Are you one of the 40 million Americans who take a low-dose aspirin every day (or every other day) to prevent a heart attack or stroke? Who gave you that idea? Your spouse, a friend, or maybe a TV or magazine ad telling you that aspirin protects your heart by “keeping your blood flowing freely?”
If it wasn’t your doctor, and you’re a generally healthy person who is taking aspirin because you hope it will keep a heart attack or stroke at bay, you should probably stop. Mounting evidence, reported recently in a number of leading medical journals, suggests doing so is a bad idea if you’re healthy and not at significant risk for a heart attack. Furthermore, these studies now show that the potential risk of cerebral hemorrhage, serious gastrointestinal bleeding, and ulcers anywhere from your mouth to your anus outweighs any heart benefits the aspirin might provide.
If aspirin was introduced as a new drug today, it would probably require a prescription.
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Aspirin Is a Powerful Drug
The fact is we only think of aspirin as benign because it’s sold over the counter, it’s inexpensive, and it’s been around for a century. But if aspirin was introduced as a new drug today, it would probably require a prescription. This is a serious drug that can have serious consequences when used too casually. So as a preventative cardiologist, I urge you to keep the following points in mind before popping another one:
• Aspirin should not be taken regularly without a cardiovascular risk assessment by your doctor. Some doctors, including some cardiologists, routinely prescribe aspirin for every patient or base their risk assessment only on the conventional risk factors. They may not be up to date on the latest aspirin literature or on the value of the newer cardiovascular tests.
• Even small doses of daily aspirin—including baby aspirin at a dose of 81 milligrams—can increase your risk of ulcers and bleeding. Buffered and enteric-coated aspirin do not eliminate the risk of developing an ulcer. Your risk for bleeding is still two to four times greater than if you were not taking aspirin at all. Aspirin can also interact with other drugs, including other nonsteroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen, naproxen, or Motrin; blood-thinning medications such as warfarin; and antiplatelet agents such as clopidogrel or ticlopidine.
• Having diabetes does not necessarily mean you need to take preventive aspirin. Diabetes is a major risk factor for heart disease and for years the American Diabetes Association recommended low-dose aspirin for every diabetic patient over the age of 40. Now, in new guidelines issued this month, the ADA has changed that recommendation to consider aspirin as a primary-prevention strategy only in those with diabetes at an above-average cardiovascular risk. This includes men over 50 or women over 60 with at least one additional major risk factor. In other words, according to the ADA, younger patients without associated risk factors appear not to benefit from taking aspirin.
• Know your real risk. If you have known risk factors for heart disease—family history, high blood pressure, high cholesterol, obesity, diabetes, smoking—ask your doctor if you are a candidate for a carotid artery ultrasound and a CT scan for coronary calcium to determine the real age of your arteries—more on that below.
That said, if you’ve already had a heart attack or stroke, or if you’ve been told by your doctor that you’re at high or moderate risk for one (and the benefit is likely to outweigh the dangers), aspirin could save your life. I like to tell my high-risk heart patients that the cholesterol-filled soft plaque that has built up in their arteries is like a ticking time bomb, and that once it goes off (or ruptures) aspirin can be their best friend. That’s because aspirin acts as both an anti-inflammatory and an inhibitor of blood clotting. And it’s the blood clots that form at the site of a ruptured soft plaque that can suddenly block blood flow to the heart muscle, causing a potentially fatal heart attack.
But how do I know if a patient is low risk or high risk and a candidate for aspirin therapy? Unfortunately the standard risk factors commonly used for assessing your chance for having a heart attack don’t always tell the whole story. Take cholesterol, for instance. You’ll probably be surprised to learn that more people die of a heart attack with a total cholesterol under 200 mg/dL than over 300 mg/dL. And, even when you factor in the amount of “good” HDL cholesterol versus “bad” LDL cholesterol a person has, it doesn’t help much in evaluating their real risk for a coronary event. So what does?
Know the Age of Your Arteries
As it happens, one of the best conventional predictors of a heart attack or stroke is your age. That’s because the atherosclerosis that eventually causes a heart attack typically accumulates for decades. In fact, the older you are, the more plaque you are likely to accumulate and the greater your risk. But there are two important things to keep in mind in understanding age as a risk factor. First, we all develop atherosclerosis at different rates. Second, in each of us, cholesterol mixes differently with both known and unknown environmental and genetic risk factors to determine how fast plaque develops. You could liken this plaque buildup to how fast a car rusts: It depends not only on how old the car is, but more importantly on its environment, what it’s made of, and how well it has been maintained.
So when we consider age as a risk factor for heart attack or stroke, what we really need to know is the “age of your arteries”―not your birth date. But the only way to find this out is to look inside those arteries noninvasively.
Two Important Preventive Tests
In my practice, I take advantage of two preventive tests that help me quickly and easily find out how old your arteries are. The first test is called a carotid artery ultrasound, and it measures the thickness of the inner linings of the arteries that run through both sides of your neck to supply blood to your brain. If the ultrasound shows that plaque is building up here, it’s likely that it’s building up in other arteries in your body as well. And that’s where the second test comes in. This test is a noninvasive cat scan (CT scan) of your heart to look for coronary calcium buildup. The result of this scan is called your “Calcium Score” and it reflects the amount of atherosclerotic plaque that you have built up in your coronary arteries over your entire life. The higher your score the more plaque you have in your arteries and the greater your risk of a future heart attack. This risk assessment is very important when it comes to deciding whether to place someone on lifelong aspirin therapy.
Remember, aspirin is not a magic bullet for preventing a heart attack or stroke, as much as we wish it was. In fact, if you make an effort to eat healthfully, exercise regularly, and maintain a healthy weight (and of course don’t smoke), you’ll have done far more to help your heart than a daily aspirin ever could―and without the potentially harmful and even deadly risks. Often what was considered good for all (a cholesterol score of less than 200, for instance) is looked upon differently as our testing better discerns what the real risk is for a particular disease. The use of aspirin is becoming another such example. What was once recommended for nearly all, we are now learning should be prescribed for relatively few.
Dr. Arthur Agatston is a leading preventive cardiologist and creator and author of The South Beach Diet. He lives in Miami Beach with his wife, Sari.
