Features February 2019 Issue

Role of Aspirin Downplayed for Preventing a First Heart Attack

Recent studies suggest the risks likely outweigh any benefits.

Low-dose aspirin does such a good job in preventing recurrent heart attacks and strokes that it is universally prescribed for individuals with diseased coronary, carotid or peripheral arteries.

Studies have suggested it might prevent a first cardiovascular event, as well. But that thinking changed in 2018, when three clinical trials found the risks of aspirin used in primary prevention to be generally far greater than any benefit.

In the ASCEND trial of 15,000 patients with diabetes, daily aspirin resulted in a modest 12 percent reduction in cardiovascular events, but a 29 percent increase in major internal bleeding.

aspirin

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In the ARRIVE study, which involved 13,000 patients at moderate cardiovascular risk, daily aspirin had no effect on rates of death or heart attack, but increased the risk of gastrointestinal bleeding.

In the ASPREE study of 20,000 adults ages 70 and older, daily aspirin had no effect on the composite outcome of death, dementia and disability. However, the death rate-primarily due to cancer-was higher among those taking aspirin than placebo.

"This information about the effects of aspirin in people without a history of heart attack, stroke or revascularization is very important, because the high rates of internal bleeding and mortality were not balanced by a reduction in major cardiovascular events," says Cleveland Clinic preventive cardiologist Leslie Cho, MD.

These results do not mean aspirin should never be prescribed for primary prevention: They do mean aspirin should no longer be considered an effective way to prevent a first heart attack or stroke, regardless of the risk factors a person might have.

"The decision to take daily aspirin should be made on an individual basis after careful consultation with your physician," says Dr. Cho.

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