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Cardiovascular disease involves plaque buildup, which can lead to blockages inside arteries of the brain (cerebrovascular disease), heart (coronary artery disease) and legs (peripheral artery disease).[1] Because cardiovascular disease causes cardiovascular events (especially heart attack and stroke), it is the leading cause of death globally.[2] Each year, about 1.2 million Americans experience a first heart attack or stroke.
Even in low doses (ranging from 75 to 100 milligrams), aspirin...
Cardiovascular disease involves plaque buildup, which can lead to blockages inside arteries of the brain (cerebrovascular disease), heart (coronary artery disease) and legs (peripheral artery disease).[1] Because cardiovascular disease causes cardiovascular events (especially heart attack and stroke), it is the leading cause of death globally.[2] Each year, about 1.2 million Americans experience a first heart attack or stroke.
Even in low doses (ranging from 75 to 100 milligrams), aspirin (BAYER ASPIRIN, ECOTRIN) inhibits the aggregation of platelets (blood cells that clump together to form blood clots). Therefore, low-dose aspirin has been considered a key potential drug for preventing heart attack and stroke. However, due to its tendency to cause internal bleeding, especially when used on a regular (long-term) basis, any potential benefits of this drug need to be weighed against its potential harms.
The Food and Drug Administration (FDA) and the National Heart, Lung, and Blood Institute recommend the use of low-dose aspirin in people who have already had a heart attack or stroke (to reduce their risk of other such events) and in those who had a heart bypass or other artery-opening procedure (to keep their arteries open), which is called secondary prevention.[3] This use is based on clear evidence demonstrating that the cardiovascular protective benefits of low-dose aspirin in this population exceed the drug’s potential bleeding adverse effects.
In contrast, the FDA does not recommend the use of low-dose aspirin for preventing a first heart attack or stroke in individuals without a history of known cardiovascular disease (which is called primary prevention) because sufficient evidence supporting such use has been lacking historically.
In the July 2020 issue of Worst Pills, Best Pills News, we presented emerging evidence from three highly regarded clinical trials that did not support the use of aspirin for primary cardiovascular disease prevention.[4]
Since then, the U.S. Preventive Services Task Force (USPSTF) — a volunteer panel of national experts in evidence-based medicine and disease prevention that works independently of industry influences — commissioned a systematic review of evidence[5] and a data-modeling study[6] to update its recommendations on initiating aspirin use for the primary prevention of cardiovascular disease.[7] The USPSTF recommendations statement and supportive studies were published in the April 26, 2022, issue of the Journal of the American Medical Association.
The updated USPSTF findings and recommendations
The USPSTF recommendations and the supportive studies pertained to men and women aged 40 years or older without signs, symptoms or history of cardiovascular disease (including heart attack or stroke) who are not at increased risk of bleeding (including no history of gastrointestinal ulcers, recent bleeding or use of medications that increase bleeding risk).[8]
The systematic review showed that initiation of daily low-dose aspirin was associated with a small but significant decrease in major cardiovascular events, although it did not significantly lower overall or cardiovascular-disease–related mortality.[9] However, daily low-dose aspirin was linked to a small risk of major bleeding.
Using the aforementioned findings, the modeling study estimated the net benefit (in terms of quality-adjusted life-years and life-years gained) of initiating daily low-dose aspirin for select age groups.[10]
The USPSTF determined that for individuals aged 40 to 59 years, only those with 10% or greater 10-year cardiovascular disease risk have a small net benefit with the initiation of regular low-dose aspirin use for primary cardiovascular disease prevention (moderate certainty evidence).[11] Consequently, as summarized in the Table below, the USPSTF recommended that the decision to initiate low-dose aspirin use for primary prevention of cardiovascular disease in this group should be an individual one. This means that after consultation with a health care professional, individuals in this group who place a higher value on the potential benefits than the potential harms may choose to initiate low-dose aspirin for the primary prevention of cardiovascular disease. On the other hand, those who place a higher value on avoiding the potential harms or the burden of taking a daily preventive medication may opt not to initiate low-dose aspirin use for the primary prevention of cardiovascular disease. The USPSTF noted that individuals in this group who are not at increased risk of bleeding and are willing to take low-dose aspirin daily are more likely to benefit.
The USPSTF also determined that initiating low-dose aspirin use in individuals aged 60 years or older has no net benefit for the primary prevention of cardiovascular disease (moderate-certainty evidence). Therefore, it recommended against initiating low-dose aspirin use in adults aged 60 years or older for this purpose.
