Aspirin: Lower Cardiac Risk, Higher Bleeding Risk

In 1973, Woody Allen amused audiences by presenting a dialogue between two doctors discussing the curious case of newly-awakened Miles Monroe, a refugee from the twentieth century who had just been revived from a coma in the 22nd century.

Dr. Melik: This morning for breakfast he requested something called “wheat germ, organic honey and tiger’s milk.”
Dr. Aragon: [chuckling] Oh, yes. Those are the charmed substances that some years ago were thought to contain life-preserving properties.
Dr. Melik: You mean there was no deep fat? No steak or cream pies or… hot fudge?
Dr. Aragon: Those were thought to be unhealthy… precisely the opposite of what we now know to be true.

In the 46 years that have elapsed since this “joke” was written, it has proven more prophetic than humorous.

Today, evidence suggests that dark chocolate, red wine, hard cheeses, even butter (as opposed to margarine) and grass-fed red meats (vs. processed, smoked deli cuts) can be healthy choices. That’s the nature of ongoing scientific inquiry. We’re constantly learning new things.

The latest conventional wisdom being turned on its head is that a daily aspirin in low doses is a safe way to help healthy people reduce their overall risk of mortality due to cardiac events such as heart attack or stroke.

A recent study evaluated data from thirteen separate clinical trials, looking at more than 164,000 adults, and concluded that, while aspirin did lower cardiac death risk by 0.38 percent, in terms of overall health risks in healthy people without heart disease, a daily aspirin was associated with a 0.47 higher risk of severe internal bleeding—and in some cases, this complication may be fatal.

But because many people perceive aspirin as a “safe” over-the-counter drug, the overall risks of aspirin may be underestimated. Contrary to long-held conventional wisdom, the United States Preventive Services Task Force does not recommend aspirin for all American adults: Their recommendation, based on the best available evidence, is:

“The USPSTF recommends initiating low-dose aspirin use for the primary prevention of cardiovascular disease (CVD) and colorectal cancer (CRC) in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, 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.” – USPSTF

Those are five distinct and separate criteria for low-dose aspirin therapy, and they warrant a clear-eyed discussion with a health care provider before adding a pill to the daily regimen.
The American College of Cardiology provides a risk calculator to help patients and physicians understand who may meet the 10% cardiovascular disease risk threshold.

Older patients (who are more likely than younger patients to be at risk of bleeding) should discuss the potential risks and benefits of a daily aspirin and its potential interactions with all other pharmaceuticals, OTC drugs, and supplements with their personal physician.

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