Using a daily, low dose of aspirin to prevent heart attacks and strokes was once widely endorsed by doctors for both primary and secondary prevention of cardiovascular disease. However, the landscape shifted following the outcomes of three pivotal aspirin trials in 2018. These trials revealed significant risks associated with aspirin, particularly an increased likelihood of bleeding and anemia. Consequently, current guidelines from the American Heart Association and the United States Preventive Services Taskforce now caution against routine aspirin use for individuals who have not previously experienced a cardiovascular event.
Despite these updated guidelines, recent data indicates that many older Americans continue to use aspirin for primary prevention. A research letter published in the Annals of Internal Medicine found that approximately 18.5 million Americans aged 60 or older—about one in three—still take aspirin daily without medical advice. This persistence may stem from outdated perceptions and a lag in disseminating new medical findings among both physicians and patients.
Dr. Mohak Gupta, a Cardiology Fellow at Houston Methodist Hospital and lead author of the letter, highlighted the slow integration of new evidence into medical practice: “This practice was supported by evidence prior to 2018. It naturally takes some time for new data to percolate and reach physicians and patients and for these to translate into changes in management.”
The risks associated with aspirin use, particularly in older adults, are underscored by its potential to increase bleeding risk, which becomes more pronounced with age. Dr. Parul M. Goyal, an Associate Professor of Medicine at Vanderbilt University Medical Center, emphasized the vulnerability of older adults: “The older adults are the most vulnerable since they are at higher risk of bleeding. They take more medications, and that can have more drug interactions with aspirin potentially causing more risk of bleeding.”
In response to the evolving understanding of aspirin’s risks, recent studies and updated guidelines have shifted recommendations away from routine aspirin use for primary prevention of cardiovascular disease. The 2018 ASCEND, ASPREE, and ARRIVE trials prompted these changes by highlighting the potential dangers of aspirin, particularly in otherwise healthy individuals.
Dr. Donald Lloyd-Jones, past President of the American Heart Association, emphasized the nuanced approach required for aspirin use in different patient groups: “When we’re talking about primary prevention patients, there’s a little bit more risk-benefit consideration. Are we more likely to prevent that first heart attack or stroke, or are we more likely to actually cause a major bleeding episode using aspirin?”
Given these complexities, experts advise that patients and healthcare providers engage in thorough discussions regarding the risks and benefits of aspirin use for cardiovascular disease prevention. This dialogue is crucial, especially for older adults, to ensure informed decision-making aligned with current medical guidelines and individual health profiles.