Notably, the USPSTF also investigated the impact of low-dose aspirin use on colorectal cancer in primary cardiovascular disease prevention populations. It found that the evidence is unclear regarding whether aspirin reduces the risk of colorectal cancer or related mortality.
USPSTF Recommendations for Initiating Low-Dose Aspirin Use for Primary Prevention of Cardiovascular Disease[12]
| Population Groups | Aspirin or Primary Prevention Recommendations | Grade of Recommendations |
|---|---|---|
| Adults aged 40 to 59 years with a 10% or greater 10-year cardiovascular disease risk | The decision to initiate low-dose aspirin use for the primary prevention of cardiovascular disease in this age group should be an individual one. Individuals who are not at increased risk for bleeding and are willing to take low-dose aspirin daily are more likely to benefit. | There is a moderate certainty that the net benefit of aspirin initiation in this group is small. |
| Adults aged 60 or older | The USPSTF recommends against initiating low-dose aspirin use for the primary prevention of cardiovascular disease in this age group. | There is moderate certainty that aspirin has no net benefit. |
What You Can Do
If you have had a heart attack, stroke or other cardiovascular event or have a history of a coronary artery surgery or stent (insertion of a metal mesh coil) procedure, you should be taking low-dose aspirin daily to prevent a heart attack or stroke unless you are allergic to aspirin, are at high risk of bleeding, drink alcohol regularly or are undergoing a dental or surgical procedure.[13]
Otherwise, if you are not currently taking low-dose aspirin and are considering initiating its use for the primary prevention of heart disease, discuss this article with your doctor. Do not initiate or discontinue daily aspirin without consulting your doctor.
If you experience a heart attack or stroke, call 911. Do not take aspirin before a 911 operator or an emergency medical technician tells you it is right for you during such an event.
Most importantly, note that prevention of cardiovascular disease should include all aspects of your lifestyle habits. This entails eating a balanced diet (one that is high in fruits, vegetables, nuts, whole grains, fish and lean vegetable or animal protein), regular exercise, smoking cessation and stress reduction.[14] Also, if you have diabetes, high blood pressure or high cholesterol, make sure these conditions are being appropriately controlled.
References
[1] Jin J. Use of aspirin to prevent cardiovascular disease. JAMA. 2022;327(16):1624.
[2] Tsao CW, Aday AW, Almarzooq ZI, et al. Heart disease and stroke statistics-2022 update—A report from the American Heart Association. Circulation. 2022;145(8):E153-E639.
[3] Food and Drug Administration. Use of aspirin for primary prevention of heart attack and stroke. December 30, 2016. https://www.fda.gov/drugs/information-consumers-and-patients-drugs/use-aspirin-primary-prevention-heart-attack-and-stroke. Accessed October 10, 2022.
[4] Daily low-dose aspirin should not be used to prevent a first heart attack or stroke. Worst Pills, Best Pills News. July 2020. https://www.worstpills.org/newsletters/view/1344. Accessed October 10, 2022.
[5] Guirguis-Blake JM, Evans CV, Perdue LA, et al. Aspirin use to prevent cardiovascular disease and colorectal cancer: Updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2022;327(16):1585-1597.
[6] Dehmer SP, O’Keefe LR, Evans CV, et al. Aspirin use to prevent cardiovascular disease and colorectal cancer: Updated modeling study for the US Preventive Services Task Force. JAMA. 2022;327(16):1598-1607.
[7] US Preventive Services Task Force, Davidson KW, Barry MJ, et al. Aspirin use to prevent cardiovascular disease: US Preventive Services Task Force Recommendation statement. JAMA. 2022;327(16):1577-1584.
[8] Ibid.
[9] Guirguis-Blake JM, Evans CV, Perdue LA, et al. Aspirin use to prevent cardiovascular disease and colorectal cancer: Updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2022;327(16):1585-1597.
[10] Dehmer SP, O’Keefe LR, Evans CV, et al. Aspirin use to prevent cardiovascular disease and colorectal cancer: Updated modeling study for the US Preventive Services Task Force. JAMA. 2022;327(16):1598-1607.
[11] US Preventive Services Task Force, Davidson KW, Barry MJ, et al. Aspirin use to prevent cardiovascular disease: US Preventive Services Task Force Recommendation statement. JAMA. 2022;327(16):1577-1584.
[12] Ibid.
[13] American Heart Association. Aspirin and heart disease. March 20, 2019. https://www.heart.org/en/health-topics/heart-attack/treatment-of-a-heart-attack/aspirin-and-heart-disease. Accessed October 10, 2022.
[14] Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140(11):e596-e646.
