- Many Americans 60 years and older still take aspirin for the primary prevention of cardiovascular disease, even though guidelines have changed.
- Aspirin can put individuals at an increased risk of bleeding and anemia and is not right for everyone.
- In the last five years, guidelines for aspirin and primary CVD prevention have shifted, but many Americans still appear unaware of them.
Older adults are still likely to take a daily, low dose aspirin for the primary prevention of cardiovascular disease, even though doing so carries significant risks.
Using aspirin to ward off heart attack and stroke used to be a no-brainer. Doctors previously recommended it for both primary and secondary prevention of cardiovascular disease.
However, following the results of three major aspirin trials in 2018, guidance around aspirin has shifted. It is generally no longer recommended for individuals who have not had a heart attack or stroke. However, it is still recommended for patients who have already experienced a cardiovascular event and are trying to prevent another from occurring.
Aspirin no longer carries a blanket recommendation because of the potential risks it carries, particularly bleeding risk and anemia.
Both the American Heart Association and the United States Preventive Services Taskforce have changed their guidelines in recent years to indicate that aspirin isn’t right for all patients and does carry risks. Despite these changes, new data reveals that many Americans who should not be taking daily aspirin still are, particularly those at the highest risk for harm.
In a research letter published in the Annals of Internal Medicine, researchers found that 18.5 million Americans aged 60 or older, about one in three, were still using aspirin for primary prevention of CVD. Many of them, about 3.3 million, were doing so without medical advice.
“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. Potentially, there may also be a component of lack of awareness and hesitancy to change medical management,” Mohak Gupta, MD, a Cardiology Fellow at Houston Methodist Hospital and First Author of the letter, told Healthline.
Older Americans continue to take aspirin
Gupta’s research utilized self-reported health data between 2012 and 2021. The sample of 186,425 American adults is a snapshot of the US population, representative of roughly 150 million people. More than half the participants were women, and about one-third were non-white.
Compared to ten years ago, fewer adults are using aspirin for the primary prevention of CVD, but the number is still high. The number of adults without CVD who reported using aspirin was 14.4%, down from 20.6% in 2021.
However, when stratified by age, a different picture emerges: for adults 70 and older, 38% are still using aspirin. That’s important because bleeding risks become more prominent with age.
“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,” Parul M. Goyal, MD, an Associate Professor of Medicine and Director of Medicine for Seniors at Vanderbilt University Medical Center who wasn’t affiliated with the study, told Healthline.
The study authors write that their findings have real-world implications: despite changing regulations, there is a disparity or knowledge gap about these changes among patients, particularly older ones. Patients and healthcare providers must have serious conversations about the risks and benefits of daily aspirin use.
“Doctors should engage in risk-benefit discussions with patients using aspirin for primary prevention, especially for adults 60 years of age and older, and discontinue aspirin where appropriate– such as in older patients, those at high bleeding risk,” said Gupta.
Why recommendations for daily aspirin use have changed
A trio of studies in 2018 represented a seismic shift in the perception of aspirin for primary CVD prevention. Those studies, the ASCEND trial, the ASPREE trial, and the ARRIVE trial, looked at the risks and benefits of aspirin in different patient populations, including those with diabetes and the elderly. The trials highlighted the potential danger of bleeding events, especially in otherwise healthy individuals, and helped to reshape aspirin recommendations.
In 2019, the American Heart Association issued updated recommendations for aspirin, indicating that while aspirin is still “well established” for secondary prevention of CVD, using it for primary prevention is “controversial.”
Three years later, in 2022, the United States Preventive Services Taskforce updated its own recommendations from 2016.
“The USPSTF recommends against initiating low-dose aspirin use for the primary prevention of CVD in adults 60 years or older,” said the statement.
“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?” Donald Lloyd-Jones, MD, past President of the American Heart Association and Professor of Preventive Medicine at Northwestern University’s Feinberg School of Medicine, told Healthline.
“In secondary prevention, it’s crystal clear: you should be on aspirin, period,” he added.
Aspirin and bleeding risk: what to know
Aspirin is a blood-thinner, meaning that it has anticoagulant or antiplatelet properties, which make it difficult for blood to clot. These properties are useful for preventing heart attack and stroke but can cause other health issues, namely increased bleeding risk.
“The kind of bleeding that led to the change in guidelines was all kinds of bleeding. So it is falling and hitting your head, but it’s a lot of spontaneous bleeding in the stomach,” Eleanor Levin, MD, a Clinical Professor of Cardiovascular Medicine at Stanford Medicine, told Healthline.
For older adults, falling can be a serious health concern. When combined with an increased bleeding risk due to aspirin, you have a potentially fatal mixture.
“You have to consider again, in older people at risk of falls and head trauma, and increased intracranial bleeding, that if they haven’t had a stroke before, that you’re putting them at risk for bleeding,” said Levin.
A 2023 study based on the ASPREE trial also found that a daily low dose aspirin put patients ages 65 years and older at a 20% higher risk of anemia.
Anemia is a condition in which your body doesn’t produce enough healthy red blood cells to transport the necessary amount of oxygen, leading to shortness of breath, dizziness, and headaches.
Experts contacted by Healthline said that patients and doctors should have an informed conversation about the risks and benefits of taking aspirin for the primary prevention of CVD.
Lloyd-Jones also cautioned that if you have been taking aspirin, even if you’re doing so without medical advice, you should consult a doctor before stopping. Doing so can lead to an increased risk of cardiovascular events.
“This paper should not make anyone stop any medication. It should make people talk to their doctor about why they are taking aspirin,” he said.
The bottom line
Many older Americans continue to take a daily low-dose aspirin for the primary prevention of cardiovascular disease, even though it may put them at increased risk of bleeding.
In the past five years, recommendations have changed around taking aspirin to prevent CVD in individuals who have never had a heart attack or stroke previously.
Experts say that patients should have a detailed conversation about the risks and benefits of taking aspirin as primary prevention for CVD to identify if they would be a good candidate.
