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Aspirin for everyone?
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The son of a friend is in medical school. One of his professors told his class, “Everyone should be on an aspirin a day.” My friend’s son was not sure about this and asked me what I thought.
As a rule, I tend to be aggressive rather than conservative in cardiovascular screening and prevention. I believe in following expert consensus guidelines but also understand there may be exceptions. All therapeutic recommendations must be individualized to the patient. However, I never would advise that everyone at all ages take an aspirin a day, not even a baby aspirin.
Guidelines suggest men older than age 45 should take aspirin for prevention of a myocardial infarction, and that women older than age 55 should take it for prevention of ischemic stroke when the benefit outweighs the risk of bleeding. The American Diabetes Association and American Heart Association suggest the use of aspirin 75-162 mg per day for those older than age 40 with type 1 or type 2 diabetes and risk factors such as microalbuminuria, family history of cardiovascular disease, hypertension, smoking and/or dyslipidemia.
None of these guidelines suggest the routine use of aspirin as primary prevention in younger ages. There may be situations where aspirin would be appropriate at younger ages. This includes secondary prevention in someone with established cardiovascular disease or primary prevention in someone thought to be at extreme risk due to other comorbidities. However, for others at younger ages, I would not recommend it.
I explained to my friend’s son that when deciding on any therapy, we must always weigh risks vs. benefits. The main risks associated with aspirin are gastrointestinal bleeding, ulcers and other bleeding. These risks increase with age. The risk from taking aspirin in someone younger than age 40 in the absence of other factors is extremely low. However, the risk of MI or ischemic stroke in this age group (in the absence of other factors) would also be expected to be extremely low. The small risk of taking aspirin might approach or even exceed the probably very small benefit. Thus, aspirin should not be recommended for everyone.
“Opinion-based” medicine is prevalent. Sometimes practicing based on our best opinion and understanding of the science and physiology is the only option we have. There are not large well-designed studies allowing us to make evidence-based decisions in every clinical situation. However, when teaching others, no matter if it is medical students or our patients, we are obligated to acknowledge when our position is opinion rather than evidence based. It is then reasonable to explain why we believe our point of view may be the correct approach for that situation.
It is not appropriate to recite our opinions as if they are fact or commonly accepted by our peers when they are not. I commended my friend’s son for questioning his professor’s comment and asking the thoughts of someone else. Too many might have simply accepted it.