evidence of vascular disease. This includes patients with who have had a heart attack, stroke, coronary artery stent, or other vascular conditions for which aspirin has been prescribed. These patients should continue aspirin because its benefits are established in these high-risk conditions.
The USPSTF now recommends against its use for prevention of a first heart attack or stroke in people aged 60 years or older with no clinical evidence or history of vascular disease. The recommendation is based on evidence that for prevention of a first heart attack or stroke in these individuals the balance of benefit vs. risk of aspirin appears to be unfavorable. This is because the bleeding risk of aspirin itself can possibly cause stroke or substantial gastrointestinal hemorrhage.
The recommendations have also been refined for other groups. In healthy people ages 40-59 without risk of bleeding, the new recommendations state that low dose aspirin may be considered for use in those with an elevated risk for cardiovascular disease: 10% or higher 10-year risk based on a formula comprising age, sex, race, smoking, cholesterol, blood pressure, and diabetes.
However, current studies indicate that:
- Aspirin use in the 40–59-year-old higher-risk group has only marginal, if any benefit, which may not outweigh its adverse potential.
- Other approaches (e.g., management of smoking, hypertension, and cholesterol) warrant greater attention and afford more value since the benefit of aspirin in primary prevention is borderline.
- Aspirin is not recommended for people of any age with increased bleeding risk.
- In all cases individual decision-making between patient and health care provider regarding therapy with aspirin is strongly supported by the guidelines.
The counsels of other professional societies vary only in detail from those of the USPSTF. The American College of Cardiology and American Heart Association recommend that low-dose aspirin may be considered for primary prevention of cardiovascular disease in people ages 40-70 with increased risk and without elevated risk of bleeding. These societies do not recommend the drug for primary prevention of cardiovascular disease in those older than 70.
Additionally, the European Society of Cardiology suggests that for people at very high risk, low-dose aspirin may be considered for primary prevention. The American Academy of Family Physicians supports the 2016 United States Preventive Services Task Force recommendation on aspirin use.
Ask your doctor
Do not start a daily aspirin regimen without consulting first with your physician.