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US Public Health Service. Office of Disease Prevention and Health Promotion. Clinician's Handbook of Preventive Services. 2nd edition. Washington (DC): Department of Health and Human Services (US); 1999.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Clinician's Handbook of Preventive Services

Clinician's Handbook of Preventive Services. 2nd edition.

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More than 13 million Americans have coronary heart disease, according to the Third National Health and Nutrition Examination Survey (NHANES III). Heart disease continues to be the leading cause of death in both men and women, and in 1993, nearly 490,000 Americans died of ischemic heart disease. Studies suggest that aspirin in low doses is beneficial in patients with ischemic cardiovascular disease. The Swedish Aspirin Low-Dose Trial (SALT) supports the indication that aspirin reduces the risk of death or stroke in subjects with transient ischemic attack (TIA) or ischemic stroke. The use of aspirin in the primary prevention of myocardial infarction (MI) in patients with stable angina is supported by the Swedish Angina Pectoris Trial (SAPAT). The use of aspirin is also supported in patients who have had a previous MI.

Evidence from the US Physicians' Health Study (a randomized controlled trial) and the Nurses' Health Study (a prospective cohort study) suggests that use of low-dose aspirin significantly decreases the incidence of first MI in middle-aged men and women. However, these studies did not document a decrease in total cardiovascular mortality with aspirin prophylaxis, and the risk of hemorrhagic stroke and sudden death may be increased with its use. A smaller British study of aspirin prophylaxis in physicians found no significant reduction in the incidence of MI. The Women's Health Study, a large randomized, controlled trial that includes aspirin prophylaxis, is in progress.

Aspirin use for the primary prevention of colon cancer is also being investigated. Observational studies have shown an association between aspirin use and a reduction in the incidence of colon cancer. Although this association is of interest, prospective confirmation (eg, in a randomized, controlled trial) is lacking.

Recommendations of Major Authorities

  • American Academy of Family Physicians --
  • Men aged 40 to 84 years with risk factors for coronary artery disease should be counseled about the risks and benefits of aspirin prophylaxis.
  • American Heart Association --
  • Care should be exercised before beginning a lifelong program of aspirin therapy. The decision to begin taking aspirin should be made only after consultation by each individual with his or her physician. The individual who begins a regular aspirin regimen should be aware of the side effects of the drug and should report symptoms to his or her physician. All risk factors for coronary heart disease and stroke should be determined and a concerted program to reduce those risk factors begun.
  • Canadian Task Force on the Periodic Health Examination --
  • The evidence is not strong enough to support a recommendation that routine aspirin therapy be used or not be used for the primary prevention of cardiovascular disease in asymptomatic men and women. The decision on whether to prescribe aspirin should be made on an individual basis after the benefits of decreased risk of ischemic cardiovascular events have been balanced against the potential risks associated with prolonged aspirin use.
  • US Preventive Services Task Force --
  • There is insufficient evidence to recommend for or against routine aspirin prophylaxis for the primary prevention of myocardial infarction in asymptomatic persons. Although aspirin reduces the risk of myocardial infarction in men 40 to 84 years of age, its use is associated with important adverse effects, and the balance of benefits and harms is uncertain. If aspirin prophylaxis is considered, clinicians and patients should discuss potential benefits and risks for the individual before beginning its use.

Basics of Aspirin Prophylaxis

1. Indications

Individuals should not take aspirin daily for cardiovascular uses without first consulting a physician. No major authority recommends routine universal aspirin prophylaxis. People who have had coronary heart disease, TIA, or ischemic stroke are most likely to benefit.

2. Dosage

The optimal dosage of aspirin for the primary, secondary, and tertiary prevention of heart disease is not clearly established. The dose regimens from clinical trials range from 50 mg to 325 mg taken by mouth daily. Doses greater than 325 mg daily confer no added protection but increase the incidence of side effects. It remains to be established whether doses of less than 325 mg every other day confer protection.

