Changing health recommendations can lead to confusion and be a frustration for patients and doctors alike. Should I take aspirin? Should I take fish oil? Is caffeine safe to consume and might it have health benefits? And, what about chocolate? Yea or nay?
Today we will tackle the questions about aspirin. If taking aspirin was safe and recommended a year ago, why is it no longer routinely recommended for primary prevention of heart disease? What has changed? In a nutshell, the patients have changed, not necessarily the science.
History of Aspirin Use in Heart Diseases
Let’s start from the beginning on the issue regarding aspirin. Not the beginning of time, but let’s go back to the 1970’s. A number of studies published in the 1970s reported a lower risk of heart attacks in individuals who regularly took aspirin. This is not surprising because aspirin prevents platelets in the blood from clumping together. When platelets clump together they block blood flow which then can lead to a heart attack or ischemic stroke.
In 1988 the FDA approved low dose aspirin to treat high risk patients – those who already had a heart attack or ischemic stroke. The use of aspirin in these groups is considered secondary prevention.
From 1980 to 2014 death rates from cardiovascular eventually dropped by 50%. But this drop was just from aspirin. During this period there was more aggressive management of high blood pressure and high cholesterol levels, too. Coupled with this we saw a decline in smoking and also a 20-fold increase in the use of nutritional supplements, some of which, like fish oil are cardioprotective.
So when you take:
- better blood pressure control,
- better management of cholesterol,
- fewer smokers,
- significant increase of dietary supplement….
…. you get a situation where there is no far lesser chance of platelets clumping together. So in today’s climate there is less benefit of taking aspirin for heart disease prevention than there was 20, 30, or 40 years ago.
NOW, that doesn’t mean that nobody should take aspirin. Some individuals certainly should continue to take it.
Who Should Take Aspirin?
To answer this we need to discuss the difference between primary prevention and secondary prevention. Secondary prevention applies to individuals who have already suffered what you are trying to prevent, in this case, heart attacks. The goal in secondary prevention is to prevent a second heart attack. Treatment in secondary prevention is more aggressive than in primary prevention.
Primary prevention applies to individuals who seem healthy but have risk factors for heart disease.
The use of aspirin is well established for the secondary prevention of heart attacks, therefore in individuals who already have existing cardiovascular disease.
Is there any place for aspirin today in primary prevention? The answer is yes.
Aspirin can be considered, and by aspirin we mean low dose which is 75 mg to 100 mg, in high-risk adults. This includes those with diabetes, or those those with multiple cardiovascular risk factors like active smoking, poorly controlled blood pressure and elevated LDL cholesterol (aged 40 to 70). These individuals should not have any increased risk of bleeding.
Who Groups Should Not Take Aspirin?
Low dose aspirin is not recommended for primary prevention in individuals over age 70 who are not at high risk of a heart attack.
And, low dose aspirin should not be used for primary prevention of heart disease in any individual at increased risk of bleeding.
Should I Take Aspirin: Summary
So should I take aspirin or not? If you had a heart attack and already take aspirin and have no increase risk of bleeding then you should continue to take aspirin. If you are healthy and have no significant cardiac risk factors then you should not take aspirin. If you are in the gray zone – healthy but with diabetes or multiple other risk factors we strongly encourage to change your lifestyle to whatever degree necessary to mitigate the risk factors and speak to your physician about whether the use of aspirin is wise in your case.