Low-dose Aspirin May Be Linked to Bleeding in the Skull

If someone tells you a wonder drug exists that can cure all of your problems, run as fast as you can. I write this in jest, but if you were alive in the 1980s, you know that Aspirin (acetylsalicylic acid) was marketed as an all-around remedy to prevent heart attacks and strokes, treat pain, inflammation, and reduce fever. The "Heart Attack Prevention Drug", as it became known, was prescribed for years in low doses to address the burden that is cardiovascular disease. 

Since then, every home seems to have a spare bottle of Aspirin on hand.

This is advice that still persists today, as a daily low-dose Aspirin is continually touted by many doctors in preventing heart attacks. But a new study by Huang and colleagues (2019) suggests that Aspirin might do more harm than good.

Let me make one clear point. It is true that the benefits of low-dose Aspirin, particularly for secondary prevention of heart attacks and ischemic strokes, are well established in the scientific literature, with the prevention of recurrent ischemic events outweighing the risks of hemorrhage (Gorelick &  Weisman, 2005; Baigent et al., 2009). But the value of Aspirin for primary prevention of symptomatic cardiovascular disease is not well established. Indeed, it’s been a topic of controversy since the risk of cardiovascular events among event-free individuals is typically lower than that of patients with symptomatic atherosclerotic disease. Thus, the increased risk of Aspirin-induced bleeding offsets the overall benefit that the drug is supposed to provide. (Capodanno & Angiolillo, 2016; Guirguis-Blake et al., 2016; Lei et al., 2016). 

Stomach damage with high risk of internal bleeding is a common and serious problem caused by Aspirin. Even more serious and common is the risk of developing internal bleeding inside of the brain with low dose Aspirin.  Its associated risk of major disability and death is significantly higher relative to the morbidity and mortality associated with stroke caused by a person with heart disease not on Aspirin (Kim et al., 2009; Cadilhac et al., 2010; Lee et al., 2010).  

Additionally, low dose Aspirin is associated with a magnified risk of intracerebral hemorrhage associated with Asian race/ethnicity and populations with a mean body mass index (BMI) less than 25 (i.e. BMI < 25 is usually indicative of better health and lower cardiovascular risk). 

It is not warranted to recommend low-dose Aspirin to the general population since the risk does not outweigh the benefit. 

Conclusions 

1. The benefits of low-dose Aspirin for primary prevention of cardiovascular events is not well supported in the scientific literature.  It is actually associated with increased risk of intracranial hemorrhage.
2. This risk is even worse among Asians and those with a BMI less than 25.  
3. The outcomes of intracranial hemorrhage are often catastrophic.
4. Serious caution must be taken with the use of low-dose Aspirin in individuals without symptomatic cardiovascular disease.

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References

Baigent, C., Blackwell, L., Collins, R., Emberson, J., Godwin, J., Peto, R., ... & Patrono, C. (2009). Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials.

Cadilhac, D. A., Dewey, H. M., Vos, T., Carter, R., & Thrift, A. G. (2010). The health loss from ischemic stroke and intracerebral hemorrhage: evidence from the North East Melbourne Stroke Incidence Study (NEMESIS). Health and quality of life outcomes, 8(1), 49.

Capodanno, D., & Angiolillo, D. J. (2016). Aspirin for primary cardiovascular risk prevention and beyond in diabetes mellitus. Circulation, 134(20), 1579-1594.

Gorelick, P. B., & Weisman, S. M. (2005). Risk of hemorrhagic stroke with aspirin use: an update. Stroke, 36(8), 1801-1807.

Guirguis-Blake, J. M., Evans, C. V., Senger, C. A., O'Connor, E. A., & Whitlock, E. P. (2016). Aspirin for the primary prevention of cardiovascular events: a systematic evidence review for the US Preventive Services Task Force. Annals of internal medicine, 164(12), 804-813.

Huang, W. Y., Saver, J. L., Wu, Y. L., Lin, C. J., Lee, M., & Ovbiagele, B. (2019). Frequency of intracranial hemorrhage with low-dose aspirin in individuals without symptomatic cardiovascular disease: a systematic review and meta-analysis. JAMA neurology.

Kim, H. C., Choi, D. P., Ahn, S. V., Nam, C. M., & Suh, I. (2009). Six-year survival and causes of death among stroke patients in Korea. Neuroepidemiology, 32(2), 94.

Klatsky, A. L., Friedman, G. D., Sidney, S., Kipp, H., Kubo, A., & Armstrong, M. A. (2005). Risk of hemorrhagic stroke in Asian American ethnic groups. Neuroepidemiology, 25(1), 26-31.

Lee, H. Y., Hwang, J. S., Jeng, J. S., & Wang, J. D. (2010). Quality-adjusted life expectancy (QALE) and loss of QALE for patients with ischemic stroke and intracerebral hemorrhage: a 13-year follow-up. Stroke, 41(4), 739-744.

Lei, H., Gao, Q., Liu, S. R., & Xu, J. (2016). The benefit and safety of aspirin for primary prevention of ischemic stroke: a meta-analysis of randomized trials. Frontiers in pharmacology, 7, 440.

Author

Dr. Payal Bhandari Dr. Payal Bhandari M.D. is a leading practitioner of integrative and functional medicine in San Francisco.