If you follow the headlines, messages to the public about the value of taking a daily aspirin have been very confusing. A series of studies in 2018 showed that in a healthy adult, a daily aspirin did not confer a measurable benefit to cardiovascular health. Last year, the U.S. Preventive Task Force that daily aspirin use has little or no benefit for most people who are not at high risk of a cardiovascular event.
Two large studies after this showed that in those with a coronary artery calcium score >100, a daily aspirin did reduce future cardiac events.
None of these studies suggested that patients with prior heart attacks, stents, or bypass surgery should stop their aspirin but many patients do. New data presented in Europe show the potential harm of stopping aspirin in the years after a heart attack.
The study used data from Danish nationwide health registries. It included patients aged 40 years and over who had a first-time heart attack from 2004 through 2017, were treated with a coronary stent and took aspirin as prescribed during the first year after their heart attack. Patients who were on anticoagulants or had a stroke or recurrent heart attack within that first year were excluded.
Adherence to aspirin was evaluated at two, four, six and eight years after the heart attack. In Denmark, every time a patient picks up a prescription of aspirin, the number of tablets and date of collection are recorded in registries. Adherence to aspirin at each of the four time points was assessed as the proportion of days patients had their pills over the preceding two years. Patients on aspirin for 80% or less of the time were considered non-adherent (i.e., not taking aspirin as prescribed) while those on aspirin more than 80% of the time were considered adherent (i.e., taking aspirin as prescribed). At each time point, patients were excluded if they had experienced another heart attack, a stroke, died, or had been started on anticoagulants or P2Y12 inhibitors like Effient.
Dr. Kristensen explained: “We assessed the effects of long-term aspirin use in patients who were not receiving other medications for the prevention of heart attack or stroke. Both anticoagulants and P2Y12 inhibitors are agents that, similar to aspirin, work to prevent the formation of blood clots. Therefore, patients undergoing such treatments were excluded from our study.”
The study included 40,114 patients with a first-time heart attack. Adherence to aspirin progressively declined with each time point, from 90% at two years following the heart attack to 84% at four years, 82% at six years and 81% at eight years.
The researchers analysed whether patients who did not take aspirin as prescribed had a higher risk of the composite outcome of recurrent heart attack, stroke or death compared with those who consistently took aspirin. A number of factors that might affect the results were taken into account including age, sex, diabetes, high blood pressure, high cholesterol, kidney disease, cancer, stomach ulcers, previous bleeding events and chronic obstructive pulmonary disease.
At each time point, patients who took aspirin as prescribed were less likely to experience the composite outcome compared with non-adherent patients.
Compared with adherent patients, non-adherent patients had a 29%, 40%, 31% and 20% higher likelihood of recurrent heart attack, stroke or death at two, four, six and eight years following the heart attack, respectively.
“Our findings suggest that not taking aspirin as prescribed after a heart attack is linked to a higher risk of having another heart attack, a stroke or dying,” said study author Dr. Anna Meta Kristensen of Bispebjerg and Frederiksberg Hospital. Frederiksberg, Denmark. “We recommend that all patients who have had a heart attack stay adherent to their aspirin in accordance with guidelines until randomised controlled trials have proven otherwise, and clinical guidelines have been changed.”
Dr. Kristensen said: “Our results should be interpreted with caution because they show an association but do not establish causality. Since the study is registry-based, we do not have information about the specific reasons as to why patients did not take their aspirin. Furthermore, our findings cannot be generalised to all patients who experience a heart attack, as our study specifically focused on those who received treatment with a coronary stent and were not taking other medications to prevent blood clot formation. With that in mind, the results support current guidelines recommending long-term aspirin after a heart attack.”
Convincing people to take an aspirin every day isn’t always an easy task.
Another study published this week by researchers at Washington University School of Medicine in St. Louis and the University of Michigan reported that fewer than half of people worldwide who have had a heart attack or stroke take a daily aspirin.
The researchers indicated that while they can’t explain why aspirin is underused, they hypothesize that there are several reasons, including varying accessibility to healthcare, inconsistent messaging surrounding the use of aspirin, and the fact that aspirin is not always available over the counter as some countries require a prescription.
The researchers looked at surveys completed by 124,505 people, with 10,589 self-reporting a history of cardiovascular disease.
They reported that in low-income countries, only about 16% of those who had experienced a heart attack or stroke took aspirin to prevent a second or subsequent one.
In lower middle-income countries, the rate rose to about 24%. Upper middle-income countries saw this number increase to 51%. In high-income countries, 65% of people with previous cardiovascular events took aspirin.
