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Should Everyone Over 50 Take a Daily Aspirin?
 The battle rages on with two experts giving Pro/Con
views
June 17, 2005 - Experts go head to head in this
weeks BMJ over whether everyone over 50 should take a daily aspirin to
reduce their risk of heart attacks and strokes.
Peter Elwood and colleagues at Cardiff University
believe that the evidence now supports more widespread use of aspirin,
and there needs to be a strategy to inform the public and enable older
people to make their own decision.
FOR "It is 30
years since the first randomized trial was published showing a link
between aspirin and myocardial infarction.1 We believe that the evidence
now supports more widespread use of aspirin prophylaxis, and there needs
to be a strategy to inform the public and enable older people to make
their own decision. The evidence focuses on a crucial questionnamely,
at what age does the balance between benefit and risk justify low dose
aspirin prophylaxis? Of further relevance is a possible reduction of
cancer and dementia by aspirin.
But Colin Baigent of the Oxford Radcliffe Infirmary
warns that it would be unwise to adopt such a policy, whatever age
threshold is chosen, until we are sure that older patients will derive
net benefit from it.
AGAINST "An age
threshold approach to aspirin prophylaxis in people without known
vascular disease has two important problems. The balance of benefits and
risks of aspirin in people aged 70 or over has not been clearly defined
in randomised trials, and the benefits do not clearly exceed the risks
in younger people without vascular disease. Consequently, it would be
unwise to adopt such a policy, whatever age threshold is chosen, until
we are sure that older patients will derive net benefit from it.
As a general rule, daily aspirin is given only to
people whose five year risk of a vascular event, such as a heart attack
or stroke, is 3% or more. The authors show that, by age 50, 80% of men
and 50% of women reach this level of risk and they suggest that 90-95%
of the population could take low dose aspirin without problems. Evidence
is also growing that regular aspirin may reduce cancer and dementia.
| |
What Is Your Risk |
|
| |
Estimates of age at which 50% and 80% of population reach a 3%
risk of a vascular event within the next five years and 1% risk
in one year.
|
Age (years) |
|
|
|
|
|
Never smoked |
Current smokers |
All |
|
Men* |
|
|
|
|
3% risk in 5 years: |
|
|
|
|
50% |
46 |
38 |
42 |
|
80% |
55 |
44 |
49 |
|
1% risk in 1 year: |
|
|
|
|
50% |
60 |
50 |
54 |
|
80% |
68 |
56 |
62 |
|
Women |
|
|
|
|
50% at 3% risk in 5 years |
53 |
47 |
50 |
|
50% at 1% risk in 1 year |
65 |
55 |
62 |
*Results obtained by applying Framingham risk
assessment formula to 2258 men in Caerphilly cohort using
baseline values of total cholesterol, high density lipoprotein
cholesterol, and systolic blood pressure. Men who had had a
stroke (17) or a myocardial infarction (246) before the study
period were excluded. Results in women were obtained by the
application of the Framingham formula to grouped data for 550
women in the Heart Beat Wales survey. Evidence on previous
vascular events was not available. |
|
The possibility that a simple, daily, inexpensive
low dose pill would achieve a reduction in vascular events, and might
achieve reductions in cancer and dementia without the need for
screening, deserves serious consideration, they write.
Although we judge that aspirin should be taken
from around 50 years, we insist that the general public should be well
informed and the final decision should lie with each person.
Based on data for 55-59 year olds, aspirin prevents
around two first heart attacks per 1000 population each year. However,
this benefit does not outweigh the expected risk of a major
gastrointestinal bleed at age 60 (1-2 per 1000 per year).
In my view, we should not contemplate an age
threshold approach to primary prevention with aspirin until we have much
better evidence of its benefits in older people, he says. We therefore
need further randomized trials comparing low dose aspirin with placebo.
A recommendation that aspirin be used for primary
prevention of vascular disease in unselected people over a certain age
could result in net harm, and we must have very good evidence to the
contrary before instituting such a policy, he concludes.
Click here to see the full paper in the BMJ:
http://press.psprings.co.uk/bmj/june/edd1440.pdf
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