Is Daily Aspirin Right for You?
New Information Helps Refine the Answer

Daily aspirin therapy may lower your risk of a heart attack or stroke. However, we are more aware now, due to recent significant studies, that this treatment may not be right for all groups of people. Almost 200 years ago, acetylsalicylic acid was developed and trademarked as aspirin—well known to be a remarkable anti-inflammatory and anti-clotting agent.  Today, it remains one of the oldest and most widely used drugs in history.

Although aspirin has been around for so many years, it is surprising that one the most controversial areas of preventative medicine is whether or not people without known cardiovascular disease should take a daily aspirin for primary prevention.  Primary prevention is concerned with preventing the onset of disease and it aims to reduce the incidence of the disease with interventions that are used before there is any evidence of disease or injury.  Secondary prevention in cardiovascular illness, for example, refers to the prevention or recurrence of a cardiovascular event or complications in people who have already been diagnosed with cardiovascular disease.

Aspirin therapy has been well established for secondary prevention of cardiovascular disease.  However, its role in primary prevention is much more controversial, especially in older patients with an increased risk of bleeding. This controversy has been brought to light with recent studies (ARRIVE, ASCEND, ASPREE (NEJM)) which suggest that in some patients there is no benefit to using aspirin. In fact, aspirin may increase the risk of morbidity and mortality in certain groups of people.  Before discussing the impact of aspirin in patients without cardiovascular disease (primary prevention), it is important to emphasize that in people who have had a heart attack, a certain type of stroke, stents or bypass surgery, lifelong daily aspirin is typically warranted.

Below are five key points regarding aspirin therapy that will help you and your health care professional decide if daily aspirin use is right for you.

1. How does aspirin work to prevent a heart attack?

Aspirin interferes with the body’s blood clotting action.  When bleeding occurs, platelets (the blood clotting cells) build up at the site of the wound.  The platelets help form a plug that seals the opening in the blood vessel to stop the bleeding.  This clotting mechanism can also happen within the vessels of the heart.  If the blood vessels are narrowed from fatty deposits or plaque, the vessel lining is at risk of rupture.  This rupture causes a blood clot to form and consequently block the artery.  This will prevent blood flow to the heart and cause chest pain and in most cases a heart attack.  Daily aspirin therapy reduces the clumping action of platelets, possibly preventing a heart attack from occurring but at the same time, decreasing the body’s ability to clot in other areas if there is damage.

2. Should you take a daily aspirin?

The role of aspirin in primary prevention is called into question in this era of modern medicine that emphasizes stricter blood pressure control, smoking cessation, and cholesterol reduction. The primary prevention studies that showed a significant reduction in cardiovascular events were completed prior to the rise of these modern preventive efforts. There is no clear indication to take a daily aspirin for the primary prevention of heart disease, unless a patient is at very high risk for cardiovascular events as evidenced by recent studies in the New England Journal of Medicine. These studies collectively showed an increased risk of complications when aspirin was used for primary prevention. In one study, over 12,000 healthy patients with no history of heart disease were randomized to either 100 mg of aspirin or placebo. After five years of following these patients, no significant benefit was found for the use of daily aspirin in this group. However, significant increase in gastrointestinal bleeding was found. There were no significant differences in the rate of heart attack, stroke or death. Aspirin is absolutely indicated if a) you have already had a heart attack or stroke b) you haven’t had a heart attack, but you have had a stent placed in one or more of the coronary arteries c) you have had coronary artery bypass surgery d) you have chest pain due to coronary artery disease e) you  have significant calcium in the coronary artery scan or calcium and plaque found on cardiovascular  screening.  Aspirin can be strongly considered in patients who have never had a heart attack, but have multiple risk factors, suggesting that they are at high risk for a heart attack, as well as patients who have diabetes and other heart disease risk factors, such as smoking or high blood pressure.

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  • Andrea Rosenhaft February 11, 2019 at 7:43 am

    I’m an (almost – birthday is 2/13) 58 yo woman with several ischemic conditions; Raynaud’s, severe and chronic migraines – although the new migraine medication Amovig, which I started last August has been a miracle medication for me – and coronary vasospasm. Memorial Day weekend of 2018, I had a stroke with none of the typical risk factors. I’m not overweight, not diabetic, no high blood pressure and my cholesterol was around 220. The stroke caused left sided weakness and cognitive deficits in executive functioning – which was exactly the skills I used as psychiatric social worker. Physically I’m recovered, except for persistent fatigue, but I continue to have cognitive challenges. None of the physicians I encountered were able to determine the cause of the stroke. I’m now taking 81mg of aspirin, 75 mg of Plavix and 10 mg of Lipitor. If I do get a migraine, I can no longer use triptans or naproxen which I used for joint pain as well due to an autoimmune disease, so all NSAID’s are out of the picture as well. I’m concerned that due to the cause of the stroke never being determined, I will now be on blood thinners for the rest of my life, and those medications will prevent me from taking other medications that contribute to my quality of life.