Canadian Heart and Stroke Foundation guidelines no longer recommend Aspirin for prevention of heart and cardiovascular disease

5.3 million Canadian adults take Aspirin to prevent heart disease. Most of them, according to new Heart and Stroke Foundation guidelines published in the Canadian Medical Association Journal, should stop.

In 2019, the American College of Cardiology and the American Heart Association reversed decades of routine medical advice and stopped recommending low-dose Aspirin for the prevention of primary—that is first time—atherosclerotic cardiovascular disease (ASCVD). This ending of the relationship with Aspirin brought the U.S. into line with current European medical advice. One year later, Canada has joined the consensus and broken up with Aspirin, no longer recommending it for the prevention of primary heart disease.

The American guidelines no longer recommend preventative low-dose Aspirin for people under 40 or over 70 or for people who are not at increased risk for ASCVD or who are at increased risk of bleeding. Though the American guidelines allow that low-dose Aspirin may be considered for people between 40 and 70 at increased risk of ASCVD but not increased risk of bleeding, they caution both that “benefits of aspirin . . . have been less evident in more recent trials" and that "the gap of relative benefit to relative harm for aspirin has narrowed." They, therefore, lower the confidence of the recommendation to take aspirin for the prevention of ASCVD even in people at higher risk.

Several recent studies explain the change in recommendations. One review of the research found no benefit, but significant risk of low-dose Aspirin in people who had not had a prior heart attack (Eur Heart J 2013;34:3403-3411). The second concluded that "There is no reliable evidence that aspirin used in the current fashionable doses of 50–100 mg/day is of any benefit in any common clinical setting." According to this study, "any common clinical setting" incudes even people "with known cardiovascular disease" (Eur Heart J 2013;34:3412-8).

Research on people at higher risk because of multiple risk factors like high blood pressure, cholesterol problems or diabetes have found either that Aspirin does not reduce risk but does increase side effects (JAMA 2014;312:2510-20) or that the side effects of gastrointestinal and extracranial bleeding offset the smaller prevention of vascular events (NEJM 2018;379:1529-1539).

A recent study published in The New England Journal of Medicine found that Aspirin provided no significant reduction in risk of cardiovascular disease in people who had not previously suffered a cardiovascular event but that it did significantly increase the risk of major hemorrhage (N Engl J Med 2018;379:1509-1518).

Another quite disturbing recent study showed that when people with no prior history of cardiovascular events take low-dose Aspirin, their risk of dying from any cause was higher: 12.7 events per 1000 person-years in the aspirin group versus 11.1 events per 1000 person-years in the placebo group. Cancer was a major cause of the increased death in the aspirin group. 2.3% of the placebo group died from cancer versus 3.1% in the aspirin group (N Engl J Med 2018;379:1519-1528).

The new Canadian Heart and Stroke guidelines is based on many of these same studies as well as another new study of people with average cardiovascular risk that also found that while the risk of bleeding was greater on Aspirin, the risk of cardiovascular events were not significantly lowered (Lancet 2018;392:1036–46). The Canadian guidelines also reference two systematic reviews that confirmed that low-dose Aspirin significantly increased the risk of major bleeding events (JAMA 2019;321:277–87; Eur Heart J 2019;40:607–17).

Because of the lack of benefit for cardiovascular events or mortality and the increased risk of major gastrointestinal and extracranial bleeding events, the new Canadian guidelines  no longer recommend Acetylsalicylic acid (ASA) for primary prevention of cardiovascular disease--that is for people without a prior history of cardiovascular events—because the harms of ASA could potentially outweigh the benefits. They continue to recommend it for people with a history of cardiovascular, cerebrovascular or peripheral artery disease.

The new guidelines make it clear that ASA is no longer recommended for prevention of a first vascular event even if you have vascular risk factors: a recommendation that is based on the studies discussed above.

Cardiovascular disease accounts for 1 out of every 3 deaths in Canada: more than all kinds of cancer combined. ASA has been the common recommendation for prevention for decades. That failing is now being addressed. For people who have never experienced a cardiovascular event, even if they have multiple risk factors—low-dose Aspirin is no longer recommended for prevention in most people because the bleeding risks outweigh the unrealized benefits.


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The Natural Path is intended for educational purposes only and is in no way intended for self-diagnosis or self-treatment. For health problems, consult a qualified health practitioner for a comprehensive program.

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