JOHN M. BOLTRI, MD MARK R. AKERSON, MD ROBERT L. VOGEL, PHD Macon, Georgia From the Department of Family Medicine, Mercer University School of Medicine, Family Practice Residency Program, The Medical Center of Central Georgia, Macon, GA. The authors report no competing interests. Address reprint requests to John M. Boltri, MD, Department of Family Medicine, Mercer University School of Medicine, 3780 Eisenhower Parkway, Macon, GA 31206. E-mail: boltri.john@mccg.org.
There are a number of limitations to this study. There were no strictly low-risk studies of aspirin for primary prevention of cardiovascular mortality, and there was a paucity of studies that included low-risk subjects. Because the studies analyzed did not include only low-risk subjects, the results may not apply to all low-risk patients. The BDS did not include a placebo and was not blinded. Although not statistically significant, the ORs tended toward a protective effect for aspirin in the 2 randomized trials. The large difference in mortality between those 2 trials remains unexplained. The NHS was the only study to include women, and it was a cohort study, which is subject to selection and reporting biases. Therefore, aspirin users may have been at higher mortality risk due to smoking, obesity, or other illness, thus rendering the association between aspirin and higher mortality meaningless.
Many studies have shown significant side effects of aspirin, including epistaxis, peptic ulcer disease, gastrointestinal bleeds, and hemorrhagic stroke.15,20-22,27-32 In the BDS, 17% more subjects in the aspirin group developed peptic ulcer disease, and 19% stopped treatment during the first year secondary to gastrointestinal complaints.21
In conclusion, there is currently no evidence to recommend for or against the use of aspirin in low-risk individuals to decrease mortality. There may be other reasons to take aspirin prophylactically such as to reduce myocardial infarction or colon cancer. However, these benefits have not been established in a low-risk population. Health care providers should ask all patients whether they are taking aspirin and evaluate the risk-benefit ratio before recommending it.
