Research suggests that if your doctor overestimates your heart attack risk, there is a good chance that your doctor will also over prescribe “preventative” medications to address this perceived risk. Is there a risk in overestimating and over prescribing medicines for your heart attack risk? Perhaps when it comes to low-dose aspirin. There is an ongoing controversy in the medical community in regard to the validity of using low-dose aspirin in healthy people and people with pre-existing cardiovascular problems or risks. Does the the benefit of possible prevention of cardiovascular disease events like heart attack and stroke outweigh the risks of prolonged usage?
The last two years of research questioning the benefits of Low Dose Aspirin
A study published, August 2020, in the American journal of cardiovascular (1) drugs sums up the changing feeling of some doctors towards the use of low dose aspirin in cardiovascular disease. This study surrounds the use of aspirin in the prevention of atherosclerotic cardiovascular disease or simply clogged or narrowed arteries.
The benefits of low dose aspirin remain debatable for atherosclerotic cardiovascular disease
“The use of aspirin has been widely accepted for the secondary prevention of atherosclerotic cardiovascular disease in all patient populations, as the benefits linked to the reduction of clinical events outweigh the risk of major bleeding. However, despite the undisputable, though modest, potential of aspirin to reduce atherothrombotic events, its overall efficacy and safety in primary atherosclerotic cardiovascular disease prevention remains debatable, despite being used for this purpose for decades.”
The benefits of low dose aspirin remain debatable for type 2 diabetes patients with heart disease
A January 2020 study (2) from an Italian research team exploring the cardiovascular benefits of low-dose aspirin in type 2 diabetes patients explains the new controversies surrounding offering low dose aspirin in type 2 diabetes patients:
“The debate on the benefit-risk balance of primary cardiovascular prevention with aspirin has been especially vivacious over the past two years, following the publication of three large randomized, placebo-controlled, primary prevention trials in different settings, spanning from healthy elderly to diabetes mellitus subjects.”
These studies, questioning low dose aspirin’s benefits will be discussed below. What the researchers in this study examined was when and if low dose aspirin should be offered to diabetes patients and how safe was it? As it is with much research, low dose aspirin may benefit some, may not benefit others, may harm the patient in the long-term. Where do you fall in? Researchers are trying to narrow that answer down to general recommendations.
When patients are less than 70 years of age, it is debatable whether low dose aspirin will help
Another January 2020 study (3) from Italy, specifically the Department of Cardiology at the University Hospital of Pisa offers general guidelines to help counterbalance low aspirin therapy risks:
“The need for aspirin therapy as part of primary prevention of cardiovascular disease is currently being highly debated, especially after 3 studies in different settings reported that a reduction in ischemic events is largely counterbalanced by an increase in bleeding events.
Following general preventive measures (physical exercise, cessation of smoking, treatment of hypertension and hypercholesterolemia, etc.), an individualized approach to prescribing aspirin is still warranted. When patients are less than 70 years of age, clinicians should assess the 10-year cardiovascular risk. Aspirin treatment should be considered only when the cardiovascular risk is very high and the bleeding risk is low, after taking into account the patient’s preferences.”
These are general recommendations and as is suggested in the study need to be discussed with your doctor.
Canadians told to stop taking aspirin to prevent first heart attack
On October 2, 2019, the University of Alberta issued a statement concerning research findings from Michael Kolber, a family medicine professor, at the University of Alberta and University of Calgary family medicine graduate, Paul Fritsch.
The headline of this statement was: Canadians told to stop taking aspirin to prevent first heart attack, stroke – Canadian family physicians warned potential harm of daily dose outweighs benefits.
The statement is in reference to a research article published by Kolber and Fritsch in the journal Canadian Family Physician (4) which suggested:
Three recent large randomized control trial studies of moderate-risk, elderly and diabetic patients do not support the use of low dose aspirin for primary prevention of cardiovascular events. The potential absolute benefit of about 1% is offset by a similar increase in major bleeding. All-cause and cancer mortality were either unchanged or increased with low dose aspirin.
