Is taking a daily Aspirin a good idea?

What was recommended years ago might no longer apply today for many people. Here's why.

Christopher Labos MD, MSc | 28 Oct 2021 

Health and Nutrition

 

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This article was originally published in the Montreal Gazette

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I have been asked a lot lately about the recent draft recommendation from the United States Preventive Services Task Force that adults over 60 do not need to take a daily Aspirin. 

While this might be surprising to some, it is actually based on nearly a decade of research and is not really news to most medical people. But, before people start throwing away their medication, we should remember that there is a difference between people who are trying to prevent a heart attack and those who have already had one.

In the medical world, we make a distinction between primary prevention and secondary prevention. In primary prevention, you are trying to prevent a healthy person from getting sick, whereas in secondary prevention you are dealing with someone who is already sick and trying to prevent them from getting worse. In secondary prevention — people who have had a heart attack or stroke or some other form of vascular disease in the past — Aspirin therapy is clearly beneficial.

But many of the people taking Aspirin do not have prior cardiovascular disease. These primary prevention patients were probably told to start Aspirin at some point or might have even started it themselves because of the often-repeated maxim that everyone over the age of 50 should take a daily Aspirin. 

In the past, some studies did suggest a benefit for a baby Aspirin once a day. Studies like the Physicians’ Health Study and the Hypertension Optimal Treatment trial showed a benefit to daily Aspirin and are likely responsible for the common perception that people, especially those with risk factors, should be taking it for primary prevention.

But the reality is that these studies are decades old and the evidence base has not held up over time. More contemporary studies have not shown a benefit to daily Aspirin for primary prevention, and a 2009 meta-analysis by the Antithrombotic Trialists Collaboration as well as a more recent 2019 meta-analysis in JAMA both showed the benefit to Aspirin therapy was minimal and largely offset by the increased risk of bleeding.

It is important to remember that these studies are not suggesting that Aspirin does not work or that the prior evidence is wrong. But Aspirin does increase the risk of bleeding, and for most patients, the benefit they draw from Aspirin is too small to justify the risk. 

Patients with prior heart disease are at higher risk and therefore draw more benefit from it. But patients with no history of cardiovascular disease, even those with risk factors, are too low-risk to benefit.

It might seem curious to people that earlier studies showed a benefit while more recent studies did not. The reality is that the medical landscape was very different in the late 1980s and early ’90s. Most medications we use today did not exist back then and those in use were not that good by today’s standards. People smoked more and many were walking around with blood pressure, blood sugar and cholesterol values that were much higher than we consider normal today.

So it isn’t that Aspirin stopped working, or that the earlier studies were wrong. The reality is that people today are at much lower risk for heart disease and stroke than they used to be because we are now better and more aggressive at treating their risk factors. Patients are lower-risk today and simply draw much less benefit from a baby Aspirin, hence the USPSTF recommendation.

There might be some primary prevention patients who are at particularly high risk for whom the cardiovascular benefit of Aspirin outweighs the bleeding risk. But for the majority of people, this is not the case. Given that patients often complain about taking too many pills, if they are truly primary prevention patients, the daily baby Aspirin could be one pill their physicians can stop.

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@DrLabos

https://www.mcgill.ca/oss/article/health-and-nutrition/taking-daily-aspirin-good-idea

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Aspirins - Platelet clumping, Heart attacks and Strokes - by Life Extension

Why Many People May Not Need Aspirin Today - One of aspirin’s beneficial effects is to prevent blood platelets from clumping and blocking blood flow,5,6 including inside a coronary or cerebral artery...

LIFE EXTENSION MAGAZINE

August 2019

By William Faloon

Starting in the 1970s, a number of published studies found that people who regularly took aspirin had reduced risk of heart attack and other vascular disorders.1-4

As evidence mounted, the FDA approved low-dose aspirin in 1998 to treat high-risk patients, including those who had already suffered a heart attack or ischemic stroke.

Tacit approval to take low-dose aspirin daily was also given for healthy adults concerned about occlusive vascular disorders.

