A daily baby aspirin has been part of the medical dogma for decades. "Take one every day and you'll never get a heart attack!" has been common advice from doctors of all specialties for years. Only recently has the necessity of this medication been questioned through some large clinical trials. The short answer now is: no, not everyone should be on a baby aspirin. But there remains a ton of nuance to this issue. Let's dive deeper.
Aspirin is an old medication. It is made from willow bark, which has been used by various civilizations for several thousand years, including the ancient Greeks (Hippocrates mentions it in his writing) and the ancient Egyptians. German scientists in the 19th century were the first to purify the modern version of aspirin, called acetylsalicylic acid (ASA). In short, people have been taking it for a very long time.
Aspirin works primarily by two mechanisms. Broadly, these are (1) decreasing inflammation and (2) decreasing platelet aggregation. In other words, aspirin functionally can decrease pain and thin the blood.
Some notable side effects, therefore, are increased risk of bleeding (from the blood thinning effect) and increased risk of gastric ulcers (slightly complicated, but related to the anti-inflammatory pathway).
For people who have never had a heart attack (or similar large clot in a blood vessel such as a stroke), start by asking yourself: Why should I be on aspirin? In relatively healthy patients, using aspirin for primary prevention (i.e. using aspirin to prevent a heart attack when you've never had one before) is not for everyone. Why would a patient at a low risk for heart attack be on aspirin? Might that just increase their risk for major bleeding events? How do you balance the risk of heart attack and the risk of bleeding?
Great questions. Luckily, there are professionals who have come together and reviewed the existing data from large studies on the safety and efficacy of aspirin. The American College of Cardiology and the American Heart Association have published the most recent guidelines on the use of aspirin for primary prevention, in 2019. The United States Preventive Services Task Force published guidelines in 2016, which are fairly similar. I won't dive into the primary literature for the sake of time, but will link below to a resource I think distills medical literature well called WikiJournalClub.
Below are the highlights of the recommendations for use of aspirin for primary prevention:
First, these guidelines offer that we should really reconsider aspirin on older adults and in those at elevated risk of bleeding - in other words: Not everyone needs aspirin!
Second, the guidelines still do leave some wiggle room. They are riddled with nebulous words such as \"consider\" and "routinely," which leave the physician some discretion to define the terms how he/she sees fit.
Third, although patients have the ability to purchase baby aspirin over-the-counter and take without consultation of a physician, it really seems worth having a discussion with a health care professional before starting (or stopping) a daily aspirin regimen.
Fourth, although there are some data to suggest aspirin decreases the risk of colon cancer, I won't dive into that here since the data aren't as robust (i.e. the benefit isn't as clear) as in cardiovascular disease and the bleeding risk remains the same. The USPSTF guidelines above actually combine daily aspirin use for both cardiovascular disease and for colon cancer, and you can read the full guidelines below.
Secondary prevention (treating people who have ALREADY had a heart attack or stroke) is a whole different story. In general, aspirin for secondary prevention is considered part of the standard of care and should be given.
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