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 U.S. doctors have long advised adults who haven't had a heart attack
or stroke but are at high risk for these events to take a daily
aspirin pill, an approach known as primary prevention. Even though
there's clear evidence aspirin works for this purpose, many
physicians and patients have been reluctant to follow the
recommendations because of the risk of rare but potentially lethal
internal bleeding.
For the current study, researchers examined data from 13 clinical
trials testing the effects of aspirin against a placebo or no
treatment in more than 134,000 adults.
The risk of intracranial hemorrhage, or brain bleeds, was rare:
taking aspirin was associated with two additional cases of this type
of internal bleeding for every 1,000 people, the study found.
But the bleeding risk was still 37 percent higher for people taking
aspirin than for people who didn't take this drug.
"Intracranial hemorrhage is a special concern because it is strongly
associated with a high risk of death and poorer health over a
lifetime," said study co-author Dr. Meng Lee of Chang Gung
University College of Medicine in Taiwan.
"These findings suggest caution regarding using low-dose aspirin in
individuals without symptomatic cardiovascular disease," Lee said by
email.
For people who have already had a heart attack or stroke, the
benefit of low-dose aspirin to prevent another major cardiac event
is well established, researchers note in JAMA Neurology. But the
value of aspirin is less clear for healthier people, for whom
bleeding risks may outweigh any benefit, the study team writes.
Already, guidelines on aspirin for primary prevention of heart
disease in the U.S., Europe and Australia have incorporated a need
to balance the potential benefits against the risk of bleeding. For
elderly people, who have a greater risk of bleeding than younger
adults, the risks may be too great to recommend aspirin.
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For adults ages 50 to 59 considering aspirin to prevent heart
attacks and strokes, for example, the U.S Preventive Services Task
Force (USPSTF) recommends the pill only for people who have at least
a 10 percent risk of having a heart attack or stroke over the next
decade and who don't have a higher-than-average risk of bleeding.
(The American College of Cardiology provides an online risk
calculator here: http://bit.ly/2VxbuAK.)
One limitation of the analysis is that the smaller clinical trials
examined a variety of aspirin doses up to 100 milligrams daily. The
analysis also only focused on brain bleeds, and not on other types
of internal bleeding associated with aspirin.
"We have long known that aspirin can precipitate bleeding, most
commonly in the gastrointestinal tract, but most devastatingly in
the brain," said Dr. Samuel Wann, a cardiologist at Ascension
Healthcare in Milwaukee, Wisconsin, who wasn't involved in the
study.
Despite the benefits for preventing heart attacks, the consensus on
aspirin has changed over time, particularly for people without heart
disease or hardening and narrowing of the arteries
(atherosclerosis).
"We have previously recommended aspirin to prevent platelets from
sticking to the inside of an individual's arteries, but the benefit,
while real, turns out to be small compared to the rare but
devastating incidence of brain hemorrhage," Wann said by email. "We
no longer recommend routine use of aspirin in individuals who have
no demonstrable cardiovascular disease or atherosclerosis."
SOURCE: http://bit.ly/2JkNavt JAMA Neurology, online May 13, 2019.
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