One of aspirin’s beneficial effects is to prevent blood platelets from clumping and blocking blood flow,5,6 including inside a coronary or cerebral artery.

Back in the early years when aspirin demonstrated efficacy, the typical Americans’ behavior patterns put them at high risk for abnormal platelet clumping, which in turn caused soaring numbers of heart attacks and strokes.7

In the period of 1980 to 2014, however, death rates from cardiovascular disease incrementally plummeted by 50%.8

This improvement coincides with better control of blood pressure and lipids, and a decrease in smoking tobacco,5,6 along with changing dietary practices and improved cardiovascular procedures and interventions.

Overlooked by the mainstream is an almost 20-fold increase in the use of dietary supplements, many of which have many similar effects as aspirin in protecting the cardiovascular system.9

Recent studies are finding that aspirin is not reducing heart attack/stroke risk in today’s healthier American population compared to earlier decades.5,6 Aspirin is still proving effective in certain high-risk groups, as will be described in this editorial.5,10

So the debate swirling in medical settings is whether otherwise healthy Americans should continue taking low-dose aspirin.

Our analysis reveals that adults at low risk of cardiovascular disease who control their risk factors, including protecting against abnormal platelet clumping, may not need daily low-dose aspirin. This editorial describes our rationale.

If we travel back to the 1950s-1970s era, a typical American man or woman might, after waking up, eat a breakfast consisting of bacon, eggs, and buttered toast, with sugar and/or cream-laden coffee. Many would also light up a cigarette.

The morning hours are when blood platelets are most “sticky.”

Mornings are also when most sudden heart attacks were occurring in those decades.11

Consumption of polyphenol-rich fruits, vegetables, and dietary supplements in this 1950s-1970s period was low.

Systolic blood pressure over 150mmHg was quite normal, and many people had high cholesterol levels,12,13 sometimes exceeding 300 mg/dL.

Add together the above five paragraphs and you may see why sudden-death heart attacks surged to epidemic levels during the 1950s-1970s period.

Typical breakfast foods consumed in that time period increased abnormal platelet aggregation (clumping), smoking caused more platelet clumping, and few anti-platelet-clumping foods or nutrients were consumed.

So, when studies published in the prior decades identified regular aspirin users as having reduced heart attack rates, there was a biological explanation for this, since aspirin markedly lowered the platelet clumping that was encouraged by typical lifestyles during this era.

 

“In 1965, 45% of Americans smoked, today it’s only 15%… That’s the lowest percentage ever recorded.”*

*Smithsonian.com based on Centers for Disease Control and Prevention 2015 report.19

American Heart Association Update March 18, 2019

Earlier this year, the American Heart Association published an article that corresponds to much of what we state as it relates to changing American health behavior patterns. Here is an excerpt from the news report:

“Heart attack rates have gone down in more modern society with lower smoking rates and better treatment of blood pressure, better treatment of cholesterol… There probably was more of a role for aspirin back in the older trials, even though the bleeding issue has always been seen there.”36

The reasons cited by the American Heart Association, and many more provided in this editorial, indicate why otherwise healthy American adults may no longer need low-dose aspirin for primary heart attack prevention.

What Has Changed Today?

Even a cursory look at health behavior patterns in the 1950s-1970s compared to recent years reveals startling changes.

There have been huge reductions in average blood pressure readings and lipid numbers.12,14,15 These two factors alone dramatically reduce platelet clumping (thrombotic) risks.16,17

Dietary practices among health conscious individuals reduce or eliminate breakfast foods like bacon, ham, and fried eggs that contribute to platelet aggregation.

Specifically, health-conscious individuals have become aware that ingestion of saturated fats (and certain other fats like trans-fats) is a culprit behind platelet aggregation and subsequent coronary heart attacks and ischemic strokes.

Tobacco usage has plummeted18 while intake of nutrients that protect against platelet aggregation has soared.

Stated succinctly, there is no comparison between the vascular health status of the typical American in the 1950s-1970s and the same indices in more recent decades.

