Long-Term, Daily Low-Dose Aspirin Intake Does Not Prevent Incidence Of Stroke, Instead Increases Risk Of Intracerebral Bleeding In Older Adults By 38%
Thailand Medical: In recent years, low-dose aspirin has been widely prescribed to reduce the risk of cardiovascular events, including strokes, in both primary and secondary prevention settings. The evidence supporting its use, particularly in younger populations, has been encouraging, leading to its widespread adoption.
However, the risks and benefits of aspirin therapy become more nuanced as we consider its effects in older adults. As the global population ages, it becomes increasingly crucial to understand how this age group responds to aspirin treatment. In a pioneering study, the Aspirin in Reducing Events in the Elderly (ASPREE) trial has shed light on this topic, revealing unexpected findings that challenge our previous assumptions.
The ASPREE Trial - Unveiling the Complexities
The ASPREE trial was a landmark prospective, randomized, double-blind, placebo-controlled study conducted between 2010 and 2014 in Australia and the United States. The study aimed to assess the efficacy and safety of daily low-dose aspirin in preventing cardiovascular events in community-dwelling older adults (median age of 74 years) who were free from symptomatic cardiovascular disease. In total, 19,114 participants were enrolled, and they were randomly assigned to receive either 100 mg of enteric-coated aspirin or a placebo.
The primary endpoint of the study was disability-free survival, which sought to determine whether aspirin treatment could improve functional outcomes in older adults.
Surprisingly, the study found no statistically significant difference in disability-free survival between the aspirin and placebo groups.
The Unexpected Intracerebral Bleeding Risk
While the primary outcome of disability-free survival did not show significant differences, secondary outcomes, particularly those related to strokes and bleeding events, revealed intriguing results.
The study discovered that low-dose aspirin did not produce a significant reduction in the incidence of ischemic strokes, a finding that contrasted with earlier studies conducted on younger populations.
What was even more alarming was the significant increase in intracranial bleeding observed among individuals assigned to aspirin. Specifically, there was a 38% higher risk of intracranial bleeding, resulting from a combination of hemorrhagic strokes and other causes of intracerebral hemorrhage.
This unexpected outcome sparked immediate concern among researchers and healthcare professionals.
The Risks of Aspirin Therapy in Older Adults
The increased risk of intracranial bleeding is of particular concern when considering aspirin therapy for older individuals. Older adults tend to have higher susceptibility to bleeding due to the fragility of small blood vessels. Additionally, they are more prone to falls and accidents, which can result in head trauma. This combination of factors makes the balance of risks and benefits of aspirin therapy more delicate in this age group.
Lead researchers, Dr Geoffrey C. Cloud from the department of Neuroscience, Monash University-Australia, told
e:16px">Thailand Medical News, “It is important to note that intracranial hemorrhage is typically less treatable than ischemic strokes and is associated with a higher mortality rate. The ASPREE trial found that one-third of intracranial hemorrhagic events were fatal, compared to only 7.7% of ischemic strokes. These sobering statistics highlight the severity of intracranial bleeding and emphasize the need for cautious consideration when prescribing aspirin to older adults.”
Understanding the Lack of Ischemic Stroke Prevention
The lack of significant reduction in ischemic strokes in the aspirin group was a surprising finding, especially given the higher age-related risk of strokes in this older population. This study finding also diverges from previous studies that demonstrated aspirin's efficacy in secondary stroke prevention.
One possible explanation for this discrepancy is the inclusion of individuals with extensive levels of blood pressure and lipid management and without preexisting cardiovascular or cerebrovascular disease in the ASPREE trial. The relatively low incidence of ischemic strokes in this cohort may have masked aspirin's potential preventive effects.
Implications for Clinical Practice
The results of the ASPREE trial provide valuable insights into the use of low-dose aspirin for primary stroke prevention in healthy older adults. Healthcare professionals should exercise caution and carefully evaluate the risks and benefits of aspirin therapy, particularly in older individuals who are prone to falls and head trauma. This study supports the recommendation of the US Preventive Services Task Force (USPSTF) against the routine prescribing of low-dose aspirin for primary prevention in this age group.
As the global population continues to age, the findings from the ASPREE trial mark a significant advancement in understanding aspirin therapy's complexities in older adults. Further research is warranted to explore alternative treatment options for primary stroke prevention in this age group. The implications of this study reach beyond aspirin and call for a broader consideration of preventive strategies for cardiovascular events in older adults.
Conclusion
The ASPREE trial has challenged our traditional understanding of low-dose aspirin's role in preventing strokes in older adults. While previous studies suggested its efficacy in younger populations, this groundbreaking research demonstrated a lack of significant reduction in ischemic strokes and, concerning increased risk of intracranial bleeding, particularly in those prone to falls and head trauma.
Healthcare professionals must carefully weigh the risks and benefits of aspirin therapy in older patients and consider alternative preventive strategies. The ASPREE trial's findings will undoubtedly influence clinical practice and pave the way for further research into the complexities of aspirin therapy in older adults, ultimately improving patient care and outcomes for this vulnerable population.
The study findings were published in the peer reviewed journal: JAMA Network Open.
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2807630
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