Aspirin for everyone over 50?

Editor—The recommendation that everyone over 50 should take aspirin ignores the issue of dose with its ratio of benefit to risk, given that a person still has at least a third of life span remaining and that older hypertensive patients are susceptible to haemorrhagic stroke.¹ The debate about what is a low dose has gone on long enough, with no definite answer beyond 75 mg to over four times its multiple at 325 mg for secondary prevention of cardiovascular and cerebrovascular thrombotic disease. Aspirin across the board for primary prevention may be considered in patients with a 10% risk of coronary heart disease, and the risk-benefit balance between the number of myocardial infarctions that can be prevented and the risk of haemorrhagic stroke and gastrointestinal bleeds must be taken into account.

Bandolier has looked at randomised controlled trials in patients at low risk of cardiovascular disease and failed to find sufficient evidence of benefit.² A meta-analysis of subjects at moderate risk indicates that the risk of thrombotic stroke is overemphasised and overpowers the risk of major bleeds even from low dose aspirin.³

Cost is often a limiting factor in Trinidad and Tobago, where enteric coated or slow release preparations, which may reduce the incidence of gastrointestinal blood loss, are not available in the public sector and are unaffordable for many patients. Patients must take responsibility for their health, but if they are also expected to choose their treatment, why do they need a doctor?

The evidence of benefit for aspirin as primary prevention in influencing cardiovascular outcomes is still awaited. Mean-while, avoid the possible harm.