The Real Truth About Aspirin

Have you ever wondered whether you really needed to take a baby aspirin every day. This over-the-counter medication, branded a wonder pill, was thought to be preventive against heart attack and stroke for older patients who had never been diagnosed with heart or vascular disease. Well, perhaps we should rethink aspirin’s magical abilities. New research suggests that healthy patients should stop daily aspirin use for primary prevention of cardiovascular disease.

For decades, aspirin has been a mainstay of treatment for the prevention of cardiovascular disease. The medication inhibits platelets to stop clots from forming that can block major arteries in our hearts and our brains. And millions of people continue to take a daily low dose aspirin, recommended by their primary care physicians.

A new study suggests that aspirin does not live up to its preventive assertions. In fact, it may be dangerous to those who take the medication daily.

Aspirin still remains the cornerstone of treatment for the secondary prevention of patients who have previously been diagnosed with cardiovascular disorders. However, its role in primary prevention is now being questioned.

Primary prevention refers to stopping the onset of disease, while secondary prevention attempts to prevent worsening of disease once it has been identified. Examples of primary prevention include smoking cessation, good nutritional habits, exercise, and water fluoridation. Until recently, aspirin was also on this list.

There were relatively few trials regarding aspirin and its role in primary prevention before 2018. Most of the previous trials looked at aspirin in secondary prevention and found great benefit. Because of benefit in patients with disease, it was assumed that there was also benefit in healthy patients who had not developed disease. Thus, low dose aspirin, also known as baby aspirin, became a household medication for many middle-aged and elderly adults.

But evidence was severely lacking in healthy patients and there was concern that the risk of adverse events from aspirin could outweigh the benefits of the medication.

This prompted a flurry of studies seen in the past year that have turned our understanding of aspirin upside-down. The results question the liberal use of aspirin and will likely culminate in new guidelines by specialty organizations.

Two of these studies garnered significant attention in 2018 while more studies continue to be released.

The ASPREE study, published in New England Journal of Medicine, showed no benefit for primary prevention of cardiovascular events in otherwise healthy elderly patients, while there was an increase in the risk of major bleeding.

The ARRIVE study, published in The Lancet, also showed no difference between aspirin and placebo in primary prevention of cardiovascular disease, while showing an increased bleeding risk.

The most recent study, published in JAMA Neurology last month, highlights an increased risk of cerebral hemorrhage — bleeding within the brain — in patients who take daily aspirin for primary prevention. This serious adverse event can lead to disability and death, raising questions about the continued use of aspirin in healthy patients.

A number of other studies are currently in progress studying both aspirin and medications with similar mechanisms of action that inhibit platelets to prevent heart attack and stroke. These studies will continue to shed light on the use of medications for both primary and secondary prevention of major cardiovascular disease.

Aspirin continues to be an important medication for patients with established cardiovascular disease, and should also be standard treatment in the emergency department for patients presenting with a potential heart attack.

However, in the primary setting for healthy patients without signs of cardiovascular disease, the truth is out. Irrespective of age or potential to develop disease in the future, we should say goodbye to a 121 year old drug with overwhelming evidence that the risk of daily use for those in good health outweighs the benefit.