An Aspirin A Day – Anymore?

In March 1998, the second column of this series was titled “An Aspirin A Day?” In that column I reported on the 1989 New England Journal of Medicine paper regarding the Physicians’ Health Study, which had found that physicians who took an aspirin every day had a significant, 44%, in the incidence of heart attacks. That was good enough for me, and I started my daily aspirin regimen in 1989. And, yes, I’m still alive and I haven’t had a heart attack, in part thanks to coronary artery bypass surgery in 2012. And I still take my aspirin twice daily -- 81 mg of baby aspirin at night and in the morning.

An Evolving Science

In the 33 years since that study, many studies have examined whether aspirin is as effective as first thought in preventing heart attacks and strokes. Our knowledge of optimal medicine evolves. COVID is a classic example; some early recommendations fell by the wayside. The cardiovascular world is another example, as knowledge has been derived from many investigations involving hundreds of thousands of participants – not just doctors!

On April 26, the U.S. Preventive Services Task Force, a non-governmental body of medical scientists, respected worldwide, released their latest recommendations for aspirin use to prevent heart attacks and stroke. Their guidelines, all based on new data, differ from previous ones.

Risk Groups

First, before considering the new recommendations, let us be clear. This new information applies to 3 groups of patients. The first is patients who have no known or no high risk for cardiovascular disease. The second group is patients who do not have known cardiovascular disease, but have a predicted risk based on family history, calcium score, or calculated risk estimation. The calculated risk estimation is based on factors such as high cholesterol, hypertension, diabetes, age, and smoking. The third comprises patients who have known heart or vascular disease and have had a heart attack or stroke or test results that show they have atherosclerotic heart disease.

Who Should Take Daily Aspirin?

Group 1 patients at any age should not take aspirin to prevent a heart attack or stroke. The risks of the treatment outweigh the benefit. In other words, the risk of bleeding from the intestine or the brain or elsewhere is greater than any benefit of potentially preventing a heart attack or stroke.

Group 2 patients aged 40 to 59 with a 10% or greater risk of cardiovascular disease can take one baby aspirin, (81 mg per day, and may have a slight reduction in the chance of having a heart attack or stroke. This benefit outweighs the low incidence of bleeding. By age 60, and certainly 70, this group is encouraged to stop taking aspirin if they still have no evidence of cardiovascular disease.

Group 3 patients have known heart disease. Because it’s known that aspirin impairs thrombosis, and thrombosis causes stroke and heart attack, a patient’s physician may recommend taking aspirin even at an older age. Patients in this group must individualize their medications by consulting with their cardiologist.

Commentary

No magic bullet or no known way exists to absolutely prevent heart attack and stroke. Heart attack still is the No. 1 killer in the United States. Men are at greater risk at a younger age than women. If you’re prescribed aspirin, bleeding happens sooner in the treatment rather than years later; you would not have to wait long to find out.

Lifestyle and medical interventions have been proven effective in reducing the risk of cardiovascular disease. They include regular exercise, a diet low in saturated fats and high in fruits, vegetables, and fiber, healthy weight, not smoking, and taking medications prescribed for coexisting diseases such as hypertension, high cholesterol, and diabetes. If coronary artery disease is detected, many interventions such as angioplasty with stent insertion or coronary bypass surgery, as well as a host of other medications including baby aspirin, are available.

Bottom Line

It’s important to talk with your physician about your cardiovascular risk category, what you should do to help prevent a heart attack or stroke, and what in your regimen might be changed as medical knowledge evolves in regard to what’s best for you. As for me, I still take the aspirin, but I am in Group 3 and even at my age, 78, and because of my long history with the drug, the benefit probably outweighs the risk, just as I thought it did 43 years ago.