By Matthew E. Fink, MD

Feil Professor & Chair of Neurology, Associate Dean for Clinical Affairs, NYP/Weill Cornell Medical College

Dr. Fink reports no financial relationships relevant to this field of study.

SOURCES: McNeil JJ, Woods RL, Nelson MR, et al; for the ASPREE Investigator Group. Effect of aspirin on disability-free survival in the healthy elderly. N Engl J Med 2018; Sep 16. doi: 10.1056/NEJMoa1800722. [Epub ahead of print].

McNeil JJ, Woods RL, Nelson MR, et al; for the ASPREE Investigator Group. Effect of aspirin on cardiovascular events and bleeding in the healthy elderly. N Engl J Med 2018; Sep 16. doi: 10.1056/NEJMoa1805819. [Epub ahead of print].

McNeill JJ, Woods RL, Nelson MR, et al; for the ASPREE Investigator Group. Effect of aspirin on all-cause mortality in the healthy elderly. N Engl J Med 2018, Sep 16. doi: 10.1056/NEJMoa1803955. [Epub ahead of print].

In a remarkable series of recently published articles, McNeil and collaborators reported on the effects of aspirin as primary prevention for cardiovascular disease in a cohort of healthy elderly people. These studies are of particular interest to clinicians whose practices are related to stroke prevention, both primary and secondary. Also, patients, families, and referring physicians often ask if it is appropriate to take daily aspirin for stroke prevention.

In these three studies, almost 20,000 people (median age, 74 years) were enrolled and assigned randomly to receive aspirin or placebo daily for primary prevention. Fifty-six percent of participants were women, 8.7% were nonwhite, and 11% reported previous regular aspirin use. Investigators ended the trial at a median of 4.7 years of follow-up when it was determined that daily aspirin use showed no benefit regarding the primary endpoints. Primary and secondary endpoints included the rate of composite death, dementia, physical disability, and cardiovascular events. The cardiovascular events included fatal coronary heart disease, nonfatal myocardial infarction, fatal or nonfatal stroke, and hospitalization for heart failure. In addition, investigators examined the effects of daily aspirin on all-cause mortality in this same group of healthy older adults. In light of the generally accepted view that daily aspirin has many health benefits, the results of this study revealed that aspirin use in healthy elderly people did not prolong disability-free survival over a five-year period. However, such use did result in a higher rate of major hemorrhages compared to placebo. In addition, the use of low-dose aspirin as primary prevention in elderly adults to prevent cardiovascular events, including stroke, did not result in a significantly lower risk of cardiovascular disease. However, such use did result in an increased rate of major hemorrhages.

When evaluating all-cause mortality, healthy older adults who received daily aspirin demonstrated a higher rate of all-cause mortality, which investigators attributed primarily to cancer-related deaths. The conclusion from this series of groundbreaking studies is that primary prevention of cardiovascular disease and death by using daily low-dose aspirin is not recommended and should be reserved for those instances in which secondary prevention has been demonstrated to be effective in randomized, clinical trials.

Clinicians should take note of these studies, which significantly affect patients.