Daily Aspirin Can Help Prevent a Second Heart Attack or Stroke, But Only 2 in 5 Adults Take It
Increasing aspirin uptake around the world could save thousands of lives each year, according to experts.
Coronary heart disease, stroke, and chronic obstructive pulmonary disease are the top three causes of death worldwide, accounting for an estimated 1 and 3 deaths, per the World Health Organization (WHO). But a new study suggests that thousands of those early deaths are preventable, given that only 40 percent of eligible patients are taking daily aspirin to prevent a second heart attack or stroke (called secondary prevention), according to a new study published on August 22 in JAMA.
Survivors of heart attacks and stroke often have a high risk of having future cardiovascular events, which can be fatal, says first author Sang Gune Yoo, MD, a cardiovascular disease fellow at Washington University School of Medicine in St. Louis. “We know from existing data that there are benefits of aspirin for secondary prevention of cardiovascular disease, but our findings suggest that aspirin use is suboptimal across the world, and particularly lower showing some disparities in aspirin use among different strata of incomes,” says Dr. Yoo.
Investigators found that in lower income countries, such as Ethiopia and Afghanistan, only 1 in 6 people (16.6 percent) took daily aspirin for secondary prevention compared with nearly 2 in 3 (65 percent) in higher income countries like the United States and the United Kingdom.
“These findings are important because they provide a comprehensive picture of the underutilization of aspirin for secondary prevention of cardiovascular disease globally, particularly in low- and middle-income countries,” says Michael Shapiro, DO, a professor of cardiology at Wake Forest University School of Medicine and cardiologist at Atrium Health Wake Forest Baptist in Winston Salem, North Carolina.
“The large sample size across diverse countries makes this a robust estimate of the gap between recommendations and actual aspirin use, evidence that can be used to inform efforts to improve adherence and prevent recurrent cardiovascular events,” says Dr. Shapiro, who was not involved in the study.
Daily Aspirin Use Part of Worldwide Strategy to Reduce Premature Deaths
The United Nations Sustainable Development Goal (STG) has a target of reducing one-third of premature deaths from noncommunicable diseases (such as heart events) by 2030 through prevention and treatment. To help achieve that goal, the WHO aims to have 50 percent of eligible people taking a daily low-dose aspirin by 2025.
Aspirin is recommended for secondary prevention of heart attack because of decades of evidence, with large prevention trials published by the Centers for Disease Control and Prevention (CDC) that date back to the late 1980s, showing that it can reduce the risk of a second cardiovascular event, such as a second heart attack or stroke, by about one-quarter.
Low-dose daily aspirin helps prevent blood clots from forming, including ones that could cut off blood flow to an area of the heart or brain, causing a heart attack or stroke.
Cost is another reason that daily aspirin therapy is seen as a potential way to move the needle — aspirin is also generally affordable, according to the authors. In the United States, a monthly supply of baby aspirin (81 milligrams per dose) can cost as little as 5 cents a day, according to GoodRx.
Daily Aspirin in Eligible People 3 Times Higher in Wealthy Countries
To evaluate aspirin use for secondary prevention of heart disease around the world, researchers analyzed data from nationally representative health surveys from 51 low-, middle-, and high-income countries. A total of 125,505 people completed the questionnaire, with 10,590 self-reporting a history of heart disease.
The study showed that in low-income countries, only 16.6 percent of eligible individuals — those who had experienced a first heart attack or stroke — were taking aspirin to prevent a second event.
In lower-middle-income countries this number was 24.5 percent, 51.1 percent for upper-middle-income countries, and 65 percent in high-income countries, including the United States.
“The findings will generate awareness of the low rates of use of an inexpensive and highly effective medication for coronary disease and stroke-TIA [transient ischemic attack] secondary prevention,” says Kristin Newby, MD, a cardiologist at Duke Health in Durham, North Carolina, who was not involved in the study. This is an important first step in devising quality improvement programs that engage health authorities, providers, communities, and patients to identify barriers to use and develop approaches to improve use, says Dr. Newby.
Given that heart disease and stroke are the leading cause of death worldwide and aspirin is so effective in secondary prevention, affordable, and readily available, simply improving its use in low- and middle-income countries to the levels in high income countries should be feasible and could go a long way in reducing disparities in outcomes after heart attack or stroke, she says.
“However, improving aspirin use alone will not eliminate disparities and will have to be part of broader efforts along with other factors including tobacco cessation, access to care, and education to achieve local, regional, and global equity in cardiovascular health and healthcare,” says Newby.
Concerns About Side Effects, Lack of Education, or Access Issues Could Play a Role in Underuse
Although the study wasn’t designed to uncover why aspirin is underused, there are likely multiple intersecting explanations, says Yoo. “It could be due to a lack of education on aspirin use for those who are eligible or access issues. In the United States we can access aspirin pretty easily, but in other countries sometimes you need pharmacy consultations or a prescription,” he says.
“Other factors that may keep people from taking aspirin for secondary prevention include concerns about bleeding risk, lack of recommendation from a provider, and simply forgetting to take it regularly. Cultural beliefs and lack of trust in medicine could also play a role in some communities,” says Shapiro.
While daily low-dose aspirin is recommended for secondary prevention, there are possible side effects and complications that come with it, including bleeding risk. While it can help prevent a clot-related stroke, it may increase the risk of a bleeding stroke, called a hemorrhagic stroke, according to Mayo Clinic. Daily aspirin use also increases the risk for developing a stomach ulcer or G.I. bleeding.
How Can the U.S. Improve Aspirin Use for Secondary Prevention?
Although the United States was included in countries with higher rates of aspirin use among eligible people, there are initiatives underway to increase those numbers.
Healthy People 2030 has set a target of increasing aspirin use to 69.7 percent of adults aged 40 years and over with a history of cardiovascular disease.
Part of that approach should include patient education around the importance of taking aspirin at every healthcare visit, including addressing any confusion patients may have between primary prevention and secondary prevention, says Newby.
For most people, daily aspirin is no longer recommended for primary prevention, meaning it should not be taken to prevent a first heart attack or stroke.
“With electronic health records and mHealth technology, there are also opportunities to directly communicate with, educate, and reinforce aspirin use (as well as other important medications for secondary prevention) directly to patients outside of office visits,” says Newby.
Finally, community education, use of community health workers and other trained and trusted lay individuals for outreach to and engagement of patients who may not have ready access to healthcare or be able to get to clinics has great potential to reach the hard-to-reach communities where barriers to care and associated disparities in care exist, she says.
Not Sure if You Should Be Taking Daily Aspirin? Talk With Your Doctor
People who are already taking a daily low-dose aspirin should not stop taking it until they have a conversation with their physician, according to the American College of Cardiology.
Likewise, if you’re not sure if you should be taking low-dose aspirin, don’t start taking it without a talk with your doctor, says Yoo.
“There are benefits for many people, as we’ve discussed here, but taking aspirin also comes with risks, and you want to discuss those with your doctor,” he says.
Becky Upham
Author
Becky Upham has been professionally involved in health and wellness for almost 20 years. She's been a race director, a recruiter for Team in Training for the Leukemia & Lymphoma Society, a salesperson for a major pharmaceutical company, a blogger for Moogfest, a communications manager for Mission Health, a fitness instructor, and a health coach.
She majored in English at the University of North Carolina and has a master's in English writing from Hollins University.
Upham enjoys teaching cycling classes, running, reading fiction, and making playlists.