Could Daily Low-Dose Aspirin Still Help Some People?

Dennis Thompson wrote . . . . . . . . .

Debate over the benefits and drawbacks of daily low-dose aspirin has flared in recent years, with guidelines now generally urging against the regimen to prevent a first heart attack or stroke in healthy people.

But some people with good heart health still might benefit from taking daily low-dose aspirin, a new study from New Zealand argues.

About 2.5% of women and 12% of men would likely benefit from daily aspirin during a five-year period, based on an analysis of more than 245,000 heart-healthy New Zealand residents.

“In our study, we were able to predict for each individual, by taking into account their personal characteristics, their propensity to benefit from or be harmed by aspirin,” said lead researcher Vanessa Selak, an epidemiologist with the University of Auckland in New Zealand.

“Using this personalized approach enabled us to identify specific individuals who were likely to benefit from aspirin after weighing up aspirin’s effects on both cardiovascular events and serious bleeding,” Selak continued.

That would seem to contradict new guidelines issued earlier this year by the American Heart Association (AHA) and the American College of Cardiology (ACC).

The two groups concluded that for older adults with healthy hearts, the risk of bleeding that comes with aspirin therapy outweighs any heart benefit.

“We used to say aspirin generally yes, occasionally no. Now we say aspirin generally no, occasionally yes,” said Dr. Amit Khera, who served on the ACC/AHA committee that wrote the guidelines.

However, Khera feels this new study actually supports the new guidelines.

“This modeling exercise confirmed it’s a very small group of the population that potentially could be eligible for aspirin,” said Khera, a professor of cardiology with UT Southwestern Medical Center in Dallas.

These guidelines are not for people who’ve had an emergency regarding their heart health. Those people do derive overall benefit from aspirin, he said.

“If you’ve had a heart attack or stroke, continue to take your aspirin,” Khera said.

But clinical trial data that emerged in 2018 showed that daily aspirin taken by people in good heart health only reduces their risk of heart attack and stroke by 11%, but increases their risk of dangerous bleeding by 43%, he added.

“I want to be clear that I’m not talking about nosebleeds,” Khera said. “I’m talking about needing a transfusion, being hospitalized, bleeding in the brain. Big stuff.”

To take a closer look at the potential benefits of aspirin, Selak and her colleagues studied hundreds of thousands of New Zealanders without heart disease who had their heart health risk calculated between 2012 and 2016.

The net effect of aspirin was calculated for each person by subtracting the number of heart emergencies the person was likely to have over five years from the number of major bleeds aspirin could cause.

After personalizing the risk-versus-benefit calculation, the researchers found that a select group of people would have a net benefit from aspirin if one heart health emergency that led to hospitalization or death was considered equal to one major bleed that led to hospitalization or death.

The percentages increased to 21% of women and 41% of men if a heart health emergency was considered equal to two major bleeds, the findings showed.

“This research suggests that decisions regarding the use of aspirin among people who have not already had a cardiovascular event should be made after undertaking a personalized prediction of cardiovascular benefits and bleeding harms from aspirin,” Selak said.

That’s already standard procedure under the U.S. guidelines, Khera said.

“No one is saying aspirin doesn’t help. It just doesn’t help as much as we used to think, and you have to appreciate the bleeding penalty,” Khera said. “Some people are more concerned about heart attack risk and are willing to pay the bleeding penalty, especially if they’ve never had any bleeding problems. It’s still OK for them to consider it.”

Both Selak and Khera recommended that people talk with their doctor about the risks and benefits before starting to take daily aspirin. Calculators are available that help physicians weigh your risk of heart attack and stroke against the risk of bleeding.

“In many ways, people think of aspirin as this benign thing because it’s been around for centuries. Anybody can get it over the counter,” Khera said. “But if you’re going to take it every day for the next couple of decades, there are definite penalties to it.”

The new study was published online in the Annals of Internal Medicine.

Source: HealthDay


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Brain Bleed Risk Puts Safety of Low-Dose Aspirin in Doubt

Amy Norton wrote . . . . . . . .

Let’s say you’re one of the millions of older adults who takes a low-dose aspirin religiously, in the belief that it will guard against heart disease and heart attacks.

Now, a new review suggests your risk of a brain bleed outweighs any heart benefit that a daily aspirin might bring you.

Researchers said the findings support a recent change to guidelines on low-dose aspirin: The blood thinner should now be reserved for people at high risk of heart attack or stroke.

Others can skip it.

The change was issued in March by the American College of Cardiology (ACC) and the American Heart Association (AHA). The groups said that while the bleeding risk with aspirin has always been known, it now appears the risk is not worth it for most people.

