Aspirin for Prevention: Latest Recommendations

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Dr. Luke J. Laffin:

Welcome to the Love Your Heart podcast. My name's Luke Laffin. I'm a preventive cardiologist at the Cleveland Clinic. I'm joined by my very good colleague, Dr. Vikas Sunder, also a preventive cardiologist. It's our pleasure today to speak with you about the latest recommendations for the use of aspirin to prevent heart disease. Now, Dr. Sunder, aspirin's been around forever, but I think we sometimes lose track of what it actually does. What does it do?

Dr. Vikas Sunder:

Exactly, yeah. Aspirin at lower doses, it's a medication that works on an enzyme. What it does is prevent those particles called platelets in the blood from getting activated and sticking together, which we know plays an essential role in heart attacks and strokes and vascular events. Aspirin at low doses can help prevent that process. At higher doses, some of us are familiar with aspirin being used to treat things like fever and inflammation and even pain. It has different effects at different doses, but that's how it works. It works on one of those enzymes.

Dr. Luke J. Laffin:

Got it. I think that we know that when people feel like they're having a heart attack or they're going to the emergency department, sometimes we give them guidance on, say, "Chew a few aspirins." Do we still do that?

Dr. Vikas Sunder:

Yeah. I think now we need to obviously have them evaluated formally in the emergency room and things like that. But no, not necessarily. Someone who has a history of heart issues, they might need to take some other medications if they have symptoms that are concerning, but otherwise, we would like that person to be evaluated first.

Dr. Luke J. Laffin:

Got it. Well, we're preventive cardiologists, of course, so we'll occasionally have our patients call with that. Really, the biggest question I think you and I get is, "How do I prevent heart disease?" Be it the first time or subsequent times in someone that's already had a heart attack. Maybe you can talk a little bit about what is the difference between a patient who's really preventing that first heart attack versus someone who has already had maybe a stent or bypass surgery and wants to take those next steps?

Dr. Vikas Sunder:

Yeah. Great question, Dr. Laffin. It’s our day-to-day practice that we see folks who are trying to do everything they can to prevent that first episode or occurrence, that first heart attack or stroke, cardiovascular event. One of those things, and one of the things I hear a lot from my patients is, "Should I be taking a daily baby aspirin?" Many of them have been doing so, taking an 81 milligram aspirin, the dose that comes in here, for decades and even multiple decades. They're saying, "Hey, Dr. Sunder, Dr. Laffin, should I still be doing this? Should I still be taking that aspirin? And what's the data supporting that?"

I think it's really important to distinguish those two different groups. Someone who has established cardiovascular disease, a history of a heart attack, a history of a heart stent or a history of an event already, versus those who are just really trying to do everything they can. I think first and foremost, we should say that should be guided by a healthcare professional such as you and I, who are preventive cardiologists, rather than feeling like that patient has to make that decision on their own.

Dr. Luke J. Laffin:

Yeah, exactly. No, that makes perfect sense. Aspirin is so easy to pick up over the counter, and I think that clarification of what is a baby aspirin is important. 81 milligrams, it's really that low dose. For example, if someone's had bypass surgery, or they've had a stent before, should they be on an aspirin?

Dr. Vikas Sunder:

Yeah, the data supporting the use of the low dose aspirin in folks who have already had a history of a heart attack or a heart stent, the data is much more supportive. We know that from some of our older clinical trials in cardiology and our large analyses, which show there is definitely a benefit unless there's a contraindication, that there's a reason not to take one of the aspirin medication, that they should be on that medication. They should just discuss that with their cardiologist.

Dr. Luke J. Laffin:

That's a very common question, right? In this era of trying to limit what we take and I get that, right? Not everyone wants to be popping a handful of pills every day. But seeing, "Do I need to be on an antiplatelet medication, of which, aspirin is it?" Yeah, of course, if you've had a stent or stroke or something like that, you want to be on it. I think the more nuanced question, and we get this a lot in clinic, is going to be, "What if I haven't? But I want to reduce my risk as much as possible." How do you think about it and how do you talk about those really sometimes a little bit challenging decisions with your patients?

Dr. Vikas Sunder:

Great question, Dr. Laffin. I think in those patients where they have not had a history of a cardiovascular event, they're trying to do everything they can, it's really important to take a thorough history. You want to know things such as what's the family history of any cardiovascular disease? We want to know other factors such as what's their individual risk based on certain risk prediction tools that we incorporate in the office. Also, what are their individual characteristics? Do they have any other issues like a history of bleeding, a history of kidney problems, or are they on a blood thinner already? Or some type of other health related issue which may affect that decision whether or not to start a baby aspirin.

So, they should always talk with their cardiologist or their primary care doctor or healthcare professional before they take on that decision. But some of the characteristics we look for are what's that individual's risk? We use certain different parameters to evaluate that, risk prediction tools. We can sometimes use imaging in some cases to get some additional data regarding risk, as well as some lab work that we have to look at cholesterol levels and even types of what we call bad cholesterol and those markers. We take all the data as well as the history, and we incorporate that into our decision making.

Dr. Luke J. Laffin:

So having a heart attack, a stroke is a pretty bad thing. You referred to it a little bit earlier, but why isn't a daily aspirin recommended for everyone? I can just get it over the counter, right? Why can't I do that?

