By Matthew E. Fink, MD
Professor and Chairman, Department of Neurology, Weill Cornell Medical College; Neurologist-in-Chief, New York Presbyterian Hospital
Dr. Fink reports he is a retained consultant for Procter & Gamble and Pfizer.
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 three articles published in the Oct. 18, 2018, issue of the New England Journal of Medicine, 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 neurologists, since much of our practice is related to stroke prevention, both primary and secondary, and we often are asked by patients and their families, as well as referring physicians, if patients should take daily aspirin for stroke prevention.
In these three studies, almost 20,000 persons (median age of 74 years) were enrolled and assigned randomly to receive aspirin or placebo daily for primary prevention. Fifty-six percent of the participants were women, 8.7% were non-white, and 11% reported previous regular aspirin use. The trial was terminated 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, which included fatal coronary heart disease, nonfatal myocardial infarction, fatal or nonfatal stroke, and hospitalization for heart failure. In addition, the 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 persons did not prolong disability-free survival over a five-year period but resulted 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, but did result in an increased rate of major hemorrhages.
When evaluating all-cause mortality, healthy older adults who received daily aspirin had a higher all-cause mortality that was 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. All neurologists should take note of these studies, which significantly affect our practice and our patients.