Instead, the average person should focus on controlling their blood pressure, blood sugar and cholesterol, eating a healthy diet, getting regular exercise and not smoking.

“All of those things are more important than taking low-dose aspirin in preventing future heart attacks and strokes,” said Dr. Meng Lee, one of the authors of the new report.

“Our findings do support the latest change to the ACC/AHA guidelines,” said Lee, of Chang Gung University College of Medicine, in Taiwan.

For the study, the investigators pooled the results from 13 clinical trials testing low-dose aspirin in older adults with no history of heart problems or stroke. On average, aspirin raised the risk of bleeding in or around the brain by 37%, the findings showed.

The risk was still small: The researchers estimate that a daily aspirin would cause an additional two brain bleeds for every 1,000 people.

But for people at lower risk of heart attack or stroke, that’s a chance they probably should not take, according to the new guidelines.

And, based on two trials, people of Asian ethnicity might be at particular risk of brain bleeding. Patients in those studies saw their risk rise by 84%.

It’s not clear why, according to Lee — but other studies have found the same pattern.

The latest finding was published online in JAMA Neurology.

If it has long been known that aspirin carries a bleeding risk, why is the advice changing now?

Research in recent years has shown that the balance of risks versus benefits has changed, explained Dr. Eugene Yang, a member of the ACC’s Prevention Section and Leadership Council.

Earlier studies did suggest that the bleeding risks with aspirin were generally outweighed by its ability to curb the odds of a first-time heart attack and stroke.

But things are different today, Yang explained. People are smoking less and there have been improvements in controlling high blood pressure and cholesterol. That means for lower-risk people, the heart benefit of aspirin has diminished — making the bleeding risk more of a concern.

Yang stressed, however, that the guideline change applies only to people without “overt” cardiovascular disease. For people with a history of heart attack or stroke, or significant narrowing in the arteries supplying the heart, brain or legs, the advice stays the same.

“In those cases, you’re trying to prevent further complications,” said Yang, who is also a clinical associate professor of medicine at the University of Washington, in Seattle.

In addition, he pointed out, aspirin is not an absolute “no” for preventing first-time complications, either.

The guidelines say people over age 70 should avoid aspirin if they do not have overt cardiovascular disease. But it may still be considered for certain people ages 40 to 70 who are at heightened risk of cardiovascular complications.

“It’s not a simple, black-and-white decision,” Yang said.

If you are currently taking aspirin and wondering if you should stop, talk to your doctor first, Yang advised.

“There could be other reasons it was prescribed, such as lowering the risk of colon cancer or to prevent blood clots,” he said.

Source: HealthDay


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Guidance for Preventing Heart Disease, Stroke Released

According to the guideline released by ACC/AHA, any effort to prevent a first instance of cardiovascular disease (called primary prevention) should ideally start with a thorough assessment of one’s risk—that is, estimating how likely someone is to develop blockages in their arteries and have a heart attack or stroke or die as a result. All patients should openly talk with their care team about their current health habits and personal risk for cardiovascular disease and, together, determine the best way to prevent it based on current evidence and personal preferences.

“We have good evidence now for how to identify these very high risk individuals with a physical exam and a good history, and for those at borderline risk there are additional factors that can help us determine who is at greater risk and should, for example, be on a medication like a statin earlier to prevent a cardiovascular event,” Blumenthal said. “In the past, a lot of people may have had a fatalistic attitude that they were going to develop heart problems sooner or later but, in reality, most cardiovascular events can be prevented.”

The document synthesizes the best data and proven interventions for improving diet and exercise, tobacco cessation and optimally controlling other factors that affect one’s likelihood of heart problems and stroke (e.g., obesity, diabetes, high cholesterol and high blood pressure). The document also discusses the challenges that may interfere with individuals being able to integrate better lifestyle habits.

Lifestyle Change Recommendations

The guideline underscores healthy lifestyle changes as the cornerstone of preventing heart disease and goes a step further by providing practical advice based on the latest research.

“We can all do better with our dietary and exercise habits, and that’s so important when we think about wanting to live longer and healthier lives, whether it’s to see our grandchildren grow up or to stay as active as possible in older age,” Blumenthal said.

