**EP51: Aspirin: Good or Bad?**
**Dr. Warwick:** Welcome to Dr. Warwick's podcast channel. I am a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. I believe educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love.
Hi, my name is Dr. Warwick Bishop, and I'd like to welcome you to my consulting room. Today, I'd like to talk a little bit about aspirin. After all, it has just recently been in the paper and on the news quite a lot. There are three main trials that have come out relatively recently which are giving us some clarity around where aspirin fits. But it's pretty important you understand what that means for you.
If you were to look up on the internet, like I just did, about aspirin today in Australia, and it's the 17th of September, you'll see a couple of quotes. Things like, "the cost of daily aspirin may outweigh the benefits," which was listed under the Sydney Morning Herald. You may also see a headline like, "doesn't prevent cardiovascular disease," attached to ABC News. And another headline from the Herald Sun warns against using aspirin in healthy adults. Well, you would be forgiven for thinking that aspirin doesn't have a role. In fact, if you're on aspirin, you might be thinking to yourself, "Gee whiz, I don't think I should be on it based on these headlines."
Well, that's why I've done today's podcast. Please, don't stop your aspirin just yet until you've listened to the rest of this podcast.
Why are these headlines in the news? Just today, or in the last 24 hours, a trial called the ASPRI trial was released into the media. This trial's acronym comes from Aspirin, A-S-P, Reducing Our Events, E, in the elderly, E, ASPRI. What they did was take about 20,000 well individuals over 70 years of age and followed them for about five years, maybe a little more, to see if giving aspirin to healthy individuals who are 70 years or older was linked with better life quality, reduced cardiovascular events, or reduced dementia.
Well, it turns out that it really didn't show much at all. Remember, this is 20,000 people over more than five years, so this is a pretty robust study. What's important to understand, though, is that this study just tells us that giving people who are over 70 years of age aspirin regularly doesn't necessarily improve their later quality of life.
There are two other studies that came out relatively recently, and these studies were also published in the New England Journal of Medicine, as was the ASPRI study, as far as I understand. A major medical journal also recently published a study called the ARRIVE study. The ARRIVE study was looking at average-risk individuals—people who have a 10 to 20% risk of a heart attack in the next 10 years receiving aspirin. This study looked at over 12,000 people for a period of 60 months. They demonstrated that giving these intermediate-risk people aspirin reduced their risk of heart attack, but it didn't really make a difference to stroke and not a great deal of difference in terms of outcome. It was, of course, associated with an increased risk of bleeding, which is what we would expect from giving people aspirin anyway.
The last study that was also presented in the New England Journal of Medicine in the last few months, and again this was also presented at the European Society of Cardiology meeting just recently, was the ASCEND trial. This trial looked at aspirin in primary prevention—primary prevention meaning before an event has occurred—in a group of asymptomatic, otherwise well diabetics. The ASCEND trial looked at over 15,000 people for over seven years.
So now we've got ASPRI, ARRIVE, and ASCEND. Together, over 45,000 patients or thereabouts studied for over five to seven years. This is incredibly robust data, and none of these trials were compelling in telling us that we should give aspirin to people.
Well, does that mean we shouldn't be taking aspirin if we're otherwise well? Basically, I think what it tells us is that if you don't have any major medical issues, you don't need to take aspirin just to keep well.
Let's turn that around a bit because I do put quite a few people on aspirin, and you may be listening to this and wondering if you should be on aspirin. I put people on aspirin if I know what's going on in their coronary arteries. If I know they've had a heart attack, for example, there's no question that aspirin reduces the risk of further events. So in secondary prevention—preventing a second event—there's no question, aspirin is beneficial. If you've had an event with your heart, a heart attack, a stent, bypass grafting, a stroke, or peripheral vascular disease, please don't stop your aspirin because there's no question that it's beneficial for you.
These three trials that I just talked about are not about secondary prevention, and they don't relate to you. So please don't stop your aspirin.
I also use aspirin in primary prevention. The situation where I do that is in patients whom I've imaged and know that they have plaque build-up in their heart. So I'm very precise and particular, and I know they are high-risk people. In fact, they are so high-risk that they could almost be considered pre-secondary prevention. This group has not been studied either. Nobody's looked at imaging patients to define who should be on aspirin. So for my patient population, I am convinced and sure that it is the right thing, though there's not a lot of data to support that.
What's the bottom line? Please don't stop your aspirin based on what you just heard on the Sydney Morning Herald, the Herald Sun, or even on ABC News. Please talk with your doctor about your specific needs for your specific medications. Aspirin is no different from anything else. It's always and should always be a conversation about the risk of a particular medication and the benefit in your particular situation, weighing those up for you. I hope that helps you.
So, ASPRI, ARRIVE, and ASCEND—very important trials. More than 45,000 or thereabouts, 45,000 odd people over about five to seven years. It's really important. It tells us that we shouldn't have aspirin in the water, but it doesn't tell us for you, if your doctor's put you on aspirin, whether it's appropriate for you or not. That is a particular and specific conversation you need to have with your doctor.
And any of my patients listening to this, please don't stop your aspirin if I've put you on it, because it will be for all the right reasons. I'm happy to speak with you about it when we catch up next.
For now, I hope you've enjoyed this podcast. I hope it's given you a little bit to think about in terms of regular low-dose aspirin and where it fits. If you've enjoyed this, I've got other podcasts coming. And of course, if you're more a listener than a reader, you may also like the audiobooks available for *Have You Planned Your Heart Attack?* and *Know Your Real Risk of Heart Attack.*
Well, I'm going to wish you the best of health. Until next time, goodbye.