Plummeting incidences of heart attacks and strokes caused by abnormal platelet aggregation attest to this.

So, while aspirin saved many lives in the past, it may not have this same effect today. That’s because there is far less abnormal platelet clumping and thus less coronary or cerebral artery blockage (occlusion) happening.5,6

CURRENT CONVENTIONAL “PRIMARY PREVENTION” GUIDELINES FOR DAILY LOW-DOSE ASPIRIN

Primary prevention in cardiovascular disease is defined as reducing the risk of having an initial cardiovascular event, like a heart attack (myocardial infarct) or stroke (cerebrovascular accident).

In comparison, secondary prevention is defined as reducing the risk of having a second, or subsequent, cardiovascular event.

Low-dose (75-100 mg daily) aspirin use for secondary prevention is well established.35

However, based upon several new, high-quality clinical studies (randomized, placebo-controlled, direct intervention trials), the use of aspirin for
generalized primary prevention has been revised.28-32

These revisions reflect the differences between patient populations today in comparison with the past5,6 – for example, patients today achieve better blood pressure control, have better cholesterol profiles, and use less tobacco than “comparable” patients in the past, especially 30-plus years ago.

According to the 2019 Guidelines for Primary Prevention of Cardiovascular Disease from the American College of Cardiology (ACC) and the American Heart Association (AHA), current recommendations on the use of aspirin for primary prevention stipulate:5

• Low-dose aspirin (75-100 mg orally daily) may be considered for primary prevention of cardiovascular disease in high-risk adults (e.g., patients at high risk of a cardiovascular event, like type II diabetes patients as well as those patients with multiple cardiovascular risk factors such as poor blood pressure control, active tobacco use, and elevated LDL cholesterol) aged 40-70 years, not at increased bleeding risk;
• Low-dose aspirin should not be administered on a routine, generalized basis for primary prevention of cardiovascular disease among otherwise healthy adults >70 years, not at high cardiovascular risk;
• Low-dose aspirin should not be administered for primary prevention among adults at any age who are at increased bleeding risk.

Nutrients That Impede Platelet Aggregation

Thrombosis is the leading cause of death in persons over age 50.20

The major cause of thrombosis is abnormal platelet aggregation (clumping) inside arteries and veins.

It is critical that aging persons follow anti-thrombotic practices that include ingesting nutrients that help prevent blood platelets from sticking together.

I believe every reader of Life Extension Magazine® is already taking many of these anti-platelet nutrients. They include plant polyphenols like curcumin, green tea, pine bark, and pomegranate, optimized forms of folate, vitamins B6 and B12, along with omega-3 fatty acids.21-27

These nutrients have differing anti-platelet properties. This is important because there are several mechanisms that cause abnormal platelet aggregation.

Compare what health-conscious Americans have done in recent decades to reduce their thrombotic heart attack and stroke risks to the 1950s-1970s period. The difference is night and day.

It helps explain why recent studies seeking to demonstrate the effect of aspirin on heart attack prevention in healthy people have largely failed to do so.28-32

Today’s radically altered health behavior patterns drastically reduce platelet stickiness. Further reducing platelet aggregation with aspirin may not add additional benefit to healthy people, as recent studies indicate.5,6

REDUCED SECONDHAND SMOKE EXPOSURE SLASHES THROMBOTIC CARDIOVASCULAR RISKS

Most of you may recall being chronically exposed to other people’s cigarette smoke in the workplace, around recreation areas, while traveling, and at home.

Here is what the Surgeon General and the Institute of Medicine write about the cardiovascular dangers of secondhand smoke:37-42

• Exposure to secondhand smoke has immediate adverse effects on the cardiovascular system and can cause coronary heart disease and stroke.
• Secondhand smoke causes nearly 34,000 premature deaths from heart disease each year in the United States among nonsmokers.
• Nonsmokers who are exposed to secondhand smoke at home or at work increase their risk of developing heart disease by 25%–30%.
• Secondhand smoke increases the risk for stroke by 20%− 30%.
• Secondhand smoke exposure causes more than 8,000 deaths from stroke annually.
• Breathing secondhand smoke can have immediate adverse effects on your blood and blood vessels, increasing the risk of having a heart attack.
• Breathing secondhand smoke interferes with the normal functioning of the heart, blood, and vascular systems in ways that increase the risk of having a heart attack.
• Even brief exposure to secondhand smoke can damage the lining of blood vessels and cause your blood platelets to become stickier. These changes can cause a deadly heart attack.

