Aspirin – is it worthwhile?

Aspirin is one of the most commonly-used drugs internationally, but what does it actually do and how effective is it? Dr Iqbal Malik investigates.

Can aspirin help people who have already had a stroke or heart attack?

We often use anti-platelet drugs to stop the blood clotting. They act to make platelets, the blood cells involved in forming a clot when you bleed, less sticky. In patients with proven heart attack or stroke, the the enemy is the clot. Aspirin in combination with other agents, such as  Clopidogrel or Ticagrelor, is used after heart attack and coronary stents. After a stroke, aspirin is often seen as not strong enough, and Clopidogrel is used more often. However, if the stroke is related to atrial fibrillation, a common heart rhythm problem, then neither aspirin or Clopidogrel are strong enough, and agents such as Warfarin, Rivaroxaban, Edoxaban,  Dabigatran, and Apixaban are used.  The newer (non-Warfarin agents) have the advantage of not needing regular blood tests and having standard dose regimes, some of which are only once a day.

Instead of aspirin, what can you recommend to patients who want to prevent cardiovascular disease?

If a patient has had a heart attack or stroke, then they should take the recommended anti-platelet drug, which may be Aspirin, Clopidogrel, Ticagrelor or a combination of them.

If, however,  they have not had a previous event, then I suggest that there is more benefit in reducing risk in other ways, such and losing weight, controlling blood pressure and diet, stopping smoking and of course considering lowering the cholesterol with a statin. Statins are well tolerated in the vast majority of people.  The risk of bleeding goes up with aspirin and the risk of heart attack and stroke goes down. The net clinical benefit becomes small! There is some emerging data that you may try to find those patients who may gain some benefit from aspirin by assessing the bleeding risk in detail, the clotting risk in detail, and then add a CT coronary calcium score (done using a small dose of X-Rays) to see if the process of coronary disease has already begun. The trouble is that the calcium score is rarely above zero under age 50.

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