A study just published in the Journal of the American College of Cardiology has found that more than 1 in 10 patients in their review of over 68,000 individuals from 119 U.S. medical practices were inappropriately receiving aspirin for primary prevention of cardiovascular disease (CVD). Primary prevention means reducing the possibility of having a first heart attack or stroke. Inappropriate use was defined by primary CVD prevention guidelines as use of aspirin therapy in patients with a 10-year cardiovascular disease risk of less than 6 percent.
This study is important because mounting evidence shows that aspirin won’t reduce your risk of dying from a heart attack or stroke if you’re healthy and not at significant risk. Furthermore, if you’re at low risk, the potential dangers of cerebral (brain) hemorrhage and gastrointestinal (gut) bleeding outweigh any heart benefits the aspirin might provide.
Here are 6 essential things to consider when it comes to taking aspirin for heart health:
1. Aspirin should not be taken regularly without a reliable cardiovascular risk assessment by a knowledgeable doctor.
As the study mentioned above made clear, many doctors are inaccurately evaluating their patients’ heart attack risk and inappropriately prescribing aspirin as a preventive. That’s in part because too many of these physicians rely on the outdated Framingham Risk Score. It’s important to realize that each person’s risk of heart attack or stroke depends on multiple factors, both known and unknown, and how they interact with each other. Simply relying on an algorithm or formula to determine risk isn’t enough. Doctors need to look for the disease itself by doing a simple, safe, and relatively inexpensive test.
Today, getting a noninvasive CT scan of your heart to look for coronary calcium is considered by most experts to be the best predictor of a future heart attack — better than all other risk factors combined. The result of this scan is called a calcium score, and it reflects the amount of atherosclerotic plaque that you’ve built up in your coronary arteries over a lifetime. The higher your calcium score, the more plaque in your arteries and the greater your risk of a future heart attack or stroke.
This risk assessment is essential when it comes to deciding whether to place a person on lifelong aspirin therapy. I urge you to ask your doctor about getting this test if you are a man or woman in your thirties with a family history of early heart disease; a man over age 40; or a woman over age 50 who is postmenopausal.
Recently, a study in the journal Heart found that while the risk of gastrointestinal bleeding increases with age, the protective benefits of aspirin therapy also increase and outweigh the risks in women (but not men) over age 65. Despite the results of this study, I would not prescribe aspirin to an older woman unless she had some plaque buildup in her arteries. In addition to a calcium score, I often use a scan of the carotid arteries to look for atherosclerosis in the arteries leading to the brain in older adults.
2. If you’ve had a heart attack or stroke, taking aspirin could save your life.
Reducing the risk of additional heart attacks or strokes is known as secondary prevention. In patients who have had a heart attack or stroke, or who have other evidence of coronary artery disease, such as angina, a coronary bypass operation, or coronary angioplasty, the known benefits of aspirin for secondary prevention outweigh the bleeding risk.
3. If you have diabetes, you don’t necessarily need to take preventive aspirin.
The American Diabetes Association recommends aspirin therapy for primary prevention only in patients with either type 1 or type 2 diabetes who have an increased risk of cardiovascular disease (and no previous history of vascular disease) and who are not at an increased risk for bleeding. This includes men over 50 and most women over 60. In my patients with diabetes, I always recommend getting a calcium score to more accurately determine cardiovascular disease risk. Just because you have diabetes doesn’t mean you have plaque buildup. If you have diabetes, discuss aspirin therapy with your physician.
4. If your CVD risk is high enough for you to be on a statin, you should also be taking aspirin.
The reason: The drugs act differently. Aspirin does not lower cholesterol nor does it prevent the development of plaque the way a statin does. Rather, it’s an anti-platelet agent that limits the ability of platelets to clot, preventing them from becoming large enough to block blood vessels and cause a heart attack or stroke. Because aspirin reduces your blood’s ability to clot, your doctor may advise you to stop taking aspirin at least five days before any surgery, test, or dental procedure that may cause bleeding. Do not suddenly stop taking aspirin without talking to your doctor.
5. Aspirin is a powerful drug.
Even taking baby aspirin at a dose of 81 milligrams daily can increase your risk for cerebral (brain) hemorrhage and gastrointestinal bleeding in the esophagus, stomach, intestines, rectum, or anus by two to four times. That’s why you should never take aspirin without an accurate risk assessment. Furthermore, buffered and enteric-coated aspirin do not eliminate your risk of developing an ulcer. Aspirin can also interact with other nonsteroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen (Advil), naproxen (Aleve), or Motrin; blood-thinning medications such as warfarin (Coumadin); and antiplatelet medications such as clopidogrel (Plavix) or ticlopidine (Ticlid).
Red-flag symptoms of a bleed can include, but are not limited to, vomiting red blood, which can indicate upper GI bleeding; vomiting dark brown, granular material that resembles coffee grounds, which results from upper GI bleeding that has slowed or stopped; and black tarry or bloody stools. If you have any of these symptoms, call your doctor immediately.
6. Aspirin is not a magic bullet.
Healthy lifestyle measures can help prevent a heart attack or stroke better than aspirin, especially if you begin them early enough in life. Make an effort to eat healthfully, exercise regularly, and maintain a healthy weight.
And by all means stop smoking, if you do.
The bottom line: Never self-prescribe aspirin and make sure you get an accurate assessment of your heart disease risk. Only then will you — and your doctor — really know if the benefits of aspirin truly outweigh its risks.