“It used to be ‘an aspirin a day keeps the doctor away,’” Justin Martin, M.D. says with a chuckle. Martin is an interventional cardiologist on the medical staff at Texas Health Heart and Vascular Specialists, a Texas Health Physicians Group Practice. “That used to be a tried-and-true recommendation by health care providers. But with time and advances in medicine, we’ve come to realize that saying doesn’t hold true for everyone.”

Martin is referring to the recent updated guidelines when it comes to prescribing a low-dose aspirin regimen for prevention of a heart attack, stroke or cardiovascular disease by the United States Preventative Service Task Force (an independent panel of experts in disease prevention). The guidelines suggest doctors stop recommending daily aspirin to people 60 and older who want to prevent their first heart attack or stroke.

The decision most likely comes from the fact that cardiovascular disease is now more effectively treated with cholesterol, diabetes, and blood pressure medications, plus the fact that as we get older, our bleeding risks go up, making the benefit of a daily aspirin regimen questionable.

“You’re constantly balancing the benefit of blood clotting to prevent heart attacks and strokes, but what we’ve realized over the last decade or more is the downside is bleeding risk,” Martin explains. “We used to look at it as an equal tradeoff, but it turns out bleeding is a bigger issue than we used to give it credit for and we’re becoming aware of that now. So even in patients who have cardiovascular disease and who are getting stents, we’re shortening the duration of aspirin therapy.”

But why is aspirin prescribed in the first place and how does it help prevent a cardiovascular event? Martin explains that aspirin is a blood thinner, and it irreversibly inhibits one of the main components of our blood clotting system called platelets. So aspirin often forms a cornerstone of treatment to prevent and treat the heart attacks and strokes that are caused by acute blockages that result from atherosclerosis or hardening of the arteries, including cholesterol build-up in our vessels.

But Martin adds the controversy regarding aspirin’s benefits has existed for some time now.

“The American College of Cardiology puts out their own guidelines for all sorts of cardiovascular conditions and they published their prevention guidelines in 2019, so this information about aspirin has already been out there,” he adds. “Generally speaking, it’s important to know the difference between taking aspirin when you already have cardiovascular disease and taking aspirin preventatively if you’ve never been found to have a blockage or cardiovascular disease. And that’s the difference between primary prevention and secondary prevention.”

• Primary prevention – You’ve never had a heart attack or stroke, nor have you ever had coronary bypass surgery, coronary angioplasty with stent placement, or blocked arteries in your neck, legs or other parts of the body, but you take a daily aspirin to prevent such heart events.
• Secondary prevention – You’ve already had a heart attack or stroke, or you have known heart or blood vessel (vascular) disease. Therefore, you’re taking a daily aspirin to prevent heart attacks or strokes.

Martin says in the primary prevention group with people who don’t have established disease, the benefit of a low-dose aspirin regimen is less certain, particularly in people over the age of 60. Daily low-dose aspirin therapy may be recommended for the primary prevention of heart attack or stroke if:

• You’re between ages 40 and 59 and you’re at high risk (10% or greater) of having a first-time heart attack or stroke within the next 10 years.
• You haven’t had a heart attack, but you’ve had coronary bypass surgery or a stent placed in a coronary artery, or you have chest pain due to coronary artery disease (angina) or any other medical condition where aspirin is proved to prevent heart attacks or stroke.
• You’re younger than 60 and you have diabetes and at least one other heart disease risk factor, such as smoking or high blood pressure.

So how can you know whether to start up an aspirin regimen or stop the one you’re currently on, especially if you’ve been taking low-dose aspirin for years?

“One of the questions I’ve been getting a lot from patients is ‘why the change?’ It seems you can hardly keep up with the guidelines,” Martin says. “At the end of the day, it’s all about individualized care.

“For instance, someone might say they feel they’re at a high risk for a stroke because both parents had a stroke and so did a sibling. So in order to feel more comfortable about prevention, they want to take a baby aspirin every day, whether it’s recommended by the guidelines or not. It’s a discussion of risks, benefits, anything else you can do to prevent a heart issue, etc. to make that decision. You need to speak with your doctor about the risks and benefits of any of these therapies.”

Martin adds it’s also worth noting that mixing aspirin with other medications, certain steroids, and antidepressants can have serious side effects, so it’s essential to chat with your doctor about possible drug interactions.

If you are currently on a low-dose aspirin regimen and have been told by your physician not to stop, but you’d still like to lower your risk of gastrointestinal bleeding, one of the more common bleeding risks, Martin suggests asking your physician about taking a preventative antacid medication to reduce excess stomach acid.

“What’s happening with aspirin is that not only is it inhibiting the clotting, it’s also inhibiting the mechanisms in our stomachs that protect the lining,” he says. “And that excess stomach acid that can form is oftentimes what leads to the gastrointestinal bleeding that we’re trying to prevent.”

As for chewing an aspirin during a possible heart attack, Martin says that is still recommended.

“That’s the one situation where if you think you’re having a heart attack, chewing a 325mg or four 80mg of aspirin is a good recommendation for acute therapy,” he adds. “Call 9-1-1, then chew an aspirin if you can. The aspirin alone isn’t going to save your life, but it can definitely buy you time until medical attention arrives.”

If you’ve been taking daily aspirin, or you’ve been considering it, and you’re worried about what to do now, Martin says it’s important not to make any decisions on your own.

“Every situation is unique, and these guidelines should not override your doctor’s advice,” he says. “Talk to your doctor first about it, but definitely not everyone needs to take aspirin like in the old days where it was kind of just this blanket statement that everyone stood to benefit from it.”

Learn more about staying heart healthy at TexasHealth.org/Heart.