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ASPIRIN - THE MAGIC PILL - PROVEN OR NOT? (July 2002) According to pronouncements made by the authors of a study in the Journal of the American Medical Association, September 12, 2001, the answer is yes. They studied 6,174 men and women who were referred because of known or suspected coronary heart disease for stress tests and a more sophisticated test, the stress echocardiograph. At the time of testing, they were queried about whether they were taking aspirin. They were then followed for three years. During that period, 4 percent of aspirin users died as compared to 8 percent of non-aspirin users. Those who appeared to benefit from taking aspirin were older, were more likely to have underlying coronary heart disease, and according to the tests, rated fair to poor in physical fitness. For those with no coronary heart disease who were physically unfit, the predicted reduction in deaths among aspirin users ages 50 to 60 years was only about 2 percent. For 70 year olds, it was 5 percent, and for those age 80 or older, it was about 9 percent. The authors conclude "thus, our findings provide additional support for recommending the routine use of aspirin in patients with or at risk for cardiovascular disease". One of the lead authors is quoted as saying "now we actually have a treatment for the out of condition patient. We can tell the patient to take an aspirin. That won’t get them in shape, but it may save their lives." Commentary: There are multiple concerns about this study. - the investigators did not ask about duration of aspirin use or dosage, so we have no idea of what dosage might be recommended. This is an important omission. - the end point was deaths from any cause. The increased deaths in the non-aspirin users could well have been from diseases that could not have benefitted from aspirin use. It is really unconscionable to make exuberant public pronouncements without having analyzed the specific causes of death in the aspirin and non-aspirin groups. - the issue of aspirin-induced severe bleeding is totally ignored. Because the benefit is modest, the risk of serious bleeding should be a major concern. To completely ignore it is unacceptable. - for those under age 65, the alleged benefit was very small. For that age group, the recommendation would not be proper. - because these patients were all referred because of known or suspected coronary heart disease, the results may actually apply only to persons with coronary heart disease, despite the authors’ attempts to broaden the results to the majority of older persons.
For those with known coronary heart disease, aspirin treatment (under medical supervision) appears to reduce heart attacks and deaths by about 25 percent; its use is recommended.
For those without known coronary heart disease, the use of aspirin as a preventive is still controversial. The notion that those over 65 who are not physically fit (the overwhelming majority of persons over age 65) should be on aspirin requires a lot more evidence. In the absence of adequate evidence, it would put such persons at risk to some degree of significant bleeding. If we are going to do that, we had better have a lot more proof than presented in this article, and we should have better information on aspirin dosage. Experience has shown that studies like this one, called observational, often look good, but turn out to be wrong. The best evidence would come from an intervention study in which subjects would be randomized to receive aspirin or no aspirin and followed for five or ten years thereafter Gum, P.A., et al. Aspirin use and all cause mortality among patients being evaluated for known or suspected coronary artery disease. Journal of the American Medical Association. Vol 286 (Sept 12). Pgs 1187-1194. 2001.
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