Some of the key lifestyle recommendations include:

  • Eating heart healthier – choosing more vegetables, fruits, legumes, nuts, whole grains, and fish, and limiting salt, saturated fats, fried foods, processed meats, and sweetened beverages; specific eating plans like the Mediterranean, DASH and vegetarian diets are reviewed.
  • Engaging in regular exercise – experts advise aiming for at least 150 minutes of moderate-intensity exercises such as brisk walking, swimming, dancing or cycling each week. For people who are inactive, some activity is better than none and small 10-minute bursts of activity throughout the day can add up for those with hectic schedules. Currently, only half of American adults are getting enough exercise and prolonged periods of sitting can counteract the benefits of exercise.
  • Aiming for and keeping a healthy weight – for people who are overweight or obese, losing just 5 to 10 percent of their body weight (that would be 10-20 pounds for someone who weighs 200 pounds) can markedly cut their risk of heart disease, stroke and other health issues.
  • Avoiding tobacco by not smoking, vaping or breathing in smoke – 1 in 3 deaths from heart disease is attributable to smoking or exposure to secondhand smoke, so every effort to try to quit through counseling and/or approved cessation medications should be supported and tailored to each individual.

Aspirin Use

For people who’ve had a heart attack, stroke, open heart surgery or stents placed to open clogged arteries, aspirin can be lifesaving. But regular use of aspirin to prevent heart attacks and stroke in healthy people isn’t as clear-cut.

In this guideline, ACC/ AHA experts offer science-based guidance that aspirin should only rarely be used to help prevent heart attacks and stroke in people without known cardiovascular disease. Recent research suggests that the chance of bleeding, given the blood-thinning effect of aspirin, may be too high and the evidence of benefit—the number of heart attacks or strokes that are actually prevented—is not sufficient enough to make a daily aspirin worth taking for most adults in this setting.

“Clinicians should be very selective in prescribing aspirin for people without known cardiovascular disease,” Blumenthal said. “It’s much more important to optimize lifestyle habits and control blood pressure and cholesterol as opposed to recommending aspirin. Aspirin should be limited to people at the highest risk of cardiovascular disease and a very low risk of bleeding.”

Based on a simplified synopsis of the latest ACC/AHA cholesterol guideline, for primary prevention, statins should be commonly recommended with lifestyle changes to prevent cardiovascular disease among people with elevated low density lipoprotein (LDL) cholesterol levels (≥ 190 mg/dl), Type 2 diabetes, and anyone who is deemed to have a high likelihood of having a stroke or heart attack upon reviewing their medical history and risk factors and having a detailed discussion with their clinician.

Diabetes

For people with Type 2 diabetes, which is one of the strongest risk factors for cardiovascular disease, there are new data that two classes of diabetes medications, which work to lower blood sugar levels, can also cut the risk of heart attack, stroke and related deaths.

Source: American Heart Association

Is Daily Low-Dose Aspirin Really Worth It for Seniors?

Dennis Thompson wrote . . . . . . . . .

There’s disappointing news for seniors: A new trial shows that taking daily low-dose aspirin doesn’t prolong healthy, independent living in otherwise healthy people aged 70 and older.

Aspirin has long been recommended for middle-aged folks with a history of heart disease, to prevent future heart attacks or strokes.

Researchers had hoped that aspirin’s specific effects might help folks ease gracefully into their old age.

“The thinking was the double action of blood thinning and anti-inflammation might decrease the risk of dementia and disability,” explained senior researcher Dr. Anne Murray, director of the Berman Center for Outcomes and Clinical Research at Hennepin Healthcare in Minneapolis.

But a major new clinical trial has concluded that daily aspirin does not prolong disability-free survival in the elderly.

In fact, aspirin could put their health at risk by increasing the risk of bleeding in the brain and the gastrointestinal tract, researchers found.

“We were so hoping that such an inexpensive and accessible medication might be effective in prolonging healthy independent life,” Murray said.

Daily aspirin is recommended for people between 50 and 59 if they are at increased risk of heart disease, according to the U.S. Preventive Services Task Force, a guideline-setting expert panel.

For people ages 60-69 “who have a 10 percent or greater 10-year [heart disease] risk,” the decision to start low-dose daily aspirin “should be an individual one,” the USPSTF said.

However, there’s not been enough medical evidence to say whether aspirin would help elderly folks, the USPSTF says.

“It’s the first of its kind to address this question,” said Dr. Basil Eldadah, chief of the Geriatrics Branch of the U.S. National Institute on Aging. “It’s an important issue because so many older people in the United States take aspirin, and there’s not clear evidence up until now whether that’s indicated.”

To answer the question, researchers recruited just over 19,000 people in Australia and the United States with an average age of 74, and assigned half to take daily aspirin and the other half to receive a placebo.

People were recruited between 2010 and 2014, and had to be free of dementia, physical disability or any medical condition that would require aspirin use. They were followed for an average of close to five years.