The advice to take a daily aspirin to prevent heart disease became dogma in the 1990s but it was based on flawed research, according to Kolber.
People at higher risk for getting low dose aspirin prescriptions? People who go to the doctor.
As a side note to this Canadian study, a March 2020 study followed up on this research to examine how many “healthy” Canadians were being prescribed low dose aspirin. In a large study published in the Canadian Medical Association Journal Open (5) researchers found that in 6231 sampled patients, 54.2% of those aged 50-69 years old with no prior history of cardiovascular disease were found to be potentially eligible for low dose aspirin use for primary cardiovascular disease prevention. Of the 6231, 1379 (22.1%) were receiving prophylactic low dose aspirin treatment.
Some factors found to be related to low dose aspirin use included age, male sex, regular medical visits, lower education level, obesity, hypertension, diabetes and dyslipidemia. In the “healthy” Canadians, a little more than 1 in 5 were prescribed low dose aspirin during a doctor visit.
Increased risk of major bleeding with aspirin – the “big” research
A January 2019 study published in the Journal of the American Medical Association (JAMA) (6) questioned if low dose aspirin’s benefits in preventing heart attacks and strokes in low-risk patients outweighed the risks of exposing these patients to bleeding episodes from the aspirin’s effect on the gastrointestinal tract.
Here is, according to researchers, an example of over prescribing.
The patients in this study were considered low risk for heart attack and stroke, yet they were given low dose aspirin recommendations because that is the “standard of care.” What this research found was that there was a higher risk for MAJOR bleeding episodes in these patients and the health problems the bleeding presented did not outweigh the risk benefit of possible heart attack and stroke prevention. The bleeding risk was just as bad for causing significant health events.
No benefits compared to risk
There have been a number of studies on the no benefits compared to risk subject when it comes to low dose aspirin.
In a November 2019 study (7), a team of European researchers published their findings in agreement with the research throughout this article that “aspirin use does not reduce all-cause or cardiovascular mortality and results in an insufficient benefit-risk ratio for cardiovascular disease primary prevention.”
A September 2019 study published in the American Journal of Cardiology (8) found that:
“Aspirin use in the prevention of cardiovascular events has been a mainstay of treatment for decades. However, the use of aspirin in primary prevention of atherosclerotic cardiovascular disease has recently come under scrutiny. Several recent studies have evaluated the use of aspirin in primary prevention and the results suggest that in many patients the risks may outweigh the benefits. Closer examination of these trials suggests that the use of aspirin therapy for primary prevention may have a role but likely needs a more tailored approach and that caution is needed in prescribing aspirin for primary prevention.”
Back to patients with Type 2 Diabetes
Another September 2019, this one published in the journal Circulation (9) addressed concerns about offering low dose aspirin to certain patients, this included type 2 diabetes patients.
“Aspirin is the cornerstone of the antithrombotic (blood clot formation) management of patients with established atherosclerotic cardiovascular disease, but major guidelines provide conflicting recommendations for its use in primary prevention. Findings from recent randomized trials totaling more than 47,000 patients called into question the net clinical benefits of aspirin in primary prevention for 3 key populations: patients with diabetes mellitus, community-dwelling elderly individuals, and patients without diabetes mellitus who are at intermediate risk for atherosclerotic events. In the context of increasing emphasis on the use of other treatments for primary prevention in patients with moderate-high future risk of developing atherosclerotic cardiovascular disease, the efficacy and safety of aspirin for primary prevention has become uncertain.”
In October 2018, over 2000 researchers and health care professionals collaborated on a study that appeared in the New England Journal of Medicine (10) that presented this conclusion:
“The use of low-dose aspirin as a primary prevention strategy in older adults resulted in a significantly higher risk of major hemorrhage and did not result in a significantly lower risk of cardiovascular disease than placebo.”
Yet despite this, many people remain on the low dose aspirin regimen.
Researchers in Spain recently noted in the journal Alimentary Pharmacology & Therapeutics (11) that in patients with low cardiovascular risk the number of gastrointestinal complaints induced by low-dose aspirin may be greater than the number of cardiovascular risk events prevented. Further, in patients with high cardiovascular risk, low-dose aspirin is recommended, but the number of gastrointestinal complications induced may still overcome the cardiovascular events saved.”
