For a long time, low-dose aspirin was the standard preventative therapy for cardiovascular disorders. However, a fresh study has raised doubt on aspirin's universal advantages.

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Q: Many individuals take low-dose aspirin on a daily basis in order to avoid having a heart attack or stroke. What function, if any, is aspirin likely to have in this case?

A: Aspirin is a blood thinner in addition to being a painkiller and an antipyretic. Heart attacks and strokes are often caused by excessive blood clotting in the heart or brain arteries. Aspirin inhibits blood clotting hence lowering the risk of heart attack and stroke in at-risk people when taken regularly.

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Q:What do the previous guidelines suggest?

A: The previous guidelines suggested a different age range, whereas the newer guidelines recommend starting low-dose aspirin in adults aged 40 to 59 years for the primary prevention of CVD The primary reason for changing these standards is to address the problem of bleeding. Recent studies have shown that when individuals quit smoking and improve their management of cholesterol and other risk factors, the benefit of aspirins has shrunk somewhat. Notably, we are becoming more aware of the rise in significant bleeding.

A lot of people use aspirin as if it were a vitamin, even though aspirin may cause brain haemorrhage, bleeding ulcers, and even hospitalisation. For most individuals, it will cause more significant bleeding than you will prevent in terms of heart attacks and strokes. This is what resulted in the creation of these new guidelines.

However, it may be appropriate for people whose risk of heart attack or stroke is still elevated and who do not have a lot of bleeding concerns. However, users should be more judicious.

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Q: What are the new recommendations?

A: The US Preventive Services Task Force (USPSTF) commissioned a systematic analysis to update its 2016 recommendation on the efficacy of aspirin in reducing the risk of CVD events (myocardial infarction and stroke), cardiovascular mortality, and all-cause mortality in those who have never had a CVD.

Evaluation of the Evidence - The USPSTF finds with moderate confidence that aspirin treatment for primary prevention of CVD events is associated with a minor net benefit in persons aged 40 to 59 years who had a 10% or higher 10-year CVD risk. The USPSTF finds with moderate confidence that commencing aspirin usage for primary CVD prevention in persons 60 years or older had no net benefit.

Recommendations -

1. The choice to begin low-dose aspirin treatment for primary CVD prevention in persons aged 40 to 59 years with a 10% or higher 10-year CVD risk should be made on an individual basis.
2. The evidence shows that aspirin usage has a negligible net advantage in this population. Individuals who are not at elevated risk of bleeding and are willing to take low-dose aspirin daily may benefit more. (Recommendation grade C) The USPSTF advises against commencing low-dose aspirin therapy in persons 60 years of age or older for the primary prevention of CVD. (Recommended grade D).
3. Aspirin lowers blood clotting, but it may also raise the risk of bleeding from the stomach or the brain, particularly if it causes tiny ulcers (erosions).
4. The advantage of avoiding heart attacks surpasses the risk of bleeding in patients with a history of cardiovascular illness, heart attacks, or strokes, and hence there is a net benefit. However, among persons with no known heart or vascular disease and a very low risk of heart attack, aspirin provides no meaningful benefit, while the danger of bleeding remains considerable. As a result, a net risk exists.
5. This danger is increased for people over the age of 60 due to the increased risk of stomach or brain haemorrhage in the elderly. As a result, it is now believed that aspirin is most beneficial for those with a history of cardiovascular diseases, such as heart attacks or strokes, who have previously undergone by-pass surgery or angioplasty, or who have been diagnosed with artery blockages or are at a high risk of cardiovascular disease (secondary prevention).
6. It should not be administered to anyone who has not been diagnosed with a cardiovascular illness, particularly those over the age of 60. Thus, random prescribing of aspirin to the elderly without a history of coronary artery disease is unwarranted.

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Q: What are the additional adverse effects of daily aspirin use?

A: When used seldom to treat pain or fever, aspirin is quite safe. However, daily usage of aspirin might result in the following adverse effects:

• Easy bruising
• Bleeding propensity
• Acid reflux and heartburn
• Nausea and vomiting
• Stomach ulcers
• Bleeding from the piles and intestines
• Inflammation of the kidneys
• An allergic response
• Dyspnea
• Renal failure

However, the advantages of preventing heart attacks and strokes exceed the tiny risk of such adverse effects in patients with established cardiovascular disease.

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Q: How is a person's risk of developing a cardiovascular disease determined?

A: Because the danger of acquiring cardiovascular illnesses and heart attacks is fairly high among individuals aged less than 60-70, people with low bleeding risk in this age range stand to benefit the most from preventative therapy.

The prognosis is based on a Western-developed scoring system that considers the existence of cardiovascular risk factors such as:

• Family history
• Smoking
• Obesity
• Diabetes
• Hypertension
• Blood cholesterol levels and their management.

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Q: Is 'clinical inertia,' or physicians' sluggish acceptance of new practises, the explanation why aspirin is still recommended to everyone regardless of the evidence? What is required to alter such a practice?

A:

1. Aspirin is a very affordable medication that is well-known for its ability to prevent and cure heart attacks and strokes. It is overprescribed with too little consideration for its adverse effects and without refining the risk-benefit ratio, which is skewed toward bleeding and may cause greater damage as age grows.
2. This is not just due to physicians' tardy acceptance or reluctance, but also because these guidelines are based on data from the West, although Indians have a far greater prevalence of risk factors and a multiple-fold increased risk of heart attacks and strokes than those in the West.
3. To make the strongest recommendations, we need to analyse data on the bleeding risks vs the heart attack and stroke preventive advantages of aspirin in Indians. But the message has been properly conveyed: Aspirin should only be provided to older patients with coronary artery disease or a history of heart attack if the danger of bleeding from the drug is clearly proven.
4. Additionally, patients who have had heart attacks, bypass surgery, angioplasties, or strokes should continue to take aspirin since it obviously helps them by avoiding heart attacks and strokes. Individuals who do not suffer from any of these ailments should consult their physicians before making any decisions.

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Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

The author is a practising super specialist from New Delhi.