As­pirin in pri­mary pre­ven­tion, BE­FORE a car­dio­vas­cu­lar event.

Great Health Guide - - CONTENTS - Dr War­rick Bishop


the pre­vi­ous ar­ti­cle en­ti­tled

As­pirin in Heart Health Part 1, the im­por­tance of us­ing as­pirin in se­condary pre­ven­tion was dis­cussed. Se­condary pre­ven­tion is stop­ping or re­duc­ing the risk of a se­cond event such as a fur­ther heart at­tack or stroke. How­ever, giv­ing as­pirin to peo­ple be­fore they have an event, i.e. in pri­mary pre­ven­tion, has caused con­tro­versy over sub­se­quent years. Does giv­ing as­pirin in pri­mary pre­ven­tion of­fer any ben­e­fits in hear health? In the last three to six months, a num­ber of tri­als have tried to an­swer this ques­tion. In Au­gust 2018, a study called AS­CEND was pub­lished in the New Eng­land Jour­nal

of Medicine. This trial stud­ied pa­tients who were di­a­betic, but had not had any his­tory of heart prob­lems, i.e. they were a pri­mary pre­ven­tion pop­u­la­tion. These pa­tients, 15,000 of them were in fact fol­lowed for over seven years and although at the end of that time, there was some sug­ges­tion that the risk of hav­ing a heart at­tack was re­duced in the group re­ceiv­ing as­pirin, this ben­e­fit was off­set by an in­creased risk of bleed­ing caused by tak­ing as­pirin for a long term. There was an in­creased risk of bleed­ing from the up­per part of the gut or of bleed­ing into the brain. Un­for­tu­nately, the AS­CEND trial did not show a ben­e­fit in giv­ing as­pirin for a group of di­a­betic pa­tients, who had not had pre­vi­ous heart prob­lems.

Re­leased at the same time as the AS­CEND trial re­sults, a study called AR­RIVE pub­lished in The Lancet, showed that as­pirin had no sig­nif­i­cant ben­e­fit in out­come when given to 13,000 sub­jects ran­domised to take as­pirin or not. These

were peo­ple with ‘mod­er­ate car­dio­vas­cu­lar risk’ but had not had a pre­vi­ous heart at­tack or stroke. Mod­er­ate car­dio­vas­cu­lar risk means that the risk of an event in the next ten years is be­tween 10 and 20% risk. This group of pa­tients was fol­lowed for ap­prox­i­mately six years and dur­ing that time any ben­e­fits in re­duc­tion of stroke or heart at­tack were matched by com­pli­ca­tions of bleed­ing. The most re­cent trial for as­pirin, stud­ied for its role in ‘pri­mary pre­ven­tion’, was the

ASPREE trial. Pri­mary pre­ven­tion deals with de­lay­ing or pre­vent­ing the on­set of a car­dio­vas­cu­lar event. Nearly 20,000 peo­ple across the world were en­rolled to try and eval­u­ate whether as­pirin given to oth­er­wise healthy older adults, over 70 years of age, would im­prove func­tion and re­duce death. These par­tic­i­pants in the trial were fol­lowed

for ap­prox­i­mately six years and there was no sug­ges­tion that giv­ing as­pirin to this healthy group of older cit­i­zens made any dif­fer­ence. In fact, there was even a small sug­ges­tion that it could worsen the out­come. It is worth not­ing that these healthy older adults had lived to be healthy older adults, be­cause they did not have coronary artery or car­dio­vas­cu­lar dis­ease up to that point and so to some de­gree, the group al­ready had a rel­a­tively low risk to ben­e­fit from as­pirin, in the con­text of re­duc­ing car­dio­vas­cu­lar risk.


It would cer­tainly seem that as­pirin should not just be tried to re­duce risk of heart at­tack and stroke for every­one. It cer­tainly does not have a clear-cut use in nor­mal pri­mary pre­ven­ta­tive sit­u­a­tions of low or mod­er­ate/in­ter­me­di­ate risk pa­tients. There is some data to sug­gest that pa­tients with el­e­vated blood pres­sure may well ben­e­fit from be­ing on as­pirin and that is be­cause el­e­vated blood pres­sure can push peo­ple into a higher risk cat­e­gory.

I tend to try and be more pre­cise about how to eval­u­ate the risk that an in­di­vid­ual may have in the pri­mary pre­ven­ta­tive set­ting by un­der­tak­ing imag­ing of their coronary ar­ter­ies. None of the pri­mary pre­ven­tion stud­ies as above, have in­cor­po­rated imag­ing as a se­lec­tor for as­pirin ther­apy or not, so the use of imag­ing in pri­mary pre­ven­tion by as­pirin re­mains some­what unan­swered and spec­u­la­tive. How­ever, if we find peo­ple with high or very high-risk fea­tures on imag­ing, then un­der­stand­ing the pros and cons of as­pirin based on the in­di­vid­ual’s sit­u­a­tion, the use of as­pirin may well be a rea­son­able con­sid­er­a­tion. This is some­thing that needs to be con­sid­ered on a pa­tient to pa­tient ba­sis with all the in­for­ma­tion avail­able and with a clear con­ver­sa­tion be­tween doc­tor and pa­tient striv­ing for the best man­age­ment strat­egy for that in­di­vid­ual. I have writ­ten a book on this very sub­ject.

When it comes to se­condary pre­ven­tion i.e. peo­ple who have had a heart at­tack or stroke, there re­mains no ques­tion that as­pirin is ben­e­fi­cial, and these cur­rent tri­als do not im­pact or al­ter the way we view as­pirin in that sit­u­a­tion. This means that if you have had a prob­lem with your heart ar­ter­ies, neck ar­ter­ies or ar­ter­ies in the legs and you have been put on as­pirin by your doc­tor, then that as­pirin is go­ing to be do­ing a good job for you. Please do not stop your ther­apy based on the way some me­dia out­lets have pre­sented the data from AS­CEND,

AR­RIVE and ASPREE, check if it re­lates to your con­di­tion. Ev­ery treat­ment needs to be con­sid­ered for the in­di­vid­ual pa­tient based on the mer­its of ben­e­fit of that ther­apy, weighed up clearly against the risks that could be in­her­ent. This is some­thing that your doc­tor needs to work through with you and some­thing you need to be aware of and in­formed of. Please work with your doc­tor for your own best out­comes.

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