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April 27, 2016

Bleeding, Hearts and Aspirin

Recommendations regarding taking low-dose aspirin to prevent heart attacks and colon cancer have changed.

For years, people who have had a heart attack have been taking daily aspirin to prevent a second attack. And while aspirin can lower the risk of a first heart attack, daily aspirin hasn't been widely recommended for people who have not had a heart attack since it raises the risk of gastrointestinal bleeding and hemorrhagic stroke.

The new recommendations strive to be more practical than the panel's 2009 guidelines.

The United States Preventive Services Task Force (USPSTF) has just issued a draft statement regarding the wider use of aspirin. It recommends that many people aged 50 to 59 now start taking daily aspirin, as well as some people 60 to 69 years old.

The recommendations are in draft form, meaning that they may ultimately change. And they are very specific about who would benefit from taking daily low-dose aspirin.

The USPSTF recommends starting low-dose aspirin for people aged 50-59 who have a 10 percent or greater cardiovascular disease (CVD) risk over the next ten years, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years. This is a Grade B recommendation.

Aspirin has been shown not only to reduce the risk of a first heart attack, but also of colorectal cancer. If you are in this age group and unsure where you fall under these recommendations, discuss the issue with your doctor.

For older people the guidelines are similar, but the recommendation is only Grade C, meaning that the overall benefits are likely smaller than for people aged 50 to 59. So instead of a blanket, Grade A, endorsement, the new recommendation says that the decision to start taking low-dose aspirin for the primary prevention of CVD and colorectal cancer in adults aged 60 to 69 years who have a 10 percent or greater 10-year CVD risk should be an individual one.

The new recommendations strive to be more practical than the panel's 2009 guidelines. Those earlier recommendations encouraged daily aspirin use in a wider age range, as long as the potential benefit of lower heart attacks (men) and strokes (women) outweighed the potential harms. Since it is quite difficult to estimate those numbers with confidence, there has been a great deal of controversy over what the recommendations actually meant in practical terms — who should be taking daily aspirin. It is well known that the risk of bleeding increases as a person ages.

Currently, the FDA does not recommend taking aspirin for primary prevention of heart attack or stroke. The USPSTF found insufficient evidence that the benefits of daily aspirin outweighed the harms for people under the age of 50 or those aged 70 or older.

An article detailing the recommendations and an accompanying editorial are freely available in Annals of Internal Medicine.
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