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Aspirin for prevention: Should you take it?

In this final piece on aspirin for prevention of heart attack and stroke, Randall Stafford explains factors for doctors and patients to consider.

Fred is now ready to visit the doctor. Fred, as you may recall is 58 and slightly overweight. His friend suggested that he should start taking low-dose aspirin to help prevent heart attack and stroke, but Fred isn't sure, so he schedules a visit with his doctor.

To prepare, Fred has his blood tested, to get information such as his total cholesterol level, and uses an online risk calculator, like this one from the American College of Cardiology, to calculate his risk of experiencing a heart attack or stroke in the next 10 years. Using that calculator, Fred's risk is 11.4 percent.

At the office visit, Fred's doctor determines he is at average risk for abnormal bleeding and colon cancer. Together, they decide that aspirin is appropriate and Fred agrees to take 81 mg of aspirin each evening. They discuss other strategies to prevent heart attacks and opt to increase Fred’s lisinopril dose to lower his blood pressure. They also strategize about how Fred can lose a few pounds. Later at the pharmacy, Fred picks up his new lisinopril prescription and buys a $4 bottle of 300 low-dose aspirin tablets.

Let’s take a closer look at the issues that Fred discussed with his doctor. They include:

Bleeding: If a person has a higher than average chance of bleeding (including past bleeding), then aspirin should be used with caution.

Colon cancer: Having a higher than normal chance of developing colon cancer might prompt use of aspirin even in someone at lower risk of heart disease and stroke.

Aspirin dose: Low dose (81 mg) is just as effective for heart disease and stroke prevention as higher doses, which carry a greater chance of internal bleeding.  Aspirin is slightly more effective when taken at night, but it’s far more important to find a convenient time for consistency.

Age: Current guidelines focus on ages 50-69 years, but many health specialists believe it can be beneficial for some people in their 70s to start taking aspirin.

Continuing aspirin: Fred and his doctor focused on the decision to start aspirin, but once started, aspirin should be continued indefinitely, except when major bleeding problems occur.

Other wellness strategies: If you are at a high enough risk of heart attack or stroke to take aspirin, you can lower your risk of those events by treating your blood pressure and cholesterol more aggressively. In addition, adopting healthier behaviors related to physical activity, food, sleep, and stress can further reduce your risk of heart attack, stroke and cancer.

Past research tells us that many people who would benefit from aspirin are not taking this low-cost, potentially helpful drug. You cannot simply leave it up to the doctor.

Knowing your risk for heart attack or stroke is important for many forms of prevention. Men older than 40 and women over 50 should find out their risk factors. This means having blood pressure measured and lab tests done for cholesterol. Once you have the needed information, use an online calculator to estimate your risk.

While 10 percent risk of a heart attack or stroke in the next 10 years is the usual threshold for starting low-dose aspirin, talking to your health provider is critical because:

1) Some people with risk levels below 10 percent should take aspirin
2) If other problems exist, some people with a risk above 10 percent should not take aspirin
3) Your calculated risk may have implications for other disease prevention strategies.

Please take the time to find out if aspirin is right for you.

This is the final piece in a series of three blog posts on aspirin for prevention. The first covered the potential benefits and harms of aspirin, while the second post covered how to calculate the risk of a future serious heart or stroke and how to interpret this risk information.

Randall Stafford, MD, PhD, a professor of medicine and director of the Program on Prevention Outcomes and Practices, is a primary care internal medicine physician at Stanford. He is developing practical strategies to improve how physicians and consumers approach chronic disease treatment and prevention. Additional information about the preventive use of aspirin is available at AspirinProject.org.

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