Use of aspirin to prevent first heart attack or stroke should be reduced, says US panel

Doctors should no longer routinely give most people at high risk for heart disease a daily regimen of low-dose aspirin, according to a new study. draft guidelines by an American group of experts.

The proposed recommendation is based on a growing body of evidence that the risk of serious side effects far outweighs the benefit of what was once considered a remarkably cheap weapon in the fight against heart disease.

The American panel also plans to withdraw from its 2016 recommendation to take baby aspirin for the prevention of colorectal cancer, a direction that was revolutionary at the time. The panel said more recent data had raised questions about the benefits for cancer and that more research was needed.

Regarding the use of low-dose or baby aspirin, the recommendation of the United States Task Force on Preventive Services would apply to people under the age of 60 who were at high risk of heart disease and for whom a new daily regimen. mild pain reliever could have been a tool to prevent a first heart attack or stroke. The proposed guidelines would not apply to those who are already taking aspirin or to those who have already had a heart attack.

The U.S. task force also strongly wishes to discourage anyone aged 60 and over from starting a low-dose aspirin regimen, citing concerns about the increased risk of life-threatening age-related bleeding. The panel had previously recommended people in their 60s who were at high risk for cardiovascular disease to see their doctor to make a decision. A low dose is 81 milligrams to 100 milligrams.

The task force’s proposals follow years of changes in the advice of several leading medical organizations and federal agencies, some of which had previously recommended limiting the use of low-dose aspirin as a disease prevention tool. heart and stroke. Aspirin inhibits blood clots that can block arteries, but studies have raised concerns that regular consumption increases the risk of bleeding, especially in the digestive tract and brain, dangers that increase with age.

“There is no longer a blanket statement that anyone at increased risk for heart disease, even if they have never had a heart attack, should take aspirin,” said Dr Chien-Wen Tseng, a member of the national task force who is the research director in family medicine and community health at the University of Hawaii. “We need to be smarter to match primary prevention with the people who will benefit the most and who will be at the least risk of harm. “

Research shows that the increased risk of bleeding occurs relatively quickly after someone starts using aspirin regularly.

Those who are already taking baby aspirin should talk to their doctor.

“We don’t recommend that anyone stop without talking to a clinician, and certainly not if they’ve had a heart attack or stroke in the past,” she added.

The working group includes 16 experts in disease prevention and evidence-based medicine who periodically assess screening tests and preventive treatments. Members are appointed by the director of the Agency for Research and Quality in Health, but the group is independent and its recommendations often help shape American medical practice.

The guidelines, which are not yet final, have the potential to affect tens of millions of adults at high risk for cardiovascular disease, which continues to be the leading cause of death in the United States, even in this era. of Covid. The panel will accept public comments on its recommendations until November 8, and its draft guidelines are typically adopted sometime after the comment period ends.

Two years ago, the American College of Cardiology and the American Heart Association jointly refined their recommendations to say that aspirin should be prescribed very selectively for people between the ages of 40 and 70 who had never had heart attack or stroke. On aspirin, organizations say “usually no, sometimes yes” for primary prevention. This opinion differs from the new draft directive of the working group for a limit of 60 years.

“When we looked at the literature, most suggested that the net balance was not favorable for most people – there was more bleeding than heart attacks averted,” said Dr Amit Khera, one of the authors of medical group guidelines. “And it’s not a nosebleed, it can be a bleed in the brain.”

And from 2014, a Food and Drug Administration review concluded that aspirin should not be used for primary prevention, for example to prevent a first heart attack or stroke, and noted the risks.

The task force, which previously recommended all high-risk adults in their 50s take baby aspirin if their chances of having a side effect were low, now proposes that high-risk adults in their 40s and 50s talk to their doctor and make an individual decision on whether to start a daily diet. (The panel defined “at high risk” as anyone with a 10% or greater risk of a cardiovascular event within the next 10 years, according to the American College of Cardiology / American Heart Association calculators used to estimate the risk.)

When the task force released its latest set of recommendations in 2016, endorsing the widespread use of aspirin for primary prevention in high-risk people and saying the benefits outweighed the risks, some critics said that the panel had made a mistake. Dr Steven Nissen, president of cardiology at the Cleveland Clinic, said at the time he was concerned that increased use of aspirin would do more harm than good. Gastroenterologists have said they fear patients taking aspirin will skip their colon cancer screens.

The first large national clinical trial to find that aspirin reduced the risk of heart attack included only male doctors, and it was stopped early, after five years, because the benefits were dramatic and seemed to far outweigh the risks. . But that was 1988, and medical practice has evolved since then, said Dr. Donald M. Lloyd-Jones, president of the American Heart Association.

With people now better able to control risk factors such as high blood pressure and the use of newer drugs to control cholesterol, “aspirin now has less room to tell the difference,” said Dr Lloyd-Jones. But, he said, “there is always a risk of bleeding. “

Research studies have also indicated that although the use of aspirin by people who have not had a heart attack or stroke reduces the risk of these events, it does not reduce the number of deaths from them. heart disease or other causes.

The National Task Force’s draft report also questions another use of aspirin, whether it reduces the risk of colorectal cancer, one of the leading causes of cancer death in the United States and which is on the rise. increase in young adults for reasons that are not clear.

In overturning its approval of aspirin for five years to help prevent colorectal cancer, the report pointed to new data from a randomized controlled study called Aspirin in reducing events in the elderly. In this study, aspirin use was linked to a near-doubling of colorectal cancer deaths after nearly five years of follow-up.

Some experts have not given up on aspirin’s promise, saying there is still “compelling evidence” for its role in cancer prevention.

Dr Andrew Chan, director of cancer epidemiology at the Mass General Cancer Center, said randomized controlled trials show aspirin inhibits the growth of polyps in the colon and reduces the chances of them becoming cancerous.

“This again underscores that we have to think about personalizing who we give aspirin to and move away from a one-size-fits-all solution,” Dr Chan said.

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