Low-dose aspirin shows no benefit for stroke prevention, even ischaemic events, in healthy patients over age 70 years.

There was a time when enthusiasm existed for aspirin for primary prevention of cardiovascular disease and stroke, with the 1989 Physicians’ Health Study showing a benefit, even at the cost of some haemorrhagic strokes (N Engl J Med 1989; 321: 129-135). But the preponderance of data over time has chilled that enthusiasm. The randomised, placebo-controlled Aspirin in Reducing Events in the Elderly (ASPREE) study contributed greatly to this evidence for people aged 70 years and older (NEJM JW Gen Med Oct 15 2018 and N Engl J Med 2018; 379: 1499-1508, 1509-1518, 1519-1528). In the 19,114 participants without cardiovascular disease, dementia or disability, aspirin (100 mg daily) was associated with higher all-cause mortality, no reductions in cardiovascular disease and greater cancer mortality during a median follow up of 4.7 years.

Now, investigators have evaluated ASPREE data for the effect of aspirin on stroke outcomes. Aspirin was not associated with lower risk for ischaemic stroke compared with placebo but was associated with greater total intracranial bleeding (1.1% vs 0.8%; hazard ratio, 1.38). 

Comment: For older patients, the ASPREE study provides no reason to use aspirin for primary prevention. Rather, aspirin was associated with a combination of higher all-cause mortality, no reduction in cardiovascular events, higher cancer deaths, greater bleeding risk – and, now, no reduction in ischaemic stroke and higher risks for intracranial bleeding. These findings support the US Preventive Services Task Force recommendations that aspirin not be prescribed for healthy, older adults. We should be asking about aspirin use by our older patients without cardiovascular disease and ensuring that they are informed about the lack of evidence for aspirin as a risk-reduction strategy.

Harlan M. Krumholz, MD, SM, Harold H. Hines, Jr. Professor of Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, USA.

Cloud GC, et al. Low-dose aspirin and the risk of stroke and intracerebral bleeding in healthy older people: secondary analysis of a randomized clinical trial. JAMA Netw Open 2023; 6: e2325803.

This summary is taken from the following Journal Watch titles: Cardiology, Hospital Medicine, General Medicine, Ambulatory Medicine.