3. Contraindications/Precautions

The only contraindication to regular aspirin use is allergy to aspirin. Because of an increased risk of adverse events, individuals with liver or kidney disease, peptic ulcer disease, history of gastrointestinal bleeding, or bleeding disorder should specifically address this issue with their clinicians before starting aspirin prophylaxis. Because of the potential increased risk of hemorrhagic stroke, it is not advisable to use aspirin for prophylaxis in patients with poorly controlled hypertension. Patients using aspirin prophylaxis should inform their surgeon or dentist before undergoing even minor surgical or dental procedures. Prolonged bleeding can persist for up to 10 days after terminating use of aspirin.

4. Adverse Reactions

Side effects of aspirin prophylaxis are dose-related and include gastrointestinal upset and bleeding disorders (eg, easy bruising, epistaxis, hematemesis, melena), gout, and kidney stones. These events require medical attention, and clinicians must consider discontinuation of aspirin prophylaxis if any of these events occur.

Provider Resources

  • Aspirin: A New Look at an Old Drug. FDA Office of Consumer Affairs. HFE 88 Room 1675, 5600 Fishers Ln, Rockville, MD 20857; (800)532-4440.
  • Summary Minutes of the January 23, 1997, Joint Meeting of the Nonprescription Drugs Advisory Committee and the Cardiovascular and Renal Drugs Advisory Committee. A copy of the summary minutes can be obtained through a written request to the Freedom of Information Office (HFI-35), Food and Drug Administration, Rm 12A-16, 5600 Fishers Lane, Rockville, MD 20857.

Selected References

  1. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination . Kansas City, Mo: American Academy of Family Physicians; 1997.
  2. American Heart Association. Heart and Stroke Facts: 1996 Statistical Supplement. Dallas, Tex: American Heart Association; 1995.
  3. American Heart Association. Physicians' Health Study report on aspirin. Circulation . 1988; 77:–. [PubMed: 3370779]
  4. Buring JE, Hennekens CH. The Women's Health Study: summary of the study design. J Myocardial Ischemia . 1992; 4:27–29.
  5. Canadian Task Force on the Periodic Health Examination. Acetylsalicylic acid and the primary prevention of cardiovascular disease. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 56.
  6. Fuster V, Dyken ML, Vohonas PS, Hennekens C. Aspirin as a therapeutic agent in cardiovascular disease. Circulation . 1993; 87:659–675. [PubMed: 8425313]
  7. Fuster V, Cohen M, Halperin J. Aspirin in the prevention of coronary disease. N Engl J Med . 1989; 321:183–186. [PubMed: 2747748]
  8. Internal analgesic, antipyretic and antirheumatic drug products for over-the-counter human use; tentative final monograph. Notice of proposed rulemaking (CFR 343. 10). Federal Register. November 16, 1988; 53:46204-46260.
  9. Manson JE, Stampfer MJ, Colditz GA, et al. A prospective study of aspirin use and primary prevention of cardiovascular disease in women. JAMA . 1991; 266:521–527. [PubMed: 2061978]
  10. Physicians' Health Study Research Group, Steering Committee. Final report from the aspirin component of the ongoing Physicians' Health Study. N Engl J Med . 1989; 321:129–135. [PubMed: 2664509]
  11. Peto R, Gray R, Collins R, et al. A randomised trial of the effects of prophylactic daily aspirin among male British doctors. Br Med J . 1988; 296:320–331.
  12. SALT Collaborative Group. Swedish aspirin low-dose trial (SALT) of 75 mg aspirin as secondary prophylaxis after cerebrovascular ischaemic events. Lancet. 1991; 338:1345-1349.
  13. Juul-Moller S, Edvardsson N, Jahnmatz B, et. al. Double-blind trial of aspirin in primary prevention of myocardial infarction in patients with stable chronic angina pectoris. Lancet. 1992; 340:1421-1425.
  14. Thun MJ, Namboodiri MM, Heath CW. Aspirin use and reduced risk of fatal colon cancer. N Engl J Med . 1991; 325:1593–1596. [PubMed: 1669840]
  15. US Preventive Services Task Force. Aspirin prophylaxis for the primary prevention of myocardial infarction.In: Guide to Clinical Preventive Services. 2nd ed. Washington, DC: US Department of Health and Human Services; 1996: chap 69.
  16. Willard JE, Lange RA, Hillis LD. The use of aspirin in ischemic heart disease. N Engl J Med . 1992; 327:175–181. [PubMed: 1285747]


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