Over the past 25 years, public health initiatives have resulted in huge reductions in secondhand smoke exposure, which further lowers thrombotic heart attack and ischemic stroke risk.

These data help further explain why studies in early years showed reduced heart attack risk in aspirin users.

In today’s relatively secondhand-smoke-free world, the potent anti-thrombotic effects of daily aspirin are not always going to show reduced heart attack risk because this major environmental threat has been largely eliminated.

Blood Pressure and Platelet Aggregation

With each heartbeat, blood is pushed through your arteries into microscopic capillaries and then out through veins for return to your heart.

Elevated systolic blood pressure increases mechanical stress that compromises the integrity of the inner arterial wall called the endothelium. This can lead to a pro-inflammatory and pro-thrombotic state that is an underlying cause of heart attack or ischemic stroke.

Blood pressure guidelines in earlier years allowed levels that were too high. Back in those days medications to treat hypertension were not particularly effective compared to more recent decades.33

When aspirin was showing significant efficacy in reducing heart attack risk, people with high blood pressure, including prehypertension­, were not adequately controlling it with diet, lifestyle, and medication.

This same problem persists today among people who are not proactive in protecting against vascular disease.

Average blood pressure readings have been dropping in recent decades in most population groups, though the growing number of overweight/obese individuals is counteracting this favorable trend.

Those who achieve better blood pressure control enjoy reduced platelet aggregation.34

These individuals are therefore less likely to benefit from daily aspirin use compared to past generations that lived with elevated blood pressure.

Lipids and Blood Pressure

In the early 1980s, the standard reference ranges for LDL cholesterol and triglycerides were too high. These antiquated reference ranges put many people at risk for coronary artery occlusion and subsequent heart attack (myocardial infarction) in earlier decades.

Elevated lipids accelerate atherosclerotic processes. This increases the risk of platelets aggregating around unstable arterial plaque and causing coronary and cerebral artery blockages.

Huge declines in average lipid levels beginning in the late 1980s provide further rationale for why aspirin is not demonstrating similar beneficial effects in more recent studies.5,6,12,15

Back in the previous period (1950s-1970s) little was done in the conventional setting to prevent atherosclerosis, be it diet, exercise, supplements or drugs.

These facts cannot be overstated. When Americans were suffering epidemic levels of heart attacks, laboratory reference ranges for blood lipids were frighteningly high.

This predisposed a large swath of Americans to abnormal platelet aggregation that aspirin helped protect against.

Many of today’s health-conscious people may no longer need this additional anti-platelet protection, as their blood pressure and blood lipids are markedly lower.

Who Should Take Aspirin?

The term “primary prevention” applies to the use of low-dose aspirin in seemingly healthy individuals who have elevated risk factors for coronary heart attack and ischemic stroke.

The box on the next page describes patient groups who should be taking low-dose aspirin for primary prevention, i.e. before they suffer a thrombotic heart attack or stroke.

The term “secondary prevention” applies to people who already suffer angina and/or severe coronary blockage, or are survivors of a heart attack, transient ischemia attack, ischemic stroke or other occlusive arterial disease.

For this group of individuals with preexisting vascular disease, aspirin is clearly established for secondary prevention, i.e. preventing another cardiovascular event.10,35

The debate going on now is what to recommend to normal, aging people with borderline vascular risks.

Alternative practitioners have long claimed the anti-platelet effects of healthy diets, exercise, and nutrient extracts that exhibit aspirin-like properties are more than sufficient.

The bottom line is that there are no clear-cut answers for otherwise healthy, aging people.

What Should You Do?

