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THE ASPIRIN DEBATE REVISITED

(December 2002)

There is agreement that aspirin with its blood thinning and anti-inflammatory properties is indicated to reduce the risk of heart attacks in people with previous heart attacks, severe heart pain, or certain abnormal rhythms. That is not at issue. The question now is, should people with increased risk of heart attack due to age, high blood pressure, smoking, high blood cholesterol levels, or diabetes be given small doses of aspirin daily or every other day?

The prestigious US Preventive Services Task Force (USPSTF) has recently made its recommendation based particularly on newer studies. The recommendation, as published in the Annals of Internal Medicine, January 15, 2002 is the following:

"The US Preventive Services Task Force strongly recommends that clinicians discuss aspirin with adults who are at increased risk for coronary heart disease. The USPSTF found good evidence that aspirin decreases the incidence of coronary heart disease in adults who are at increased risk for heart disease. It also found good evidence that aspirin increased the incidence of gastrointestinal bleeding and fair evidence that aspirin increases the incidence of hemorrhagic stroke" The benefit of aspirin in high risk persons was calculated as a 28 percent reduction in non-fatal heart attacks, but no reduction in heart attack deaths or strokes.

"The USPSTF concluded that the balance of benefits and harms is most favorable in patients at high risk for coronary heart disease (those with a ten-year risk of at least 6 percent), but is also influenced by patient preferences".

In May 2002, a careful review article in The New England Journal of Medicine concluded that those with a ten-year risk of 15 percent are good candidates for aspirin treatment.

The definition of what constitutes high risk is the issue. Because aspirin can cause serious, rarely even fatal, hemorrhage, the goal is to set the bar high enough in defining high risk that the benefit of a reduction in non-fatal heart attacks outweighs the dangers of aspirin treatment.

The table used most to define high risk has been developed by the renowned Framingham Heart Study. Risk is based on points given for age, cholesterol levels, blood pressure, and smoking. Age is, by far, the heaviest weighted variable. Some experts define high risk as a 6 percent 10-year risk for heart attack; others use 10 percent as the definition; still others, 15 percent. If high risk is based on a 6 percent chance of heart attack in the next ten years, every man over age 60 would be on aspirin just because of age. If high risk is defined as ten-year risk of heart attack of 10 percent, then every man over age 70 would be on aspirin. That makes no sense. Healthful Life believes that, for men, high risk should be defined as a 15 percent, ten-year risk of heart attack for those under age 70, and a 20 percent, ten-year risk for those over age 70. For women, the point scoring is different and not so heavily dependent on age; for women, a 6 percent ten-year risk should define high risk for those under age 70, an 8 percent risk for those over age 70, and an 11 percent risk for those over age 75.. No matter what the definition is (point score) for high risk, nobody should be urged to take aspirin just because of age.

There are other problems.

Conclusions: The minority of high risk men and women destined to have a heart attack in the next ten years according to their point scores will have their risk of non-fatal heart attack reduced by 28 percent by aspirin and may have a small reduction in risk of heart attack deaths, but will not have any reduction in strokes. For that benefit, they will risk some bleeding into the intestinal tract or, rarely, into the brain. The majority of high risk men and women with the same point scores who are not destined to have a heart attack in the next ten years will get no benefit from aspirin, but will incur the risk of intestinal bleeding and, rarely, bleeding into the brain. Of course, we cannot predict which of the high risk people will be in the minority and which will be in the majority.

Healthful Life will, for the present, not change its current stance of not urging aspirin for ostensibly healthy persons at greater risk of heart attack because of age, high blood pressure, smoking, or high cholesterol. However, we think it reasonable for physicians to decide to use it in those at particularly high risk (defined as 15 to 20 percent risk of heart attack in the next ten years for men, 6 to 11 percent for women). But, aspirin should probably not be given to those with high blood pressure. What we do urge very strongly is control of the risk factors by:

If you do opt for aspirin, be very sure you check out the interactions of aspirin with other drugs you are taking.

Aspirin for the primary prevention of cardiovascular events. Recommendation and rationale. US Preventive Services Task Force. Annals of Internal Medicine. Vol 136. (January 15) Pgs 157-172. 2002.

Lauer, MS. Aspirin for primary prevention of coronary events. The New England Journal of Medicine. Vol 346 (May 9) Pgs 468-1474. 2002.