Dr. Vikas Sunder:

Yeah, it would seem like a good idea, but there are certainly some risks, the biggest one being the risk of bleeding. Based on how we talked about how aspirin works, one of the detriments of it is that it can increase the risk of bleeding, especially in patients who are already prone to having an increased risk of bleeding or who have a history of bleeding. Patients who have history of kidney problems, those platelets, those particles in the blood don't work as well, so they have some issues with clotting already, so adding an aspirin to the regimen may not be the best thing. Those are some of the issues that we run into.

Dr. Luke J. Laffin:

Sometimes people think about bleeding as really nuisance bleeding, like I cut myself shaving or it takes a little bit longer. But you and I see it when we're taking care of patients in the hospital. Not all bleeding is really benign and nuisance, right?

Dr. Vikas Sunder:

Correct. Some bleeding can cause some major issues resulting in hospitalization, such as bleeding in the head. People who are at increased risk, who partake in some activities that predispose themselves to injury, things like that, can have a higher risk of bleeding as well to take into account.

Dr. Luke J. Laffin:

Now, based on all these recommendations, or I guess based on the data more than anything else, why have recommendations around the use of aspirin changed over the past 10 years?

Dr. Vikas Sunder:

Well, I think there's been some mixed data. That's why when you look at our different professional societies, the recommendation is there in certain groups, but it's not necessarily a strong recommendation, and it's not necessarily an umbrella recommendation. We know for older individuals above the age of 70, for instance, aspirin for preventative purposes, where you're trying to prevent that initial cardiovascular event, may not be the best idea. Actually, that risk of bleeding may outweigh the potential benefit to be gleaned from the baby aspirin.

However, there has been some data in recent years that there are certain individuals with characteristics where a low dose aspirin may be beneficial. Some of those characteristics could be, in certain cases, having a high coronary calcium score or having a genetic type of bad cholesterol marker that we call lipoprotein(a). In those types of patients, maybe it warrants a further discussion about whether they could benefit from a baby aspirin.

Dr. Luke J. Laffin:

I think those are all really wonderful points. But what about other things we can do beyond aspirin or cholesterol lowering medicines, et cetera? How do the lifestyle things that we counsel patients on every day – they may or may not do them – but how do they actually work, and how do they compare to a medication like aspirin?

Dr. Vikas Sunder:

We know from the limited data that generally, the aspirin does provide a net benefit in certain individuals, but it may be small and maybe we should prioritize, or rather, we should prioritize really optimizing those factors that we know play a role in preventing initial heart attacks and strokes. That includes lifestyle factors like exercise and avoiding sedentary behavior. That also includes eating a heart healthy diet. It also includes things like managing sleep and stress levels. Not just sleep duration, but quality. It also incorporates managing other factors like cholesterol and blood pressure, especially that bad type of cholesterol that we know increases the risk of heart attacks and strokes.

Dr. Luke J. Laffin:

I think to that point as well, not smoking, right? Obviously, rates of smoking have decreased substantially throughout the world, particularly in the United States. That's one posited reason why we may not need aspirin as much. Because the rates of cardiovascular disease are decreased, people aren't smoking as much, maybe you don't get as much benefit from aspirin, right?

Dr. Vikas Sunder:

Correct. Yes, we absolutely know the rate of cardiovascular disease in this country has decreased in recent years, but we're seeing a deceleration in that decrease and some of those factors that are maybe associated with that are rising incidences of obesity and diabetes. We really need to focus on treating those conditions as well. That might be something else to prioritize: treating obesity and diabetes, which we know are associated with the risk.

Dr. Luke J. Laffin:

As we think about really sort of wrapping this up and summarizing for patients listening at home right now or on their drive, can you come up with a few key takeaways for us that we really should be saying? Maybe patients should be taking these to their family members or to their primary care doctor or their cardiologist, and either asking or saying, "I heard this on the Love Your Heart podcast, what do you think?"

Dr. Vikas Sunder:

Yeah, absolutely, Dr. Laffin. First of all, you don't have to make the decision on your own. I think that's the number one takeaway. Speak with your physician, talk to them, have an informed discussion about it. What are the benefits, what are the risks?

Number two, know your health history. Always speak with the physician. Again, the physician might not be able to know certain things about your history if you don't tell them. Do you have a history of bleeding? Do you have a family history of heart problems? Have you had any issues in the past? What's your day-to-day like? Do you do any types of activities that could increase your risk of bleeding? So, always have that informed discussion with your physician, don't do it yourself.

Also think about other things that you can do for your heart health as well. That includes lifestyle factors, other medications that are being recommended to control other factors. I think those are the big takeaways in terms of should you be on a baby aspirin. Don't feel like you have to make that decision on your own.

Dr. Luke J. Laffin:

One thing I will add, I think those are great. If you have had a stent or a stroke or something like that, probably you will be on it most likely, so don't go stopping it, right? We definitely see that all the time.

Dr. Vikas Sunder:

Absolutely. Yeah, we really need to make that distinction between those who have had cardiovascular events, who have established cardiovascular disease where you should be on the baby aspirin unless there's a reason not to be, versus those who have not had a history of events where they're thinking about, "Should I be taking a daily aspirin?"

Dr. Luke J. Laffin:

Well, I think that was great. Thank you very much, Dr. Sunder. Thank you all for listening to the Love Your Heart podcast.

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