Categories: Expert CommentaryIHVI

Aspirin & Heart Risk: Revised Guidelines Encourage More Selective Aspirin Use

~ Updated as of November 22, 2021

New recommendations discourage aspirin use as a preventive heart measure for some, but patients should talk to their doctor before discontinuing daily aspirin use.

Wayne Batchelor, MD, is Director of Interventional Cardiology and Interventional Cardiology Research at Inova Heart and Vascular Institute. His outpatient practice is based at Inova Cardiology’s Fairfax office. He is board certified in cardiovascular disease with added qualifications in interventional cardiology.

“An aspirin a day keeps the doctor away” is a long-used maxim almost as popular as the adage touting an apple. But while taking low-dose aspirin to prevent heart attack and stroke was once more widely recommended, new guidelines whittle down whom daily aspirin use can still benefit while pointing out the regimen’s potential pitfalls.

In 2019, the American College of Cardiology (ACC) and American Heart Association (AHA) jointly updated their aspirin guidelines, discouraging the use of daily aspirin to avoid a first heart attack or stroke. The measure was based on growing research around aspirin-related bleeding problems.

In October 2021, the United States Preventive Services Task Force (USPSTF) announced they are considering changes to national recommendations regarding the use of aspirin for the primary prevention of heart disease in patients without existing heart disease. The USPTF guidelines are changed every five years and incorporate new research data in each revision. This means that the changes take into consideration the updated guidelines announced in 2019 by the ACC and AHA.

The pending USPSTF update recommends that people ages 40 to 59 who are at increased risk of cardiovascular disease (CVD) talk with their doctors about whether or not to take aspirin for the primary prevention of CVD. The update also recommends against people age 60 or older taking aspirin regularly for the primary prevention of CVD.

This has created a lot of confusion for patients, as the practice of taking aspirin to prevent a heart attack had been widely used in the past. However, these older recommendations were developed when we were not as effective at addressing other CVD risk factors. We now have better recommendations for living a healthy heart lifestyle, including diet, exercise, weight loss and smoking cessation, and have more effective therapies for treating high blood pressure and high cholesterol. This more comprehensive focus on risk factors has considerably reduced the risk of developing heart disease for many patients, rendering aspirin use less effective for primary prevention on top of these measures.

Also, we have become more aware of the risk of gastrointestinal (GI) bleeding associated with aspirin use. Therefore, with less benefit seen in primary prevention using aspirin and a better understanding of aspirin’s risks, the updated guidelines have recommended against the regular use of aspirin for the primary prevention of CVD.

Still, we recommend that you continue taking aspirin if you are already taking it, especially if you have a prior history of heart attack, stroke or stent placement, or if you are taking it for atrial fibrillation. The proposed guidelines will not affect aspirin use in these cases. In addition, some patients who are at low risk of bleeding but high risk of future heart attacks or strokes may need to remain on aspirin.

If you do not have existing conditions that warrant the continued use of aspirin, talk with your primary care provider or cardiologist to discuss whether it is best to stop taking aspirin once the new national guidelines have been finalized. Do not decide on your own to start or discontinue aspirin use.

Aspirin’s Effects

Low-dose aspirin – defined as 81 mg, the amount in a baby aspirin (compared to the amount in a standard aspirin tablet, which is 325 mg) – can lower the risk of heart attack or stroke by thinning the blood and discouraging clots. But in some patients, especially those over age 60, these benefits are offset by higher risks of bleeding.

The new guidelines balance these pros and cons.

Aspirin should NOT be routinely recommended for:

  • People who are considered to be at low risk of heart attack or stroke
  • Patients over age 60 who do not have an existing condition that requires continued aspirin use
  • Patients who are at increased risk of bleeding (these individuals should first check with their physician)

Aspirin is recommended for:

  • Those who have already had a heart attack, stroke or other condition that requires continued aspirin use to reduce the risk of a second cardiovascular event
  • Patients who have undergone certain interventions or procedures, such as bypass surgery or stent placement to open narrowed blood vessels

Aspirin may be considered:

  • For those considered at high risk of a first heart attack or stroke due to factors such as a strong family history, poor diabetes control, high cholesterol or high blood pressure, especially if they are at low risk of GI bleeding
  • For patients ages 40 to 59 who are at high risk of CVD and not at increased risk of bleeding

Caution: Talk to Your Doctor

Whatever your individual health situation, it is very important that you do not decide on your own to start or stop aspirin use.

If you haven’t had a prior heart attack or stroke, how can you and your doctor decide whether your risk factors point toward daily aspirin use? An annual physical and discussion of your family heart history and other risk factors with a primary care provider is the first step. Another indicator to bring to your discussion with your doctor would be results from a simple-to-use online cardiac health risk assessment.

Another, more sophisticated, online tool that requires specific clinical values is called the Atherosclerotic Cardiovascular Disease (ASCVD) Risk Calculator. This tool allows you to plug in age, gender, race, blood pressure and cholesterol levels and offers a percentage risk of suffering a significant cardiovascular event over the coming 10 years.

Your doctor can help with this, and sometimes an app isn’t needed to determine if patients should be on aspirin. But it’s not like one brush stroke can be applied to every single patient. We need to hit the mark on the balance between aspirin’s risks and benefits.

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Wayne Batchelor

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Wayne Batchelor
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