In order to understand whether we should be using Aspirin to prevent a cardiac event, it is essential to understand the difference between primary and secondary prevention.
Primary prevention is for people who are healthy, not at risk of a given event and are choosing to do something to try to prevent an episode. In this case, the risk of the treatment must be very low, as the risk of having an event is low. People at low risk of having a heart attack, for example, have not had angina or an attack, though perhaps they have a family history that is concerning or have smoked when they were younger and less aware of the risks. Nonetheless, they have not had an event, so mitigating any risks is considering primary prevention.
Secondary prevention, on the other hand, is for people who have already had an event, or are at high risk of having one, and are choosing treatment to prevent another episode. Perhaps a patient has had a mild heart attack or a transient ischemic attack. Or maybe that person has angina or chest pains and is on prescription medication to lower his or her risk.
Aspirin affects the platelets in the blood, making them less sticky, thus decreasing the chance of having a blood clot. This may be very important in a small blood vessel, especially if it has already been narrowed by cholesterol plaque. But in making the blood less sticky, there is a risk of easy bleeding. That can cause blood vessels to leak or rupture, and diminish the body’s ability to form clots, in order to stop the bleeding.
So what is the best advice with respect to Aspirin? New guidelines from the American College of Cardiology were published last month. They’re based on a review of all the major studies and guidelines. The college focused on shared decisions between patient and physician, with a focus on implementing all the recommended strategies for good cardiac health, such as quitting smoking, exercising, etc. For today, let’s review the Aspirin issue.
Aspirin has been, and continues to be, widely recommended for secondary prevention. Here, the benefits – reducing the risk of another event in the cardiovascular system – outweigh the risks of taking the medication. However, recent studies do not support the use of Aspirin for routine primary prevention, due to a lack of net benefit.
Most importantly, we need to avoid this treatment for people who are already at risk of bleeding, such as those who have had ulcers, are on other drugs such as nonsteroidal anti-inflammatories, have kidney disease and so on. Also, everyone age 70 and above is considered at higher risk for bleeding, so again, Aspirin is not a good choice. It can, perhaps, be considered in selected cases with patients who are at higher than average risk of developing heart disease and are between the ages of 40 and 70 and are not at risk of increased bleeding.
So what should you do? The answer is different for different people. This is what we mean by personalized medicine. What is right for you, given your age, risk factors, family history and past medical history is not the same for your partner or spouse. Everyone is different and you need to have that discussion with your primary care provider, who can help you figure out the best course of action, given your story, your background and your level of risk.
It’s not one size fits all – it rarely is.