HealthMatters: Risk of bleeds and death with daily aspirin use higher than thought. (See Details)

Research suggests 3,000 people die a year in UK from long-term use of aspirin or similar drugs, but also taking heartburn medication could help reduce risk......

The risk of long-term aspirin use causing major bleeding and death is higher than previously thought, with over-75s particularly vulnerable, a study suggests.

Around 40% of adults aged 75 or over in the UK take a daily aspirin and lifelong treatment is recommended for patients who have previously had a heart attack or stroke.

The preventative effects are well-established in people who have suffered a major heart event, reducing the risk of another by 20%.

But Prof Peter Rothwell, from Oxford University and the lead author of the study, said there are about 20,000 major bleeds and around 3,000 deaths caused by aspirin or other antiplatelet drugs each year.

He says the answer is for people taking aspirin to be prescribed heartburn drugs known as proton-pump inhibitors (PPIs), which reduce the risk of bleeding by 70% to 90%. Currently they are prescribed only in a minority of cases.

The research, published in the Lancet on Tuesday , found that for patients under 65 taking daily aspirin to prevent a recurring stroke or heart attack, the annual rate of bleeds requiring hospital admission was approximately 1.5%, compared with 3.5% for patients aged 75 to 84, and 5% for those aged 85 or over.

The annual rate of life-threatening or fatal bleeds was less than 0.5%, for patients under 65, 1.5% for those aged 75 to 84 and almost 2.5% for patients aged 85 or over.

“The risk of serious bleeding is much higher in the over-75s,” said Rothwell. “In people under 75 the benefits of taking aspirin for secondary prevention after a heart attack or stroke clearly outweigh the relatively small risk of bleeding – these people needn’t worry.

“In the over-75s the risk of a serious bleed is higher – but the key point is that this risk is substantially preventable by taking PPIs alongside aspirin. Since many of the 3,000 excess deaths are preventable by taking PPIs, people over 75 should be prescribed a PPI along with their aspirin. Regardless of age, nobody should suddenly stop taking aspirin without speaking to their doctor.”

The Oxford Vascular Study followed 3,166 patients who had previously had a stroke or heart attack and were prescribed antiplatelet drugs (mostly aspirin). Over the 10-year period, 314 patients were admitted to hospital for bleeding. Analysis showed the risk of bleeding, in particular the risk of fatal or disabling bleeding, increased with age.

As the study was observational, it could not establish that increased risk is entirely caused by aspirin but previous research suggests about half of bleeds would have occurred whether or not people were on the drug.

The authors believe the low uptake of PPIs is partly due to their side effects, but also to previous underestimations of the risk of bleed. As the population has aged so the proportion of people taking aspirin likely to experience major or fatal bleeds has increased.

The results also have consequence for people who choose to take an aspirin for its primary preventative effects – it also reduces the risk of cancer – ie who have not previously suffered a stroke or heart attack. This accounts for around half of the total number of people aged 75 and over taking the drug daily.

Rothwell said he personally would not take an aspirin for primary prevention but he also said that for safety reasons no one currently taking it daily should stop doing so without consulting their doctor.

Dr Tim Chico, reader in cardiovascular medicine and consultant cardiologist at Sheffield University, said: “Prescription of any drug is a balance between the benefits of the medication against its risks, and aspirin is no different. Certainly, people should not stop their aspirin if it has been prescribed by a doctor after a stroke or heart attack, since stopping it can cause another heart attack or stroke.

“However, I would strongly recommend that people who are considering taking aspirin to prevent potential future problems such as cancer or heart attack (ie not for secondary prevention) should discuss this with their doctor.”