The issue of aspirin for people who have never had a heart attack has been highlighted again after findings from President Donald Trump’s annual physical exam were released last week, and observers noticed the persistent aspirin use recorded in the doctor’s report.
Trump (78) has no apparent history of cardiovascular disease (CVD) and had normal results on ECG and echocardiogram. He had well-controlled hypercholesterolemia, supported by current use of rosuvastatin and ezetimibe (Zetia).
Medpage Today reports that one line stood out, however: his ongoing use of aspirin for “cardiac prevention”.
While it is acknowledged that there are people for whom aspirin’s benefits may outweigh the risks, the guidelines are steadfast in rejecting the blood-thinner for people who have never had a heart attack or stroke, especially older people more prone to bleeding side effects.
Since 2019, US guidelines have recommended that prophylactic low-dose aspirin not be routinely used for adults over 70. The US Preventive Services Task Force similarly recommends against initiating low-dose aspirin for primary prevention of CVD in people over 60.
“Aspirin is not recommended for primary prevention of CVD due to the increased risk of haemorrhage, with the net clinical benefit not in favour of aspirin,” Christopher Reid, PhD, MSc, of Curtin University in Melbourne, Australia, told MedPage Today.
Daily aspirin used as primary prevention was associated with modest benefit at the cost of excess bleeding in major randomised trials. In elderly people, the risk of gastrointestinal bleeding was up 60% tab over fve years in the ASPREE study.
In practise, however, the case of Trump and many others show that the use of aspirin for primary prevention persists – albeit to a lesser extent in recent years, according to National Health and Nutrition Examination Survey data showing its 46.1% prevalence in 2017-2020 dropping to 34.4% in 2021-2023 among adults older than 70.
One’s CVD risk estimate seems to drive the decision-making around primary prevention with aspirin.
“Many guidelines don’t routinely recommend aspirin for primary prevention because of the risk of bleeding. However, it is left to doctors’ discretion based on the patient’s risk. Aspirin is more commonly used for primary prevention in the US than in Europe, dating back many years, so I don’t think this is particularly controversial,” said Jane Armitage, MBBS, emeritus professor at the University of Oxford.
At face value, if Trump is taking aspirin for primary prevention at his age, he may be considered at high or very high CVD risk, suggested Maciej Banach, MD, PhD, of Medical University Lodz, Poland.
“Thus, taking into account both (American Heart Association) or (European Society of Cardiology) guidelines, aspirin may be used in patients in primary prevention at high CVD risk and with low risk of bleeding (we do not have any data on such risk),” he said. “So, in my opinion, having obviously only publicly available data, this therapy seems to be OK.”
Aspirin is still recommended for secondary prevention of CVD.
MedPage Today article – Is Trump getting guideline-recommended care for cardiac risk? (Open access)
See more from MedicalBrief archives:
Aspirin for secondary prevention of atherosclerosis – evidence or dogma?
Experts challenge ‘one size fits all’ aspirin guidelines
Regular aspirin increases anaemia risk in seniors – ASPREE study