Heart of the Matter

The end of aspirin for primary prevention


Just when I thought that all the nonsense about the benefits of aspirin for the prevention of heart attack had been obliterated with a series of reports on its danger and lack of benefit, more fake news arrived in the form of a proposal by the Centers for Disease Control and Prevention.

It proclaimed that there were “213 million opportunities to improve cardiovascular risks in America,” one of which would be to change behavior so that 9 million Americans would take a daily baby aspirin (MMWR 2018 Sep 7;67[35];983–91). Although the proposed benefits of aspirin have been around for a long time, the major contemporary emphasis resulted from the report of the Physicians’ Heart Study in healthy men in 1989 that there was a decrease in fatal and nonfatal MIs as a result of taking daily aspirin. However, listed in a separate endpoint analysis, sudden death, for some reason not considered to be a fatal event, was twice as frequent in the aspirin treated group compared to the placebo, and when included with fatal events wiped out most of the benefit of aspirin (N Engl J Med. 1989 Jul 20;321:129-35). Ask your friends like I do, if they take a baby aspirin daily and they all smile innocently and complacently and say, “Yes.”

Over the intervening years, there has been a general jousting around the benefits of aspirin with conflicting data and little convincing evidence. With the recent publications, there seems to be at least some glimmer hope that the public and medicine may come to their collective senses. In a series of articles published from the ASPREE and ASCEND trials, which included 19,114 and 15,480 healthy and diabetic patients, respectively, there is little benefit and significant risks to taking aspirin, not the least of which is severe bleeding and cancer.

In the ASPREE trial of healthy elderly men over 70, aspirin has no effect on both total all-cause mortality and cardiovascular mortality and is associated with increased major bleeding. ASPREE also reported that, in healthy elderly men, aspirin was associated with an increase in mortality because of increased cancer incidence (N Engl J Med. 2018 Oct 18;379:1499-529).

The ASCEND trial, which included in the patients with diabetes and without evidence of coronary vascular disease, aspirin use as primary prevention was associated with a decrease in cardiovascular mortality, which was erased by an increase in serious bleeding (N Engl J Med. 2018 Oct 18; 379:1529-39). In a companion review, Paul M. Ridker, MD, of Brigham and Women’s Hospital, Boston, concludes that “the best strategy for the use of aspirin in the prevention of cardiovascular disease may simply be to prescribe a statin instead” (N Engl J Med 2018 Oct. 18; 379:1572-4)

Someone needs to call the CDC.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

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