Randall S. Stafford, MD, PhD
Randall S. Stafford, MD, PhD, professor of medicine at Stanford Prevention Research Center and director of the Program on Prevention Outcomes and Practices, both at Stanford School of Medicine, California.
Bottom Line: Low-dose aspirin is a lifesaver for many, but could be harmful for some.
If you’re one of the millions of people who rely on an aspirin a day to keep heart attack or stroke away, changing advice on who should and shouldn’t be on a low-dose regimen can leave you confused…and even thinking about stopping the drug altogether. Here’s the latest info that anyone taking or thinking of taking aspirin should know…
Aspirin can be a wonder drug for many people because it prevents blood platelets from clotting—a blood clot forming in a critical blood vessel can cause a heart attack or the ischemic type of stroke. Sometimes it seemed as though it was being recommended as casually as a multivitamin. The US Preventive Services Task Force (USPSTF) put the brakes on exactly who should start taking aspirin when in 2016 it updated its recommendations for using the drug to prevent heart attacks and strokes. It says…
People ages 50 to 59 who have a 10% increased risk for cardiovascular disease over 10 years but not an increased risk of bleeding will benefit the most. (Note: High blood pressure, smoking, older age, high cholesterol, diabetes and being male are factors that increase cardiovascular disease risk.)
People ages 60 to 69 who are at an increased risk for cardiovascular disease but not an increased risk of bleeding might benefit, but this should be determined on an individual basis with your doctor.
The USPSTF added that you need to be willing to take aspirin for at least 10 years to get its full benefits.
Also, there isn’t enough evidence to assess the benefits and harms of starting aspirin in people younger than age 50 or older than age 70. Or to know whether there is a difference in the risks and benefits between men and women or among different races or ethnicities.
In contrast, the FDA has continued to maintain its position on drug marketing that there’s not enough research to show that aspirin acts as a preventive treatment in anyone who’s never had a heart attack, stroke or cardiovascular problem, and this includes people with family histories of heart disease, a heart attack risk factor. That’s because the bleeding risk of taking aspirin can outweigh any benefit. Its recommendation, consistent with the current FDA approval for aspirin, is to take aspirin after you’ve had a heart attack or stroke to prevent a second one or if you have a disease of the blood vessels in the heart.
Another important difference between the two agencies is that the USPSTF singles out aspirin’s effectiveness at preventing colorectal cancer.
Randall S. Stafford, MD, PhD, professor of medicine at the Stanford Prevention Research Center at Stanford School of Medicine, California, and a leading researcher in heart health, says that the differing advice can be confusing, but there’s a difference between starting and staying on a low-dose aspirin regimen. The USPSTF is making recommendations about who should begin taking aspirin, not who should continue taking it if they’ve already started. In terms of starting, the decision should come after a personalized analysis of its potential benefits and potential harms to you done with your doctor.
If you’re already taking low-dose aspirin, you want to know whether to stay on it. If you are currently taking aspirin on the recommendation of your doctor, even if you are over age 70, continue to do so, says Dr. Stafford. He adds that if you are over age 70, took aspirin in the past for prevention of cardiovascular disease and then stopped, you still may get benefits from going back on aspirin. In this situation, ask your doctor whether this is a good strategy for you.
If you initiated low-dose therapy on your own because you read about its potential, now is a good time to ask your doctor whether you should continue to do so. Women and younger people are more likely than others to be taking aspirin when it may not be warranted.
Above all, if you’re on aspirin therapy, no matter why or when you started it, don’t stop it on your own. Swedish researchers found a 37% higher rate of cardiovascular events among people who stopped daily aspirin therapy compared with those who continued. The risk rose shortly after they stopped and stayed elevated—it did not go down over the course of the three years of the study.
How can aspirin stop working so quickly? It’s because the life span of a platelet is only eight to 10 days. So if you stop taking aspirin, in just over a week your blood will repopulate with new platelets whose sticky ways are unchallenged, and your risk for cardiovascular events will go up.
It’s precisely because of the limited life of platelets that people are told to stop taking aspirin seven to 10 days before surgery or a medical procedure. There’s less risk of unwanted bleeding—a post-surgery complication—if you have normal, unimpaired platelets. But according to Dr. Stafford, surgeons are starting to change their approach, allowing patients at high risk for heart attack and stroke to stay on aspirin therapy before surgery when the cardiovascular benefits outweigh the downside of the surgery being more complicated to do.
While there are more studies under way that may uncover more benefits of aspirin, Dr. Stafford emphasizes that the decision around who should be taking aspirin right now should be driven only by each candidate’s heart disease, stroke and colon cancer risks.
He also stresses that aspirin needs to be considered as part of a more integrated plan for heart disease prevention that includes controlling cholesterol and blood pressure. Making a decision about aspirin isn’t enough if you have sky-high cholesterol and/or high blood pressure and aren’t taking measures to bring those conditions under control. In addition, health behaviors are key to prevention of heart disease, stroke and cancer—engage in regular physical activity, avoid tobacco exposure and eat a plant-predominant diet.
