FEATURE

Does baby aspirin bring on heart attacks?

Prof. B. M. Hegde,
hegdebm@gmail.com

  “OF the terrible doubt of appearances, Of the uncertainty after all-that we may be deluded, That may-be reliance and hope are but speculations after all.”

Walt Whitman

It has been a fashion to prescribe baby aspirin (50-75 mg) daily in healthy people above the age of 30 for preventing a heart attack. A couple of decades ago Professor Cleland, cardiology professor at Southampton University had analysed the data and had clearly shown that while aspirin might or might not prevent non-fatal heart attacks, it definitely increases fatal cerebral haemorrhagic stroke in them by ten per cent! This did not deter the drug industry from coming out with their infamous “poly-pill” with the same aspirin in addition to rat doses of many other drugs in a single pill with lots of fanfare and propaganda claiming that a daily pill of this cocktail will keep death at a distance from the consumer. Thank God that poly-pill remained a non-starter. Man is dreaming of immortality always and the industry caters to that dream despite the fact that George Bernard Shaw in his classic, Doctor’s Dilemma, did emphasis: “do not try to live here for ever, you will certainly not succeed.”

“Knowledge advances not by repeating known facts but by refuting false dogmas.” A recent excellent study from Southampton University in the U.K. and the Maastricht University in the Netherlands found that daily aspirin intake may lead to increased odds of heart attacks by 190%! The study also revealed that a class of drugs called direct oral anticoagulants were also tied to increased odds of heart attack in patients with atrial fibrillation. The results were published in the British Journal of Clinical Pharmacology.The findings echo guidance issued by NHS watchdog NICE in 2015 which said aspirin does more harm than good for AF patients.Atrial fibrillation affects up to 900,000 patients in England and causes their hearts to beat very fast and irregularly, greatly increasing the risk of stroke and early death.But as many as one in seven - up to 120,000 patients - are taking aspirin even though it isn’t very effective and may itself cause a stroke

Look at this irony. An earlier study in 2016 did say that aspirin is a panacea for elderly people to live longer!Older Americans who take a low dose of aspirin every day will drastically cut their risk of contracting heart disease or cancer, a new study claims'Although the health benefits of aspirin are well established, few people take it,' said lead author David B. Agus, a USC professor of medicine and engineering. The authors of this study claim“multiple health benefits and a reduction in healthcare spending from this simple, low-cost measure that should be considered a standard part of care for the appropriate patient.” 

The long-term benefits of low-dose, daily aspirin were questioned this year after conflicting guidelines were published by the U.S. Preventive Services Task Force (USPSTF), a government-backed panel of experts, and the U.S. Food and Drug Administration.The USPSTF issued updated aspirin guidelines that declared the clinical benefit of aspirin. However, the FDA is concerned that some patients, particularly those 60 and older, face an increased risk of stroke and bleeding - both gastrointestinal and in the brain - if they take aspirin daily. However, this much publicised study was not a prospective one and was derived from observations done by different sets of examiners at different times and with different entrycriteria and is not as reliable as the Southampton study detailed above.

There was a more detailed study from Scotland published in 2010 in the JAMA which did show aspirin in bad light.Another study revealed that regular aspirin intake did not decrease the likelihood of suffering heart attack in at-risk patients. Scottish researchers found that high-risk patients who took aspirin on a daily basis had a similar stroke and heart attack rates as those who were on placebo treatment. The results were published in the Journal of the American Medical Association. About three years ago, Bayer AG requested to label aspirin as a heart attack prevention drug. This was later denied by the FDA, basing its decision on the 2010 Scottish study. The FDA has also cautioned patients taking aspirin with blood thinners.Other serious adverse effects associated with aspirin intake include internal bleeding, peptic ulcers, asthma, and kidney disease.

Although there are many more studies on aspirin these three give an idea to the reader how medical research throws up uncertainty as its only certainty. A lay man would be simply floored by this kind of reductionist research. Before one relies on these studies, especially the ones that support a common drug for uncommon indications one has to be careful to see who funds that research? Of these three studies the Scottish and Southampton studies were prospective done on NHS patients and not much money changed hands but the American studies are all money based studies where research simply means getting more funds, writing more papers and, fattening their CVs. Even if one goes by the democratic principles there are more reliable studies that show aspirin in bad light vis-à-vis studies done to show aspirin as good. Even the much hyped poly-pill did not make it to the market very well because of side effects.

I would be happy to accept the Southampton study for the time being as the best guidelines for aspirin treatment. I would go one step further to warn doctors to be very parsimonious in prescribing NSAIDS for simple upper respiratory infections as the latter in the long run could precipitate a stroke or heart attack. Many young people get a heart attack probably due to NSAID use earlier, even as far ago as five years prior. There were some studies suggesting inflammation as the cause of vascular diseases, the new target for new drugs from industry. I have a hunch that it is the NSAID s that must have connected the two. One cannot get better with reductionist thinking in a holistic human being with his mind in the driving seat. In the medical field where wise people insist on evidence base we do not have a scope to gauge the human mind (mindoscope). Until then all our reductionist studies remain only tentative, but caution is our wiser bet. Logically chemical drugs cannot be used for preventing any disease when they have potentially dangerous side effect. Using them for treatment in a desperate situation is logical but not for prevention.

“To be, or not to be, that is the question”  

William Shakespeare