Aspirin has been in the news a lot lately.  Recently, the guidelines regarding aspirin use have changed so I would like to clarify these updates for my Wise Patients. In this updated article for 2021, we will discuss the new aspirin recommendations from the United States Preventive Services Task Force (USPSTF). The new guidelines for aspirin center around prevention of cardiovascular disease. But before we can understand the aspirin guidelines, we need to discuss primary and secondary prevention.

Primary vs Secondary Prevention

In primary care, we focus our efforts on prevention of disease. We understand that an ounce of prevention is worth a pound of cure. The two main types of prevention that we deal with are primary and secondary prevention. 

It is important to know the difference for several reasons. For instance, doctors may use this jargon around you, and it’s helpful to know what we are talking about. More importantly, risks and benefits between primary and secondary prevention are quite different. Knowing the difference can help you to become a Wiser Patient. 

Primary Prevention

Primary prevention is an attempt to prevent you from ever having a disease. One good example of primary prevention is getting an immunization to prevent infectious diseases. Another common example would be using diet and exercise to prevent diabetes.  Primary prevention is where we get the most bang for our buck. For example, free diet and exercise could prevent you from spending hundreds to thousands of dollars on diabetes labs, medications, or hospitalizations. Prevention is our most cost-effective way to help keep you healthy. 

Secondary Prevention

Secondary prevention is an attempt to prevent you from having complications from a disease that you already have. For instance, taking a daily cholesterol medication (statin) when you have coronary artery disease.. We always recommend that patients who have had a heart attack take a statin to prevent a heart attack from happening again. Another example of secondary prevention would be taking diabetes medication in order to keep your sugars under control. This secondary prevention will help to prevent eye, kidney, and nerve damage that can occur when you have uncontrolled diabetes. 

What About Aspirin?

How does this all apply to aspirin?  In the past, medical societies have recommended that most adults take a baby aspirin 81mg dose once daily for primary prevention of heart attacks and strokes. More recent data suggests that in people who have low risk for heart attack and stroke, the risks of bleeding from aspirin may outweigh the benefits of primary prevention. In 2019, guidelines changed to recommend against using aspirin for primary prevention in adults >70 years old due to the increased risk of bleeding. Aspirin was still recommended for primary prevention in individuals between the ages of 40-69 with a low bleeding risk and an elevated risk of heart attacks and strokes (>10% estimated risk in the next 10 years). 

New Recommendations From USPSTF:

In October 2021, the USPSTF changed their guidelines regarding aspirin use for primary prevention of cardiovascular disease. The task force recommends against the use of aspirin for primary prevention of cardiovascular disease in patients age 60 and older. This was given a grade D recommendation (see below).

See the full description of USPSTF Grade Definitions here:

Grade	Definition	Suggestions for Practice
A	The USPSTF recommends the service. There is high certainty that the net benefit is substantial.	Offer or provide this service.
B	The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.	Offer or provide this service.
C	The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.	Offer or provide this service for selected patients depending on individual circumstances.
D	The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.	Discourage the use of this service.
I Statement	The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.	Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

Review the new guidelines here at USPSTF. See the updated recommendation summary below:

Recommendation Summary

Population	Recommendation	Grade
Adults ages 40 to 59 years with a 10% or greater 10-year cardiovascular disease (CVD) risk	The decision to initiate low-dose aspirin use for the primary prevention of CVD in adults ages 40 to 59 years who have a 10% or greater 10-year CVD risk should be an individual one. Evidence indicates that the net benefit of aspirin use in this group is small. Persons who are not at increased risk for bleeding and are willing to take low-dose aspirin daily are more likely to benefit.	C
Adults age 60 years or older	The USPSTF recommends against initiating low-dose aspirin use for the primary prevention of CVD in adults age 60 years or older.	D

Aspirin is still recommended for secondary prevention in nearly all patients with a history of heart attack and stroke. And, other medical groups, like the American College of Cardiology (ACC), have not changed their recommendations yet.

In this article, I am speaking about general guidelines. It is important that you discuss your own individual risk and benefit ratios with your doctor before making any medical decisions. Above all, please do not make any medication changes until you speak with your doctor. Certainly, if you are one of my own patients, please don’t make any changes until we speak directly.

To learn more about primary prevention of cardiovascular disease, check out my article “Cholesterol: Treat the Risk, Not the Numbers“

Curious about other risky over-the-counter medications? Consider reading my article: The 5 Most Dangerous Over-The-Counter Medications

For more daily tips for living your best life, read my other articles in the Every Day Health category