The recommendation, not yet finalized, is based on evidence that has accumulated over the past few years showing that the risk of potentially fatal internal bleeding caused by regular aspirin use may be greater than the preventive benefits. “This update will bring the USPSTF recommendations more in line with the current recommendations of other national organizations, such as the American Heart Association (AHA),” says John Wilkins, MD, a cardiologist and an associate professor of medicine at Northwestern Medicine in Chicago. “It’s good to review evidence and update recommendations accordingly — that’s the nature of science,” he says.
New Recommendations Focus on Primary Prevention of Cardiovascular Events
In adults ages 40 to 59 who have a 10 percent or higher 10-year cardiovascular disease (CVD) risk, the decision to take low-dose aspirin “should be an individual one,” says the panel. “Evidence indicates that the net benefit of aspirin use in this group is small.” Per the statement, people who are willing to take low-dose aspirin every day and aren’t at increased risk of bleeding are more likely to benefit. For people age 60 or older, the panel recommends against starting low-dose aspirin for the primary prevention of CVD. “It’s very important to distinguish between primary and secondary prevention,” says Dr. Wilkins. Primary prevention recommendations are intended to prevent the first occurrence of a heart attack, stroke, or other cardiovascular disease event, he says. “Secondary prevention of cardiovascular disease is preventing recurrent events in people who have already had a heart attack, stroke, or coronary revascularization procedure — like a stent or a bypass surgery,” says Wilkins. “These guidelines apply only to the primary prevention group — they don’t apply in any way to people who already have established cardiovascular disease. The last thing we want is for people who have had a procedure, such as having a stent put in, to stop their daily aspirin. That would be very dangerous,” he says.
Evidence Shows Modest Benefits of Aspirin Often Don’t Outweigh Risks
The panel’s proposed recommendations are in line with existing evidence, says Jim Liu, MD. Previous studies through the years have suggested that aspirin offers only a very modest, if any, benefit in preventing cardiovascular disease, he says. “In the past three years, there have been a couple of large randomized trials once again studying aspirin for preventive purposes. These newer studies have all found no significant benefit to aspirin when it comes to preventing all-cause mortality or cardiovascular mortality,” says Dr. Liu. These studies did still find a slight benefit in aspirin for preventing nonfatal heart attacks, but this benefit was mostly seen in higher cardiovascular risk patients who were also at low risk of bleeding, he adds.
Why Is Taking a Daily Low Dose of Aspirin Risky for Some People?
“The main risk of aspirin is bleeding complications,” says Liu. Aspirin is an anti-platelet agent and prevents clot formation; in theory, it would help prevent heart attacks and strokes, which can occur from blood clots obstructing flow to either the heart or brain, he says. A drawback of this is that aspirin can increase bleeding, which is an important factor to consider in someone who already has a bleeding tendency or has a known history of bleeding problems, says Liu. “Most bleeding complications seen with aspirin involve gastrointestinal (GI) bleeding, but any bleeding can occur,” he says.
Over-the-Counter Doesn’t Mean It’s Always Safe
There can be a misperception that if a drug is sold over the counter and a prescription isn’t necessary that it is safe in all contexts, and that’s not true, says Wilkins. “Aspirin is an effective medication, and it’s great when used appropriately, but it’s not without significant side effects,” he says. The same with drugs such as acetaminophen or ibuprofen — if taken for too long or in the wrong context, these medications can cause serious side effects, he says.
Evidence for Aspirin’s Efficacy in Colorectal Cancer Prevention ‘Inadequate’
If the draft recommendation statement is confirmed, it will replace the 2016 recommendations, which included protection from colorectal cancer (CRC) as an additional potential benefit of a daily lose dose of aspirin. According to the panel, “evidence is inadequate that low-dose aspirin use reduces CRC incidence or mortality,” and more research is needed. For people who are concerned about their risk of CRC, the panel recommends talking with your doctor about aspirin when you get screened.
Unsure if You Should Continue to Take Aspirin? Talk With Your Provider
If your doctor has put you on aspirin for any reason, don’t stop taking it without talking with them first, says Wilkins. “There could be other reasons besides heart disease prevention that you are on aspirin,” he says. Wilkins also emphasizes that people on aspirin who have established heart disease should not stop taking their aspirin. If you’ve been taking aspirin for primary prevention of heart disease, talk to your provider to see if you really should still be taking aspirin, says Liu. “While there is now more evidence coming out that goes against taking aspirin for preventive purposes, it can still be considered in certain patients,” he says. Liu echoes the panel’s recommendation for adults ages 40 to 59, stating that the decision to take aspirin is an individual one that you should make with your doctor after assessing the risks and benefits. “Sometimes, the answer to taking aspirin isn’t always a clear yes or no,” he says. “Personally, for my patients taking aspirin for prevention, I have been more proactive in discussing this and discontinuing the aspirin if they don’t have a strong reason to be on it based on the recent updates,” says Liu.
Expert Tips on Reducing Your Risk of Heart Disease
The American College of Cardiology and American Heart Association offer an online prediction tool to calculate your 10-year risk of heart disease. If your current risk level doesn’t indicate that aspirin is appropriate, there are still many ways to optimize your cardiovascular risk profile and reduce your chances of a first heart attack or stroke, says Wilkins.
Optimize your blood pressure and cholesterol levels. “That can be achieved through lifestyle modifications, and for some people, that may mean medications,” he says.Try to eat a balanced and healthy diet, get the recommended amount of physical activity, and have a BMI within the normal range.Avoid all tobacco products.
