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Many people take low dose aspirin, usually 81 mg, to prevent cardiovascular complications. Doctors frequently prescribe aspirin after a patient has had a heart attack or after a stent has been placed in a coronary artery. But is it safe to stop this medicine? A new study suggests that stopping aspirin suddenly may have grave consequences (Circulation, online, Sept. 26, 2017).

Stopping Aspirin and Cardiovascular Events:

A large Swedish study used medical records and the national death registry to answer the question whether stopping aspirin can lead to dangerous cardiovascular outcomes. In Sweden, low-dose aspirin is available only by prescription. As a result, the investigators were able to determine who was taking the drug and who stopped.

Between 2005 and 2009, more than 600,000 people over 40 were taking low-dose aspirin. During three years of follow-up, about 15 percent of these people stopped taking their aspirin, and more than 62,000 were hospitalized or died from a heart attack or stroke.

What They Found About Stopping Aspirin:

In analyzing the data, the researchers discovered that people who had quit their low-dose aspirin without a clear medical reason were 37 percent more likely to suffer such an event.

Here’s what the researchers reported:

“In this large nationwide patient cohort, discontinuation of long-term low-dose aspirin was associated with a >30% higher risk of cardiovascular events, corresponding to an additional cardiovascular event observed per year in 1 of every 74 patients who discontinue aspirin. The risk appeared to increase as soon as the patients discontinued aspirin, with no safe interval.”

People who were taking aspirin because of a previous heart attack had a higher rate of heart attack, stroke or death if they stopped. In that situation, as many as 1 in every 36 of these patients suffered a cardiovascular complication.

The Swedish investigators characterized the risk this way:

“Aspirin discontinuation appeared especially perilous among patients with previous cardiovascular disease…”

Stopping Aspirin and Rebound Risk:

The Swedish researchers note that “experimental studies have suggested a rebound effect after aspirin discontinuation…” This may increase the risk for blood clot formation.

They pose an important but unanswered question:

“For patients undergoing planned surgery or other procedures, it is unknown whether treatment gaps >7 days or <24 hours before the procedure are safe. For patients discontinuing aspirin therapy, it is unknown whether or when the rebound effect happens. In addition, for patients with poor adherence, any rebound effects may be in play more or less continuously.”

Their Conclusions About Stopping Aspirin:

What are we to make of this new research? The authors conclude:

“Among long-term users of low-dose aspirin, discontinuation of aspirin in the absence of major surgery or bleeding was associated with a >30% increased risk of cardiovascular events. The risk increased shortly after discontinuation. These findings can help policymakers focus on simple measures to ensure treatment persistence with a cheap medication like aspirin with substantial public health gains.”

Other Research on Stopping Aspirin:

The most recent Swedish research is not the first study to report that stopping aspirin suddenly may increase the risk for a heart attack. Not surprisingly, aspirin, even in low doses, can lead to severe stomach irritation. Sometimes low-dose aspirin can cause bleeding ulcers. In such cases physicians almost always stop the aspirin immediately.

One small study in the journal Clinical Gastroenterology and Hepatology (Jan., 2013) reported:

“In patients with cardiovascular disease, discontinuation of low-dose aspirin therapy after peptic ulcer bleeding increases risk of death and acute cardiovascular events almost 7-fold.”

Needless to say, such results put patients between a rock and a hard place. A bleeding ulcer can turn into a life-threatening event. But suddenly stopping aspirin appears to pose scary cardiovascular complications.

The authors of this research state the dilemma:

“Balancing between the cardioprotective effect of aspirin and the increased risk of rebleeding associated with aspirin use requires a careful clinical tradeoff.”

They go on to conclude:

“in patients with cardiovascular comorbidities who are treated for peptic ulcer bleeding, aspirin therapy should not be discontinued at the time of discharge from hospital.”

What Should Patients Do?

We encourage any patient taking aspirin for its heart protective effects to consult with a knowledgeable specialist before stopping aspirin. Every situation is different, so any recommendation needs to be tailored to each patient’s special needs.

