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Aspirin for prevention of heart attacks
(November 2006)

Healthful Life has been skeptical about recommendations for middle-aged and older people to take aspirin to prevent heart attacks and strokes.  We agree that, if a person has suffered a heart attack or has severe chronic heart pain (angina) or has suffered a mild stroke due to reduced blood supply to the brain, then aspirin or other anti-clotting agents makes sense.  It is the ostensibly healthy individual without a history of heart attack or stroke we are concerned about.  We have argued that, for such persons, the possible benefit is equaled by the danger of drug-induced bleeding into the intestinal tract or even into the brain.

A well-balanced review article in The New England Journal of Medicine, December 1, 2005, is quite supportive of our views.  The review by authors from Italy, Spain, and the United Kingdom focuses first on high risk and then on low risk persons.  They support the administration of 75 to 100 (or even 160) milligrams daily (the usual adult dose aspirin contains 325 milligrams) for those with a history of mild to severe stroke, heart attacks, or significant chronic heart pain (angina).  A somewhat higher daily dose is also recommended for those with a chronic heart rhythm abnormality (atrial fibrillation) that can lead to strokes.  In those instances, the benefits of heart attack or stroke prevention outweigh the dangers related to aspirin-caused bleeding.

They then turn to low risk individuals (no history of heart attack, stroke, or mild transient stroke symptoms called transient ischemic attacks).  Here, they note the extent of the benefits is unclear and it is uncertain whether the potential benefits outweigh the risk of bleeding.  They also point out that those over age 70 are at greatest risk of developing a heart attack or stroke and, therefore, might get the greatest benefit from aspirin, but the potential increased benefit is balanced by risk of aspirin-induced bleeding which increases substantially after age 70.

The bottom line is that for low risk persons, the argument for low dose aspirin use is unpersuasive; this is particularly true for women.  Even for men, the potential benefits are pretty much balanced by the potential harms, particularly among those age 70 or over who are more likely to experience bleeding episodes.  Healthful Life still believes the best approach is to control risk factors (especially blood pressure, smoking, and elevated blood cholesterol levels) rather than take aspirin.  There is, however, one group in addition to those at high risk that should consider daily low dose aspirin.  These are men who have not had a heart attack or stroke, but could be called at intermediate risk because of a combination of age and other risk factors (high blood cholesterol level, high blood pressure, smoking, low blood levels of high-density lipoprotein cholesterol - good cholesterol).  If, according to the Framingham Point Score determined at a routine health examination, men under age 70 are at a 15 percent or greater 10-year risk of heart attack, or after age 70 at a 20 percent or greater 10-year risk, then aspirin is a reasonable choice.

Patrono, C., et al.  Low-dose aspirin for the prevention of atherothrombosis.  The New England Journal of Medicine.  Vol 353 (December 1) Pgs 2373-2383.  2005.