Treatment with 100 milligrams of aspirin per day did not affect the chances a person would live longer free from dementia or disability, researchers found.

In fact, the group taking aspirin had a slightly increased risk of death — 5.9 percent died compared with 5.2 percent taking a placebo. However, the higher death rate was due to more cancer deaths in the aspirin group, which could have been due to chance, the researchers said.

More troubling was the fact that people taking daily aspirin suffered clinically significant bleeding.

Hemorrhagic stroke, bleeding in the brain, gastrointestinal bleeding, or bleeding at other sites that required transfusion or hospitalization occurred in 3.8 percent of people on aspirin versus 2.7 percent of people on placebo.

“There’s definitely an increased bleeding risk, and it’s not benign,” said Dr. Vincent Bufalino, a cardiologist and spokesman for the American Heart Association. “The intracranial bleeding risk is obviously a terrible complication.”

The clinical trial’s results suggest that “if seniors don’t have a valid medical need for taking aspirin, you are unlikely to benefit from it and there are some risks,” concluded lead researcher John McNeil, head of epidemiology and preventive health at Monash University in Melbourne, Australia.

However, all of the experts agreed that if you’re now taking aspirin under a doctor’s direction you shouldn’t stop until you discuss it with them, regardless of your age.

“Many people are taking aspirin for important medical reasons,” McNeil said. “It would be unwise to stop without speaking to their doctor about it.”

The clinical trial was published online as three papers in the New England Journal of Medicine.

Source: HealthDay

Daily Aspirin Might Ease COPD Flare-Ups

Steven Reinberg wrote . . . . . . . . .

Many Americans take a daily low-dose aspirin to protect their hearts. Now it appears aspirin may also reduce flare-ups of chronic obstructive pulmonary disease (COPD).

In a study of COPD sufferers, researchers found that aspirin was linked to fewer moderate exacerbations, but not severe bouts, of the lung disease. It also reduced moderate and severe episodes of labored breathing.

“This study highlights that adding aspirin to current treatment regimens may potentially improve the well-being of patients suffering from a burdensome chronic disease while reducing health care utilization,” said lead researcher Dr. Ashraf Fawzy. He is a pulmonary and critical care fellow at Johns Hopkins University in Baltimore.

However, Fawzy said more research is needed before broadly recommending that patients start taking aspirin as part of their COPD treatment.

The study was funded by the U.S. National Institutes of Health. Fawzy and his colleagues looked at nearly 1,700 people with COPD. About 45 percent of participants reported regularly taking low-dose aspirin at the start of the study. (Low-dose aspirin is generally 81 milligrams.)

The researchers found the aspirin users had fewer flare-ups over three years.

Patients also reported better quality of life and less shortness of breath, compared with patients who did not use aspirin, according to the study.

COPD includes bronchitis and emphysema, two chronic lung diseases. Smoking is its main cause, but long-term environmental exposure to toxic dust or chemicals is another culprit.

Millions of Americans suffer from COPD, and it is the third leading cause of disease-related death in the nation, according to the American Lung Association.

There is treatment but no cure. Medications usually include a bronchodilator that opens the airways, making it easier to breathe, and an anti-inflammatory. In the most severe cases, patients need a constant supply of oxygen.

Aspirin has already shown a benefit in preventing heart attacks and strokes in patients with cardiovascular disease, but its role in COPD has been unclear.

However, because this study can’t actually prove that aspirin caused the reduction in flare-ups, experts aren’t ready to make a general recommendation about aspirin use for COPD.

“It’s really too early to say,” said Dr. Alan Mensch, senior vice president for medical affairs at Plainview and Syosset Hospitals in Long Island, N.Y.

“COPD is a chronic condition where we really have limited options to treat patients,” said Mensch, who wasn’t involved in the new research.

Although new treatments would be welcome, he said it’s hard to tell from this study if aspirin really reduced flare-ups.

That’s because it was what’s called an observational study. Researchers compared patients who self-reported they did or didn’t take aspirin, but weren’t randomly assigned to one group or the other.

Fawzy added that “a randomized controlled trial of aspirin use in patients with COPD is warranted to rigorously assess whether aspirin is beneficial in this patient population.”

One problem in comparing COPD patients is that many suffer from other conditions. Most COPD patients, for example, also have cardiovascular disease, Mensch pointed out.

However, he noted that other studies have found aspirin may extend the life of COPD patients and slow the progression of emphysema. “It may help,” Mensch said.

So how exactly might aspirin work its magic? Mensch noted aspirin is an anti-inflammatory, which might explain the reduction in COPD flare-ups.

The report appears in the journal Chest.

Source: HealthDay


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