An Aspirin a day

“An aspirin a day can keep the doctor away”, goes the saying. Aspirin indeed does a world of good, but there is a caveat: it isn’t harmless. Though millions of people benefit from daily aspirin to reduce their risk of heart attack or stroke, for some, the downsides of aspirin — mainly gastrointestinal bleeding — outweigh its benefits.  

From its origins as herbal folk medicine used for alleviating pain, inflammation and fever to its newly-found position, as a life saving preventive medicine, aspirin’s role has been constantly changing. After the first positive report in the British Medical Journal in 1974, larger trials conducted in the US showed that aspirin reduced the risk of heart attacks in a mixed cohort of people by 44 per cent. A later study reported in the Lancet brought better tidings: aspirin also effectively reduced the risk of strokes in patients with ‘early warning signs’ of a paralytic attack.  

Aspirin acts by making certain blood elements called platelets less ‘sticky’, and so less likely to clump in the bloodstream to form clots. Most heart attacks and strokes happen when a clot blocks blood flow in a vessel that feeds the heart or the brain. Dampening the clot-forming process by using aspirin lowers the odds of blockages. But here’s a “catch 22” situation. The beneficial effects of aspirin can be offset as it has the potential to inhibit the formation of substances that protect the stomach’s delicate lining. As a result, bleeding in the stomach and intestines can occur as a side-effect.

Therefore, though daily aspirin therapy may lower your risk of heart attack and stroke, it is not for everyone. You should take a daily aspirin only if your doctor advises you to do so. If you have had a heart problem or stroke (secondary prevention) your doctor will recommend you to take an aspirin daily; but if you have a serious allergy or history of bleeding, he may not. If you don’t have a heart problem (primary prevention) but have a high risk of having a first heart attack, your doctor will recommend aspirin after weighing the risks and benefits. 

Daily aspirin therapy is compulsory for those who have had a heart attack or stroke, a stent placed in a coronary artery or a coronary bypass surgery. Aspirin is also advised to those who have angina (chest pain due to coronary artery disease). In patients with such cardiovascular problems, the known benefits of aspirin outweigh the risk of bleeding.

Must healthy patients take daily aspirin? Primary prevention trials in randomly selected healthy patients involving a combined total of 1,00,000 individuals have shown that aspirin reduces the risk of a first heart attack and stroke by 20%. Yet the American Heart Association recommends aspirin only for those healthy patients with an “intermediate” or “high” risk of heart attack or stroke. It does not recommend aspirin for low or normal-risk patients, because here the benefits of aspirin may be outweighed by the risk of provoking bleeding, which, though small, is real. 

The risk level is calculated on factors like race, gender, age, total cholesterol, HDL (good) cholesterol, blood-pressure, use of blood pressure medication, diabetes and smoking status. We often find healthy individuals popping aspirin pills on their own to reduce the possibility of a first heart attack or stroke but it deserves to be reiterated that FDA does not approve general use of aspirin in primary 

prevention.  

Aspirin, however, is now also being used to prevent cancers. A recently concluded study published in the Annals of Oncology highlights the role of aspirin in cancer prevention. 75 mg of aspirin daily for at least five years in those aged between 50 to 60 years reduces the risk of developing and dying from colon, stomach or esophageal cancer by 30%. But, considering possibility of side effects, medical advice is must, not self-medication. 

For long-term prevention of any disease, the recommended dose of aspirin is 75 to 325 mg once daily. Chewable baby aspirin (75 mg) is said to be the best. Chewing the pills gets the anti-clotting chemicals into your bloodstream much faster than if you swallow them. Higher doses cause more gastrointestinal bleeding and do not provide additional protection. Risk of gastric irritation and bleeding can be reduced by the use of a proton pump inhibitor (e.g. omeprazole) in combination with aspirin. 

Hailed now as a wonder drug, thanks to its ability to help stave off heart attacks, strokes and cancers, aspirin’s story is really fascinating. Doctors believe that aspirin’s preventive effect will in future be extended to avert many other dreadful diseases. That is surely heartening news – and time to salute the simple, unassuming and inexpensive Aspirin!

(Dr Francisco Colaço is a senior most consulting physician)