Should I take a daily aspirin…or not?

Posted: Aug 30, 2019

There has been a lot of questions in the past few months I’ve received regarding aspirin therapy.

Not so long ago, patients over the age of 50 were regularly given advice to take an aspirin daily to prevent heart attacks and stroke – even if they had never had a problem with heart or blood vessel disease.

This advice was based upon a study initiated in 1982, The Physicians’ Health Study I [1].

Taking a medicine to prevent a disease is called primary prevention, and that is exactly what the advice to take aspirin was: an effort to prevent a disease or bad event in a person who has not had it before.

What is important to understand here is that aspirin, like any other substance or drug, can have some serious side-effects. This is despite the widespread use and acceptance of aspirin.

The major concern with aspirin is major bleeding events, such as a stomach ulcer that bleeds enough to cause death.  So as with all interventions that are recommended, patients and doctors must discuss the risk vs. benefit.  Some people have a condition that is so high risk for blood clots that cause heart attacks and strokes that they really do need to take aspirin to prevent one.

For example, if you have coronary artery disease and have had a stent placed in one of the vessels of your heart, you need to stay on aspirin (or another medication that prevents blood clots from forming in the vessel), even if you have not had a heart attack.

This is not the primary prevention I mentioned before.

This example and other conditions, such as atrial fibrillation or peripheral vascular disease, are conditions for which aspirin will routinely be recommended as a good daily medicine.

This use of a medicine is called secondary prevention.

Three studies done much more recently that were done to answer the question: Is aspirin a good medication for primary prevention? Is the risk of taking aspirin was worth the benefit [2-4]?

The studies looked at all of the reasons a person might die as they relate to taking, or not taking, aspirin.  The conclusion was that aspirin causes about the same number of people to die as it keeps from dying, in a least for primary prevention.  And yes, if you have no known heart disease and have diabetes, taking aspirin would be considered a primary prevention use [2].

Because of these newer studies, medical professionals are now telling patients is that should not take aspirin for primary prevention.

First, do no harm.

For those of you who have been instructed to take aspirin for secondary prevention, well, keep taking it until further notice.

Marcus A. Button, M.D.

References:

1. Physicians Health Study, http://phs.bwh.harvard.edu/
2. Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus.  ASCEND Study Collaborative Group, Bowman L, et. al., N Engl J Med. 2018;379(16):1529.
3. Effect of Aspirin on Disability-free Survival in the Healthy Elderly. McNeil JJ, et. al., ASPREE Investigator Group. N Engl J Med. 2018;379(16):1499.
4. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Gaziano JM, et. al., ARRIVE Executive Committee.  Lancet. 2018;392(10152):1036.