A series of recent studies have caused the powers that be in the medical community to suddenly look with disfavor on the use of daily, low-dose aspirin for preventing heart disease.
Millions and millions and millions of people around the world have been taking daily, low-dose aspirin for decades because the medical community has told them that this will prevent heart attacks and strokes. After all, taking aspirin is easy to do (a whole lot easier than losing weight, exercising, and eating healthy), costs just pennies, and almost every doctor recommends it to their patients – especially their elderly patients. It is thought by the medical community that aspirin’s anti-inflammatory properties help delay the onset or progress of some diseases (especially heart disease) over a long period. In truth, however, this theory has not been proven. In fact, information on the use of aspirin to increase healthy independent lifespans in older persons is quite limited. The bottom line is that whether 5 years of daily low-dose aspirin therapy can extend disability-free life in healthy seniors is unclear.
This question was answered in five studies and one set of guidelines that were released in three devastating blows from September 2018 through March 2019.
First Blow: Aspirin Doesn’t Help, and It Does Increase Gastrointestinal Bleeding
The first blow was the large observational ASPREE Study (Aspirin in Reducing Events in the Elderly), which was initiated in 2010 and involved participants in Australia and the US. It focused on the efficacy and safety of daily, low-dose aspirin in the elderly for the prevention of a range of disabilities, including heart disease, and the results were published last fall in The New England Journal of Medicine.
From 2010 through 2014, participants were enrolled who were 70 years of age or older (or ≥65 years of age among blacks and Hispanics in the United States) and did not have cardiovascular disease, dementia, or physical disability. Participants were randomly assigned to receive 100 mg per day of enteric-coated aspirin or placebo orally. The primary end point was a composite of death, dementia, or persistent physical disability. Secondary end points reported in this article included the individual components of the primary end point and major hemorrhage. A total of 19,114 persons with a median age of 74 years were enrolled, of whom 9,525 were randomly assigned to receive aspirin and 9,589 to receive placebo.
The trial was terminated at a median of 4.7 years of follow-up after a determination was made that participants would receive no benefit with continued aspirin use, at least regarding the primary end point. The rate of the composite of death, dementia, or persistent physical disability was 21.5 events per 1,000 person-years in the aspirin group and a slightly – albeit statistically insignificant – lower figure of 21.2 per 1,000 person-years in the placebo group. Additionally, differences between the aspirin group and the placebo group once again favored the placebo group – at a statistically insignificant level – with regard to the secondary individual end points of death from any cause (12.7 events per 1,000 person-years in the aspirin group and 11.1 events per 1,000 person-years in the placebo group). But more statistically significant and shocking was the fact that the rate of major hemorrhage was 36% higher in the aspirin group than in the placebo group (3.8% vs. 2.8%).
To put it in simple terms, the study’s conclusion stated:
“Aspirin use in healthy elderly persons did not prolong disability-free survival over a period of 5 years but led to a higher rate of major hemorrhage than placebo.”
Second Blow: Aspirin Does Not Reduce Mortality and It Profoundly Increases Major Bleeding Events
The second mortal blow to the use of low-dose aspirin came on January 22, 2019, when the Journal of the American Medical Association published the results of a study that found that taking aspirin on a regular basis to prevent heart attacks and strokes can lead to an increased risk of almost 50% in major bleeding episodes.
The results showed that:
Aspirin use was associated with an 11% lower risk of cardiovascular events. To put this in more easily understandable terms based on the criteria and study participants of 164,225 people, approximately 250 patients needed to be treated with aspirin for 5 years to prevent a single heart attack, stroke, or cardiovascular death.
Aspirin use was associated with a 43% increased risk of major bleeding events, compared to those who did not take it.
Approximately one in 200 people treated with aspirin had a major bleed.
No effect was seen with aspirin on new cancer diagnoses or deaths.
In a University news release, lead author, Dr Sean Zheng, Academic Clinical Fellow in Cardiology at King’s College London said: “This study demonstrates that there is insufficient evidence to recommend routine aspirin use in the prevention of heart attacks, strokes, and cardiovascular deaths in people without cardiovascular disease.
Third Blow: The Coup de Grace.
And then on March 17, 2019, the American College of Cardiology and the American Heart Association dealt the coup de grace.
The ACC/AHA Task Force on Clinical Practice Guidelines commissioned this guideline to consolidate existing recommendations and various recent scientific statements, expert consensus documents, and clinical practice guidelines into a single guidance document focused on the primary prevention of Atherosclerotic Cardiovascular Disease (ASCVD)–including newly generated, specific recommendations for aspirin use. Those recommendations stated:
Low-dose aspirin (75-100 mg orally daily) MIGHT be considered for the primary prevention of ASCVD among select adults 40 to 70 years of age who are at higher ASCVD risk but not at increased bleeding risk.
Low-dose aspirin (75-100 mg orally daily) should not be administered on a routine basis for the primary prevention of ASCVD among adults >70 years of age.
Low-dose aspirin (75-100 mg orally daily) should not be administered for the primary prevention of ASCVD among adults of any age who are at increased risk of bleeding.
In other words, taking a low-dose aspirin every day to prevent a heart attack or stroke is no longer recommended for most older adults, according to the guidelines. After doctors have almost universally proclaimed for decades that a daily dose of 75 to 100 milligrams of aspirin could prevent cardiovascular problems, while at the same time presenting minimal risk, this represents a startling about face.
The Guidelines went on to state that whereas low-dose aspirin was no longer recommended, lifestyle changes were. Some of the key lifestyle recommendations include engaging in regular exercise (at least 150 minutes of moderate-intensity activity each week); aiming for and maintaining a healthy weight; avoiding tobacco (including vaping or second-hand smoke); and eating healthier.
In a simultaneous statement, also published by the American College of Cardiology, Roger S. Blumenthal, MD, co-chair of the 2019 Guidelines, said, “The most important way to prevent cardiovascular disease … is by adopting heart healthy habits and to do so over one’s lifetime. More than 80 percent of all cardiovascular events are preventable through lifestyle changes, yet we often fall short in terms of implementing these strategies and controlling other risk factors.”
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