For the study, researchers examined data collected between 2011 and 2018 from 11,392 adults age 50 and older about their history of cardiovascular events and any use of aspirin, a common over-the-counter nonsteroidal anti-inflammatory drug (NSAID), or statins, prescription drugs that lower cholesterol. Low-dose aspirin use was more common with older age, with more than 45 percent of people 75 and older taking the drug daily to help prevent a first-time cardiovascular event like a heart attack or stroke, a strategy known as primary prevention. The trouble with this is that aspirin has been shown to help prevent heart attacks and strokes in middle-aged adults, but not in the elderly, says the lead study author, Greg Rhee, PhD, an assistant professor in public health at the University of Connecticut School of Medicine in Farmington. RELATED: How to Prevent a Heart Attack “Older adults who have not had any cardiovascular disease event before should not take aspirin,” Dr. Rhee says. “It’s better to focus on healthy diet and exercise, as they are well-known protective factors for cardiovascular disease.” Another troubling finding of the study is that 44 percent of elderly adults who do have a history of events like heart attack or stroke weren’t on a long-term statin regimen to prevent another event like this, a strategy known as secondary prevention that is proven to work for this age group, Rhee says. “With a history of cardiovascular disease events, older adults have a high risk of having another event,” Rhee says. “Statin use is particularly effective for secondary prevention.”
What U.S. Aspirin and Statin Guidelines Say
The U.S. Preventive Services Task Force (USPSTF) doesn’t recommend daily low-dose aspirin for primary prevention in adults younger than 50 or older than 70 because evidence of its benefits is insufficient for these age groups. The best evidence in support of aspirin for primary prevention is for people in their fifties, according to USPSTF. Those who do take it for this use should meet the following criteria:
At least a 10 percent risk of a cardiovascular event like a heart attack or stroke in the next 10 years. (The American College of Cardiology has a free online risk calculator.)A life expectancy of at least 10 yearsAble to take daily low-dose aspirin for at least a decadeLow risk of bleeding, which is a side effect of aspirin
By contrast, USPSTF does recommend that middle-aged and older adults take statins for primary prevention if they meet these three criteria:
Age between 40 and 75 yearsAt least one cardiovascular risk factor such as smoking, diabetes, high blood pressure or high cholesterolAt least a 10 percent risk of a cardiovascular event like a heart attack or stroke in the next 10 years.
Emerging Evidence on Aspirin and Statins
More recent guidelines, issued in 2019 by the American Heart Association and the American College of Cardiology recommend statins as the first medication most patients should try for primary prevention and discourage routine use of aspirin for this purpose owing to bleeding risks. The benefits for secondary prevention, meanwhile, must be balanced against bleeding risks for aspirin, particularly for older patients. But the idea that aspirin isn’t the first pill everyone needs for heart health runs counter advice that has shaped a generation of doctors and patients, says Ian Kronish, MD, MPH, of the Center for Behavioral Cardiovascular Health at Columbia University Irving Medical Center in New York City. A pivotal study published in the late 1980s in the New England Journal of Medicine found that daily low-dose aspirin reduced the risk of heart attacks by 44 percent, driven in large part by results seen in adults over 50. In this clinical trial, aspirin didn’t reduce mortality from cardiovascular causes. More recently, a study published in October 2018 in the New England Journal of Medicine found that aspirin didn’t help healthy older adults without cardiovascular disease live longer. In fact, this study, which focused on adults 70 and older, found aspirin was associated with an increased risk of premature death from all causes, driven by cancer fatalities. “It takes a long time to reverse the tide of support in favor of aspirin,” says Dr. Kronish, who wasn’t involved in the current study. It might take a decade or more to really see if shifting guidelines result in clear changes in what medicines patients use to prevent heart attacks and strokes, he adds.
Resistant to Change
Change may happen slowly in large part because many elderly patients started taking daily aspirin when they were young and are reluctant to stop now, says Jeremy Van’t Hof, MD, an assistant professor of medicine and a preventive cardiologist at the University of Minnesota in Minneapolis who wasn’t involved in the latest study on use of the drugs for heart health. “It is true that cardiovascular disease risk increases with age,” Dr. Van’t Hof says. “But if a patient has been taking aspirin for 20 years without any side effects or bleeding complications, both the patient and provider might be reluctant to stop.”
