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Rethinking aspirin for prevention: New studies suggest more limited use

A team of Stanford physicians explains why research has found that taking aspirin to prevent cardiovascular disease may be riskier than previously thought.

Recent studies have provided new information about when aspirin should be used to prevent disease and in general they suggest that doctors cut back on the use of aspirin for cardiovascular disease prevention.

The new findings do not affect everyone: People with a history of heart attack, stroke, or other types of cardiovascular disease are still strongly recommended to take a daily low-dose aspirin to reduce their risk of a future event. There is no question that aspirin has an important role after someone has already developed heart disease, also called "secondary prevention."

But now, rigorous new research has forced us to reconsider whether aspirin should be used in people without known heart disease. Aspirin has been used in this type of "primary prevention" for decades.

Recent studies show that the risks of side effects from aspirin (such as bleeding) likely outweigh the potential benefits (such as prevention of a first heart attack or stroke). These findings have prompted a major shift in clinical practice.

For instance, the new guidelines from the American Heart Association and American College of Cardiology now recommend against routine use of aspirin for primary prevention for most patients.

However, there is still a role for aspirin in primary prevention for certain people (such as those with a high risk for cardiovascular disease and low bleeding risk), but this is not a simple decision. Individuals considering the use of aspirin for primary prevention should have a conversation with their health care provider to clarify the potential benefits and harms. Similarly, people already taking aspirin for primary prevention should have a discussion to see if they should consider discontinuing.

My recent JAMA article, with Stanford colleagues Randall Stafford, MD, PhD, and Kim Chiang, MD, highlights the new studies and provides a practical approach to the use of aspirin for primary prevention. We also review a process in which patients and health care providers can work together to decide on treatment recommendations, called "shared decision making." Given the complexities involved, the stepwise approach can offer a helpful framework for the discussion.

As you initiate shared decision-making with your health care provider, an upcoming blog series by Stafford can be a useful resource. It will provide practical strategies for chronic disease treatment and prevention. The three posts will examine:

  • The benefits and harms of aspirin
  • How to calculate the risk of a future serious cardiovascular disease event
  • How to use the risk information to make decisions about aspirin

Because low-dose aspirin is available without a prescription, and may not be on your medication list, it is important to let your health care providers know about everything that you are taking -- including all over-the-counter medications.

As a primary care physician, I work to identify patients who are currently taking or are interested in starting aspirin for primary prevention and having these discussions. I feel this is especially critical given the potential for aspirin side effects that could lead to unnecessary harm.

My colleague Chiang, also a primary care physician, suggests that while there may be a limited role for aspirin in preventing a first heart attack or stroke, that there are many other strategies that can help reduce this risk.

"Lifestyle interventions, such as physical activity and a heart healthy diet that is low in sodium and saturated fats, but high in vegetables, fruits and whole grains, can make a big impact. Furthermore, smoking cessation, weight management, stress reduction, and improved sleep quality all have beneficial cardiovascular effects," Chiang said. 

She adds that other medications, such as cholesterol-lowering or blood pressure reducing medications, are very useful for certain people. These health behavior changes and medications can go a long way towards preventing heart disease and stroke.

Shreya Shah, MD, is a clinical assistant professor of medicine in primary care and population health. Kim Chiang, MD, is also a clinical assistant professor of medicine and investigates strategies for improving patient care. Randall Stafford, MD, PhD, is a professor of medicine and director of the Program on Prevention Outcomes and Practices.

Photo by Daniel Foster

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