Is low dose aspirin right for you?
It is very important to talk to your doctor about whether or not aspirin is appropriate for you. Especially if you have heart disease, prior heart surgery or chronic chest pain due to clogged arteries.
At the Magaziner Center for Wellness we use a functional medicine approach to treat heart disease naturally. Whereas conventional healthcare focuses on the use of medication or other methods that suppress symptoms or block the natural function the body, we use natural therapies that work in conjunction with the body. Our treatments work by facilitating, enabling and assisting normal physiologic reactions. In other words, rather than fighting the body and its natural function, we support it, giving it the tools it needs to heal itself.
Using a series of extremely thorough tests, we work to determine the root cause of the imbalance and develop an individualized plan of treatment based on each patient’s unique needs and contributing factors. No two patients are identical so we look at each patient’s lifestyle, stressors, environment, heavy metals, diet, health history, and the level of vitamins and minerals or any toxins present in the body to determine the specific and unique factors contributing to the imbalance. Using methods such as chelation therapy, various nutrients and nutraceuticals to improve heart function, and anti-inflammatory based-diet and lifestyle, stress reduction techniques and controlled exercise, we treat the cause of the imbalance, rather than the symptoms, helping the body to return to a state of optimal health—fully and naturally.
1 Fras Z, Sahebkar A, Banach M. The Use of Aspirin in Contemporary Primary Prevention of Atherosclerotic Cardiovascular Diseases Revisited: The Increasing Need and Call for a Personalized Therapeutic Approach [published online ahead of print, 2020 Aug 18]. Am J Cardiovasc Drugs. 2020;10.1007/s40256-020-00424-y. doi:10.1007/s40256-020-00424-y
2 Rocca B, Patrono C. Aspirin in the primary prevention of cardiovascular disease in diabetes mellitus: A new perspective. Diabetes Research and Clinical Practice. 2020 Jan 8:108008.
3 Aimo A, De Caterina R. Aspirin for primary prevention of cardiovascular disease: Advice for a decisional strategy based on risk stratification.
4 Fritsch P, Kolber MR. Acetylsalicylic acid for primary prevention of cardiovascular events. Canadian Family Physician. 2019 Jul 1;65(7):480-.
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6 Zheng SL, Roddick AJ. Association of aspirin use for primary prevention with cardiovascular events and bleeding events: a systematic review and meta-analysis. Jama. 2019 Jan 22;321(3):277-87.
7 Gelbenegger G, Postula M, Pecen L, Halvorsen S, Lesiak M, Schoergenhofer C, Jilma B, Hengstenberg C, Siller-Matula JM. Aspirin for primary prevention of cardiovascular disease: a meta-analysis with a particular focus on subgroups. BMC medicine. 2019 Dec 1;17(1):198.
8 Thobani A, Dhindsa DS, DeMoss BD, Raad M, Sandesara PB, Sperling LS, Baer JT. Usefulness of Aspirin for Primary Prevention of Atherosclerotic Cardiovascular Disease. The American journal of cardiology. 2019 Sep 9.
9 Marquis-Gravel G, Roe MT, Harrington RA, Muñoz D, Hernandez AF, Jones WS. Revisiting the role of aspirin for the primary prevention of cardiovascular disease. Circulation. 2019 Sep 24;140(13):1115-24.
10 McNeil JJ, Wolfe R, Woods RL, Tonkin AM, Donnan GA, Nelson MR, Reid CM, Lockery JE, Kirpach B, Storey E, Shah RC. Effect of aspirin on cardiovascular events and bleeding in the healthy elderly. New England Journal of Medicine. 2018 Oct 18;379(16):1509-18.
11 Lanas A, Polo-Tomás M, Casado-Arroyo R. The aspirin cardiovascular/gastrointestinal risk calculator – a tool to aid clinicians in practice. Aliment Pharmacol Ther. 2013 Feb 17. doi: 10.1111/apt.12240.