For many readers of this magazine, daily low-dose aspirin may be a reasonable option, but there is no real “typical” reader of this magazine.

I’m sometimes surprised that those who support our healthy longevity projects do not always optimize their own cardiovascular health.

What’s important to understand is that there are several mechanisms by which an abnormal clot can form inside a blood vessel.

By consuming a healthy diet, taking a spectrum of anti-platelet nutrients, and avoiding other platelet clumping factors, thrombotic risks are likely to be significantly reduced, and the published medical literature supports this.

For longer life,

William Faloon, Co-Founder
Life Extension Buyers Club

P.S. For an in-depth review of different approaches to reduce a hypercoagulability condition and/or abnormal platelet aggregation please visit our blood-clot prevention protocol at: LifeExtension.com/thrombosis

References

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2. Aspirin in coronary heart disease. The Coronary Drug Project Research Group. J Chronic Dis. 1976 Oct;29(10):625-42.
3. Linos A, Worthington JW, O’Fallon W, et al. Effect of aspirin on prevention of coronary and cerebrovascular disease in patients with rheumatoid arthritis. A long-term follow-up study. Mayo Clin Proc. 1978 Sep;53(9):581-6.
4. Breddin K, Loew D, Lechner K, et al. Secondary prevention of myocardial infarction. Comparison of acetylsalicylic acid, phenprocoumon and placebo. A multicenter two-year prospective study. Thromb Haemost. 1979 Feb 28;41(1):225-36.
5. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease. Circulation. 2019 Mar 17:CIR0000000000000678.
6. Ridker PM, Cook NR, Lee IM, et al. A randomized trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med. 2005 Mar 31;352(13):1293-304.
7. Haft JI. Role of blood platelets in coronary artery disease. Am J Cardiol. 1979 Jun;43(6):1197-206.
8. Roth GA, Dwyer-Lindgren L, Bertozzi-Villa A, et al. Trends and Patterns of Geographic Variation in Cardiovascular Mortality Among US Counties, 1980-2014. JAMA. 2017 May 16;317(19):1976-92.
9. Available at: https://www.fda.gov/news-events/press-announcements/statement-fda-commissioner-scott-gottlieb-md-agencys-new-efforts-strengthen-regulation-dietary. Accessed May 31, 2019.
10. Smith SC, Jr., Benjamin EJ, Bonow RO, et al. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011 Nov 29;124(22):2458-73.
11. Schwartz BG, Mayeda GS, Burstein S, et al. When and why do heart attacks occur? Cardiovascular triggers and their potential role. Hosp Pract (1995). 2010;38(3):144-52.
12. Carroll MD, Lacher DA, Sorlie PD, et al. Trends in serum lipids and lipoproteins of adults, 1960-2002. JAMA. 2005 Oct 12;294(14):1773-81.
13. Moser M. Historical perspectives on the management of hypertension. J Clin Hypertens (Greenwich). 2006 Aug;8(8 Suppl 2):15-20; quiz 39.
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15. Hopstock LA, Bonaa KH, Eggen AE, et al. Longitudinal and secular trends in total cholesterol levels and impact of lipid-lowering drug use among Norwegian women and men born in 1905-1977 in the population-based Tromso Study 1979-2016. BMJ Open. 2017 Aug 21;7(8):e015001.
16. Blann AD, Nadar S, Lip GY. Pharmacological modulation of platelet function in hypertension. Hypertension. 2003 Jul;42(1):1-7.
17. Sikora J, Kostka B, Marczyk I, et al. Effect of statins on platelet function in patients with hyperlipidemia. Arch Med Sci. 2013 Aug 30;9(4):622-8.
18. CDC. Centers for Disease Control and Prevention. Achievements in Public Health, 1900-1999: Tobacco Use — United States, 1900-1999. MMWR. 1999;48(43):986-93.
19. Available at: https://www.smithsonianmag.com/smart-news/only-15-percent-americans-smoke-180956504/. Accessed June 10, 2019.
20. Becker Richard C. MD. Textbook of Coronary Thrombosis and Thrombolysis.

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