This is especially important prior to surgery. Physicians have been wrestling with the question about stopping aspirin prior to surgical procedures for years. A review in the International Journal of Surgery (online, Nov. 15, 2013) asked the following question:

“…should patients on acetylsalicylic acid (ASA) for secondary prevention stop or continue the medication prior to elective, abdominal surgery.”

After reviewing the available literature these authors conclude:

“…it appears that continuing ASA isn’t associated with excessive bleeding. Further adequately powered trials with well-defined end points are needed to answer this important clinical question.”

The People’s Pharmacy Perspective:

It is sad that more research is needed to answer the critical questions of:

  1. Should aspirin be discontinued, especially in heart patients?
  2. If aspirin should be stopped, what is the best way to do that?
  3. Is there a rebound blood clotting reaction to stopping aspirin?
  4. Is there any way to prevent a heart attack or stroke if aspirin is discontinued?

In the meantime, patients will need to ask their doctors about this controversy. Some surgeons will recommend that aspirin be stopped at least a week before they operate. Others may suggest that a day or two is sufficient. As far as we can tell, there is no one-size-fits-all answer to this quandary. That is why it is critical to have a meaningful conversation about the pros and cons of aspirin before any procedure.

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  1. Glenda
    Winter Haven Fl
    Reply

    I am taking one aspirin a day to help lower my C-reactive protein along with Vit C, Vit E, and turmeric.
    Any problems with doing this? All the doctor recommends is a satin but my cholesterol is excellent and so is all my blood work.

    How do I get a reply from you on my situation?

  2. John
    Seattle
    Reply

    If your stomach can’t handle aspirin, try Pycnogenol. It’s a natural supplement made from European Pine Bark. It thins the blood and also works well for curbing hot flashes.

  3. Retired RN
    Reply

    I take low dose ASA (81mg). When purchasing this product, I have noticed that the price is 3-4 times higher than the regular (325 mg) dose ASA. With a drug that has been used for over 100 years, this kind of price gouging should not happen.

  4. David
    NYC
    Reply

    Why are so many people taking low dose aspirin in the first place? I read that in studies showing positive results from aspirin it was the magnesium in buffered aspirin (which were used) that helped cardiovascular conditions. People should take magnesium as most do not get enough in their diet.

  5. ray
    Reply

    Whoa, a 700% increase! All the more reason to follow your advice from ’99 in ‘PP’s Guide to Home and Herbal Remedies’….under Blood Clotting in the index.

  6. Mary
    Raleigh NC
    Reply

    This is a true story. In the 1950’s, my grandmother had been taking a “heart pill” from her doctor. The older doctor retired and my Granny went to see the young doctor to get her “heart pill” refilled. The young doctor told her,” Mrs. G , this is nothing but aspirin. There is nothing wrong with your heart ” and he refused to refill her heart pill. Three weeks later she died of a heart attack. That was in the 1950’s before any research had been done on the affects of aspirin and the heart!

  7. Anne Foster A
    Seattle, WA
    Reply

    I have been taking low dose aspirin for several years now since my heart surgery for hypertrophic caridiomyopathy with an obstruction. I don’t have the arterial plaque condition that many patients have. At 74, I have clear arteries confirmed by angiogram and CT heart scans. I know cholesterol issues are different from clotting but I cannot stand to know the unnecessary ingredients in aspirin besides the main ingredient.

    Why do we have to have carnauba wax and propylene glycol in our aspirin? I asked a compounding pharmacist if she could just formulate pure ACA for me and she said yes. Of course, this would not have a coating to protect my stomach. I have been taking nattokinase concurrently with 81 mg aspirin.

    Wouldn’t this do the same thing if I took only that? My cardiologist says I have a slight risk for stroke because of a remnant of an apical pouch. My mild heart attack was due to atrial fibrillation (one time episode) due the the HCM. That is now corrected. Any comments?

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