Martin O’Riordan’s cardiology practice in the Philadelphia
area, it happens weekly.
A 45- or
50-year-old patient mentions that her father had a heart
attack at the same age. Worried that the same fate will befall
her despite being in good health, she takes baby aspirin every
typical response: Please stop.
have known for decades that daily, low-dose aspirin makes
sense for patients who have had a heart attack or stroke, as
it sharply reduces the chance of having a second one.
people who have never had one of these cardiovascular
"events," the thinking on aspirin is less clear,
despite two recent large-scale studies. The reason for caution
is the very reason that aspirin wards off heart attacks and
strokes: It interferes with blood clotting, putting the
patient at higher risk of serious gastrointestinal bleeding.
line: Aspirin is more potent than many people realize, said O’Riordan,
of Mercy Cardiology.
have kind of looked at it as, ‘Aspirin, an apple, a glass of
milk, it’s all good for you,’" said O’Riordan, who
is on staff at Lankenau Medical Center. "Aspirin is a
It is a
medication drawing renewed scrutiny, 30 years after the Food
and Drug Administration approved its use after a heart attack.
suggests it is also a good idea for some people who have not
had a heart attack but who are at risk of having one — those
with multiple risk factors such as high cholesterol, high
blood pressure or diabetes. But the FDA has not approved it
for that use.
one is precisely sure at what point aspirin’s benefits
outweigh the risk of bleeding, said J. Michael Gaziano, chief
of the division of aging at Brigham and Women’s Hospital in
know that it prevents heart attacks in everybody," said
Gaziano, who is helping to oversee one of three ongoing
aspirin trials. "What we don’t know is exactly what’s
the break point."
issue is deciding how much "weight" to assign to a
serious bleed. It is generally not as bad as a heart attack,
yet some aspirin-related bleeding is severe enough to require
a blood transfusion.
problem is the low rate of heart attacks in the broader
population, which is dropping with healthier lifestyles.
Statistically, it is hard to measure a reduction in something
that is uncommon to begin with.
those who have never had a heart attack or stroke, studies
have linked aspirin use with a nearly 12 percent reduction in
the chance of suffering one. But that is a reduction in a very
small number. Instead of 57 heart attacks and strokes per year
in a group of 10,000 people, you get 51, according to a
meta-analysis published in the Lancet.
impact on serious bleeding, meanwhile, varies from study to
study. As with the drop in heart attacks, however, the yearly
increase in major bleeds per 10,000 people is in the single
digits — though higher in older people.
and other physicians use one of several "risk
calculators" to determine a patient’s chance of a
cardiovascular event in the next 10 years, generally
recommending aspirin if that risk is above 6 to 10 percent.
have found that some of these calculators, popular online, may
overestimate the chance of a heart attack. The most recent
evidence was published recently in the Annals of Internal
the numbers are compelling enough for Cherry Hill, Pa.,
resident Frank Plunkett, who has not had a heart attack but
who has taken daily aspirin for more than a decade.
has high blood pressure and a total cholesterol count that at
times has exceeded 200, so his physician told him aspirin was
a good bet.
think it helps prevent clots and keeps my blood vessels from
getting clogged," said Plunkett, chair of the school of
criminal justice at the ITT Technical Institute in Levittown,
has taken a more cautious stance. In May, the agency rejected
Bayer HealthCare’s request to market low-dose aspirin for
use by people who have not had a heart attack.
people take it — even those who are at low risk of heart
disease, according to a January study in the Journal of the
American College of Cardiology.
population of nearly 69,000 patients at 119 cardiology
practices, study authors found 11.6 percent were taking
aspirin despite having less than a 6 percent risk of
cardiovascular disease in 10 years.
number reflected only those for whom aspirin use was recorded
in the physician’s chart. So the rate of people taking
aspirin inappropriately may actually have been higher, said
lead author Ravi S. Hira, an interventional cardiology fellow
at Baylor College of Medicine in Houston.
the "worried well" sometimes take aspirin when they
should not, studies have found some heart attack victims fail
to take it even though they should, said Garret FitzGerald, a
professor at the University of Pennsylvania’s Perelman
School of Medicine.
the human condition, right?" FitzGerald said.
first clues that aspirin could prevent heart attacks came in
the late 1940s, when California physician Lawrence Craven
noticed patients who had their tonsils removed were prone to
bleeding if they took aspirin for the pain.
hypothesized the medicine might interfere with the formation
of clots that can lead to heart attacks, and science
eventually proved him right.
1980s, FitzGerald and his Penn colleagues conducted some of
the key research leading to a consensus that even a low dose
of the drug could prevent a second heart attack.
recent research suggests aspirin may have another benefit.
Studies have associated it with a reduced rate of colon
cancer, though FitzGerald called that "an interesting
suggestion rather than compelling evidence."
no mistake — that longtime staple of medicine cabinets is a
drug. Use it with caution.