healthmedicinet

By
Thea Jourdan

Published:

18:44 EST, 26 May 2014

|
Updated:

18:44 EST, 26 May 2014

By John Cleland, Professor of Clinical Cardiology at Imperial College London

Millions of people around the world take aspirin every day in the belief that it will prevent a heart attack or stroke.

But
the Food and Drug Administration (FDA), the official body that
regulates medicines in the U.S., has just announced that unless you have
already had a heart attack or stroke, aspirin does more  harm than good
and should not be used for this purpose.

People take aspirin every day in the belief that it will prevent a heart attack or stroke

At last, people are beginning to scrutinise the evidence, separating the ‘hype’ from the facts and seeing sense.

For
years, I have been saying that aspirin is being prescribed to people
without evidence that they will benefit, but I seemed to be a lone
voice. In this country, NICE, the National Institute for Health and Care
Excellence, recommends that people who are at increased risk of heart
disease and stroke should take low-dose aspirin (75?mg each day) even if
they have not had a heart attack or a stroke.

I think this advice should be reconsidered.

The
cause of most heart attacks is rupture of cholesterol deposits (plaque)
in the wall of the blood vessels supplying the heart muscle. Rupture of
the plaque exposes the cholesterol ‘soup’  to the blood inside the
artery, causing a blood clot.

Aspirin reduces the stickiness of the
blood, which can prevent some blood clots forming and cause others to
break up without doing too much harm. However, plaque rupture is also
often caused by bleeding from tiny, fragile blood vessels that grow into
the plaque from outside the artery wall.

Prof. Cleland has been saying that aspirin is being prescribed to people without evidence that they will benefit

So while aspirin could
prevent some heart attacks, by stopping clots forming, it may trigger
others by causing bleeding into the cholesterol plaque, resulting in no
overall benefit in terms of heart attack or stroke prevention.

The
FDA still suggests that aspirin is beneficial for people who’ve already
had a heart attack or stroke, but I think the evidence for taking it for
more than four weeks after such an event is also weak.

It would not
matter if popping an aspirin every day were harmless, but it isn’t. The
FDA points out that aspirin can lead to  all sorts of health problems,
including bleeding in the  stomach or brain.

So how is it that aspirin has had the green light      for so long?

Thirty
years ago there were very few effective medicines around for people
with heart disease. Doctors were desperate for anything that might help.
Aspirin was the ‘straw that  got clutched’.

Also, around this time,
some of the most prestigious journals  in the world published very 
biased reports of aspirin data  that confused both doctors  and
regulators.

Take the U.S. Physicians’ Health Study (published in The
New England Journal of Medicine in 1989). This looked at more than
22,000 U.S. doctors taking a regular dose of aspirin or a placebo to see
if this could reduce deaths from heart disease.

The trial was
stopped early because aspirin wasn’t working: a similar number of
doctors were dying of heart attacks in  the aspirin group as in the 
placebo group.

After the study had finished, the investigators
re-analysed the data, and found that the doctors in the aspirin group
did have a lower  risk of non-fatal heart attacks -  in other words,
aspirin did seem  to reduce some types of heart attack. But there were
more sudden deaths among those taking aspirin, and this wasn’t taken
into account.

If you’re at risk of the sort of heart attack that
gets you rushed to hospital for life-saving treatment, swapping it for a
sudden death doesn’t seem like a great idea.

Another often-forgotten
trial compared aspirin and a placebo in 13,000 older people with a hip
fracture to see if it could prevent pulmonary embolism, a blockage in
the artery going to the lungs.

This study, published in the Lancet
in 2000, found an increased risk of a heart attack among those taking
aspirin but the result was buried in a footnote.

The only substantial
study which supports the use of aspirin, in my opinion, is the ISIS-2
study, which enrolled about 17,000 patients who had a heart attack
between 1985 and 1987. It showed that taking a daily dose of aspirin
could help lower the risk of dying in the four weeks after a heart
attack.

That’s because after a heart attack, the ruptured plaque
leaves a raw patch inside the artery. Giving aspirin in this situation
helps prevent further blood clots forming on it. Maybe aspirin should be
used more like antibiotics, as a short course after a heart attack or
stroke, then stopped.

At the moment, for people who have not already
experienced a heart attack or stroke, there is  no evidence that the
benefit of aspirin exceeds the harm that it can do. Even among people
who have had a heart attack or stroke, questions remain about long-term
benefit and safety.

Interview by  THEA JOURDAN

or comment on this article

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