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The Spectacular Fall from Grace of Aspirin

There was a major publication a couple of months back describing the risk of taking aspirin as a preventive drug for heart vessel thrombosis (coronary artery disease) outweighed the benefit in elderly subjects with a number of factors- most of which were reasons to take aspirin to begin with. For 2 decades + we were instructed by cardiologists that low dose aspirin was critical to ward off heart attacks. 50,000 doctors in the US (cardiologists alone), including primary care practitioners another 100,000, so 150,000 doctors telling us to take low dose aspirin. A huge business taking low dose 82 mg aspirin pills.... 20 years the best thing ever.... now not....

There are lessons about everything in medicine in this fall from grace, that also applies to everything else.

Patient selection for studies. Patient selection is absolutely crucial and crucial to understand. Very elderly patients with instability are at risk for falls. Aspirin is very effective as an anti-platelet anticoagulation drug, and when drugs really work for something, there is a risk for that function to happen. So a study with a lot of elderly patients who fall, will result in a lot of intracranial hemorrhage occurrences, and the drug will look dangerous. Individuals who are somewhat younger and who do not fall a lot than this risk will not be high.

Reliability of adhering to protocols. If you take too much of a drug, for example very elderly and confused, then increased risk of hemorrhage will result.

Age and health. Elderly patients have a much higher likelihood of decreased renal function, which means there will be more of a drug still in the body than those with better renal function. All other sources of decreasing drug activity also occurs: lower metabolism, lower activity of liver enzyme function.

So although at some level many of us, who are at least a little bit dubious of health care, may have seen some dark humor in the spectacular fall from grace of aspirin, at the same time there may be critical selection issues in this and other studies. I also use it to be wary of how studies are done, even the most revered of study designs: randomized controlled trial (RCT) studies. The results of these type of studies are dramatically effected by designs, like number of subjects and patient selection.

I take this to mean: if you have a tendency to fall a lot, don't take daily aspirin. Otherwise it probably still is beneficial. Presently ofcourse we have to think of the tragic and uncertain explanation of the death of comedy icon Bob Saget when we think of intracranial hemorrhage. My opinion it was not an accident, with skull fractures in the posterior and anterior skull. I also have to wonder if he was on low dose aspirin... probably, since he had coronary artery disease.

Richard Semelka, MD


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