Saturday, October 16, 2021

Should I keep taking my aspirin?

Many news outlets led this past week with the headline “government panel advises those 60 and older against using aspirin to prevent heart attacks.” What alarming new data led to this recommendation? None, really. Let’s look carefully at the reasoning behind this decision.

Aspirin has a long history of use for heart attack and stroke prevention. It works by preventing platelets from clumping together and blocking blood vessels. As far back as 1974, a study in Britain showed that giving aspirin to patients admitted to hospital with a heart attack reduced deaths. An influential study published in 1988 looked at a series of trials and concluded that giving aspirin to people who had suffered heart attacks lowered their likelihood of future heart attacks, strokes and deaths.

Why not put aspirin in the water supply? Platelets are our first line of defense against bleeding. If you cut yourself, platelets rush to the torn blood vessels and plug the holes until a more permanent clot can seal the break. Thus, aspirin’s effect on platelets increases your risk of bleeding.

Another British study, published 21 years ago, looked at 5000 men 45-69 with hypertension but no prior heart attack. The men taking aspirin had 20% lower risk of heart attack and stroke, but this was outweighed by an increased risk of stomach and other internal bleeding.

The U.S. Preventive Services Task Force commissioned a review of all the many trials looking at aspirin as primary prevention, that is, giving it to people with no known coronary disease. The data included 13 trials, enrolling a total of 162,000 people. Very similar to the 2000 British study, they found that those taking aspirin had 10-18% fewer heart attacks and strokes and that they had 30% more bleeding into the brain and 50% more bleeding elsewhere. (Note that these are relative differences. The absolute numbers are small: 2/1000 brain bleeds and 9/1000 other bleeds.)

Bleeding risk from use of aspirin goes up with age. Hence, the draft recommendation is that people 60 and up with no known coronary disease not take aspirin as a preventive. For those 40-59, they suggest the decision be individualized.

What is the take-home for you?

1.If you have coronary disease (prior heart attack, angina, a coronary stent or bypass surgery) keep taking your aspirin.

2.If you are a generally healthy person 60 and up, I would not take aspirin as a preventive measure.

3.If you have coronary risk factors such as high cholesterol, diabetes, smoking or a strong family history of coronary disease, discuss the pros and cons of aspirin with your doctor.

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