After years of advocating middle-aged and older Americans to take low-dose aspirin to avoid a first heart attack or stroke, an influential medical task group plans to revise its recommendations, citing new research showing the dangers may outweigh the benefits.
Regularly taking low-dose aspirin to prevent a first heart attack or stroke may have a “small net benefit” for persons aged 40 to 59 who are at risk of cardiovascular disease. The task panel highlighted that individuals should only use aspirin after seeing their doctor.
“If you don’t have a history of heart attack and stroke, you shouldn’t be starting on aspirin just because you reach a certain age,” according to Chien-Wen Tseng, a member of the U.S. Preventive Services Task Force (USPSTF).
Aspirin, a blood thinner, can help prevent heart attacks and strokes by preventing clots from developing in blood vessels leading to the heart or brain.
However, taking aspirin can induce severe bleeding, which can be fatal, especially in the elderly, according to Tseng. As a result, the task force has concluded that persons 60 and older should not begin taking aspirin daily to reduce the risk of a first heart attack or stroke, determining that there is “no net benefit” in doing so.
“At that point, the higher risk of bleeding with age actually cancels out the potential benefit of aspirin,” Tseng said.
The proposed recommendations do not apply to those who have previously suffered a heart attack or stroke and are now taking aspirin on a daily basis. People without a history of heart attack or stroke who are already taking preventive dose, according to Tseng, should not discontinue taking them without first checking with their doctor.
Tseng stated that one of the task force’s key goals is “to get people to talk with their clinicians instead of just buying a bottle off the shelf and saying, ‘I should be on aspirin.’ ”
The proposed recommendations statement, which is open for public comment until November 8, represents a major change from the guidelines’ last update in 2016. (Recommendations from task forces are routinely reconsidered every five years.)
The task force previously suggested that people between 50 to 59 with a greater chance of cardiovascular disease start taking low-dose aspirin, as long as they weren’t at higher risk of bleeding. For older people, the task force stated, the decision to start taking an aspirin regimen “should be an individual one.”
However, after looking at data from more than a dozen recent controlled studies and conducting simulation modelling, Tseng said the task force determined that, while aspirin continues to have a benefit for people at increased risk of heart attack or stroke, the benefit is much “smaller” than previously observed.
“Before, when the benefit was greater, we could recommend it for people just within their age group who have high risk,” she said. “But now, because the benefit is smaller, it’s become even more clear that it’s got to be matched to the right person, and somebody’s personal values and preferences also become much more important.”
Additionally, the proposed recommendation statement would bring the USPSTF guidelines into line with those published in 2019 by the American College of Cardiology (ACC) and the American Heart Association (AHA). Low-dose aspirin may be explored for primary prevention in “select” persons between the ages of 40 and 70 who are not at higher risk of bleeding, according to the ACC/AHA recommendations. Additionally, the guidelines advise against routine aspirin use in persons above the age of 70.
Donald Lloyd-Jones, president of the American Heart Association, called the task force’s proposed updates a “welcome adjustment.”
“The USPSTF is appropriately updating their recommendations on aspirin for primary prevention, specifically in response to changes in the evidence,” said Lloyd-Jones, chair of the Department of Preventive Medicine at Northwestern University’s Feinberg School of Medicine. “This is how science should work and should translate to clinical care.”
These revisions are likely to affect millions of people, according to Amit Khera, head of the University of Texas Southwestern Medical Center’s Preventive Cardiology Program and a member of the writing group for the 2019 ACC/AHA primary prevention guideline. According to the Centers for Disease Control and Prevention, heart disease is the top cause of death in the United States, with one death occurring every 36 seconds. Each year, around 1.2 million people in the United States have their first heart attack or stroke, according to Tseng.
While Khera acknowledges the importance of preventing heart attacks and strokes, he expects that health care practitioners will be “more prudent” in providing aspirin regimens and will focus on individuals who would benefit the most.
For example, aspirin may be a suitable choice for someone who is at high risk of cardiovascular problems and has been unable to reduce their risk factors through other ways, Tseng said, as long as they are at low risk of bleeding and willing to take medication daily. The task committee suggests that you use the ACC/AHA online prediction tool to determine your risk of cardiovascular disease.
The generally accepted approach of taking aspirin to prevent a first heart attack or stroke originated in 1980s and 1990s research, Lloyd-Jones explained.
“That was a time when we weren’t really focused on or doing a particularly good job of controlling things like blood pressure and cholesterol, so aspirin had room to add value in preventing heart attacks and strokes.”
However, as our ability to lower or manage risk factors has increased and a greater emphasis has been placed on healthy living, additional research have revealed that the added value of aspirin as a primary prevention technique appears to be “at best marginal and sometimes nonexistent,” Lloyd-Jones said.
“We just don’t really need aspirin so much anymore.”
Khera agreed. “Society changes, people change, and so the place for aspirin also changes,” he said.
Adopting a more cautious approach to aspirin use would also send the message that the OTC medication is not without risk, experts said.
“Many people think of aspirin almost like a vitamin and that it’s benign, but that’s not true,” Khera said. “When we talk about major bleeding, we’re talking about bleeding in the brain, bleeding that needs transfusions, so not like nosebleed-type stuff.”
Additionally, experts urge the public to understand that taking aspirin is only one method of preventing a heart attack or stroke. Additionally, effective risk-lowering measures include simple lifestyle changes like as stopping smoking, eating a nutritious diet, and obtaining at least 30 minutes of moderate to strenuous activity on a regular basis.
“All those things add value together . . . and they work together synergistically,” Lloyd-Jones said. “Those are really the secrets here, and you won’t need aspirin if you’re doing those other things successfully.”
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