Should an elderly patient with no history of myocardial infarction (heart attack) or cerebrovascular accident (stroke), recently relocated to the US, continue taking aspirin (acetylsalicylic acid) 100 mg daily?

Should This Elderly Patient Continue Aspirin?

No, this elderly patient should discontinue aspirin 100 mg daily. Without a history of heart attack, stroke, or coronary revascularization, this represents primary prevention use, and current evidence demonstrates that aspirin's bleeding risks outweigh cardiovascular benefits in elderly patients, particularly those over 60-70 years of age. 1, 2, 3

Why Aspirin Should Be Stopped

Age-Related Risk-Benefit Analysis

• Adults over 60-70 years have greater bleeding risk than cardiovascular benefit from aspirin, regardless of cardiovascular risk level. 1, 2, 3
• The US Preventive Services Task Force (2022) explicitly recommends against initiating aspirin in adults 60 years or older for primary prevention (Grade D recommendation). 3
• The American College of Cardiology/American Heart Association downgraded aspirin to Class IIb (may be considered) for primary prevention in select adults aged 40-70 years only, and recommend against routine use in those over 70. 2

Bleeding Risk in Elderly Patients

• Major bleeding risk is approximately 2-5 per 1,000 patients per year, but this increases substantially with age. 1
• The ASPREE trial (2018) in elderly people was terminated early because aspirin had no effect on disability-free survival but significantly increased major hemorrhage and unexpectedly increased all-cause mortality. 4
• Age >70 years is itself a high bleeding risk factor, independent of other considerations. 1

Lack of Cardiovascular Benefit in Primary Prevention

• Recent large trials demonstrate that aspirin's modest cardiovascular benefit is offset by comparable bleeding risk when patients receive contemporary evidence-based therapies. 2, 4
• The ASCEND trial showed only a 12% reduction in cardiovascular events but a 29% increase in major bleeding. 2
• The number of cardiovascular events prevented equals the number of bleeding episodes induced in patients with over 1% annual cardiovascular disease risk. 2

When Aspirin IS Clearly Indicated (Not This Patient)

Secondary Prevention - Strong Indication

Aspirin 75-100 mg daily remains strongly recommended for patients with: 5, 1, 6

• Prior myocardial infarction
• Prior stroke or transient ischemic attack
• History of coronary revascularization (PCI or CABG)
• Documented significant obstructive coronary artery disease (>50% stenosis)

This patient has none of these conditions.

Alternative to Aspirin if Secondary Prevention Were Indicated

• Clopidogrel 75 mg daily is recommended as a safe and effective alternative to aspirin in patients who cannot tolerate aspirin. 5, 6

Clinical Action Plan

Immediate Steps

1. Discontinue aspirin 100 mg daily - no tapering required. 2, 3
2. Ensure optimal management of actual cardiovascular risk factors (hypertension, diabetes, hyperlipidemia) with evidence-based therapies that provide greater benefit than aspirin. 2, 4
3. Document the rationale for discontinuation in the medical record to prevent inadvertent reinitiation.

Patient Education Points

• Explain that aspirin was likely started under older guidelines that have since changed based on new evidence. 2, 3
• Clarify that stopping aspirin does not mean ignoring cardiovascular health - focus should be on blood pressure control, statin therapy if indicated, diabetes management, and lifestyle modifications. 2
• Reassure that this decision is based on the most current evidence showing harm exceeds benefit in this specific situation. 4, 3

Common Pitfalls to Avoid

• Do not continue aspirin "just to be safe" - the evidence shows net harm in elderly patients without established cardiovascular disease. 2, 4, 3
• Do not use a 10% 10-year cardiovascular disease risk threshold as an automatic indication for aspirin - even at this risk level, aspirin is only a "may consider" (Class IIb) recommendation in younger patients (40-59 years), and is contraindicated in those over 60-70. 2, 3
• Do not confuse primary prevention (this patient) with secondary prevention (where aspirin remains strongly indicated). 1, 2