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Aspirin & Your Heart: Get the Facts
Dr. Keith Miller discusses if taking aspirin can help prevent a heart attack, how often you should be taking it, risks or side effects associated with aspirin use, and other cardiovascular disease prevention tips.
Featured Speaker:
Dr. Miller is certified by the American Board of Internal Medicine with a subspecialty certification in Cardiovascular Disease. He has expertise in non-invasive imaging, including echocardiography, nuclear stress testing and cardiac computed tomography (CT) scanning. Dr. Miller is an IBHRE Certified cardiac device specialist physician, with expertise in implanted rhythm devices including pacemakers and defibrillators. He has an interest in preventive cardiology, cardiovascular risk assessment and cardiometabolic health.
Keith Miller, MD, PhD
Dr. Keith Miller, MD, PhD, FACC was raised in Omaha, Nebraska, and completed his undergraduate studies at Cornell University in Ithaca, New York. He earned his medical degree and research doctorate degree from the University of Nebraska College of Medicine in Omaha, Nebraska, in 1997. Dr. Miller completed his residency in internal medicine at the University of Iowa Hospitals and Clinics, followed by a fellowship in cardiovascular diseases at the University of Chicago Medical Center in Chicago, Illinois. He joined Bryan Heart in 2003.Dr. Miller is certified by the American Board of Internal Medicine with a subspecialty certification in Cardiovascular Disease. He has expertise in non-invasive imaging, including echocardiography, nuclear stress testing and cardiac computed tomography (CT) scanning. Dr. Miller is an IBHRE Certified cardiac device specialist physician, with expertise in implanted rhythm devices including pacemakers and defibrillators. He has an interest in preventive cardiology, cardiovascular risk assessment and cardiometabolic health.
Transcription:
Aspirin & Your Heart: Get the Facts
Melanie Cole (Host): We hear so much today about aspirin and its uses to help prevent cardiovascular disease but how do you know what to believe? Should you take an aspirin? Is there a certain age that you should? Or risk factor? We’re going to find out and clear some of that up today with Dr. Keith Miller. He’s a cardiologist with Bryan Heart. Dr. Miller, I’m so glad to have you with us today as this is something I’ve thought about myself being 55 and in menopause and tell us a little bit about aspirin. What’s the main function of it?
Keith Miller, MD, PhD, FACC (Guest): It’s a great topic. It’s such a basic and such a fundamental but it has been a little bit of a moving target, so, I’m really happy to have a chance to talk about aspirin. It’s kind of at the core of what we do in cardiology.
Aspirin has been around forever as you know. And it’s been an important part of taking care of cardiology patients for a long time. It helps prevent blood clots. We think it has an anti-inflammatory effect and we know that it protects people from heart attack in the right setting. And I think one of the most important things to remember is that for people that have already been diagnosed with a coronary problem; so they’ve had a heart attack or an unstable coronary syndrome or they’ve gotten a coronary stent, or they’ve had a bypass surgery; aspirin is still important. And I emphasize that because there’s been a lot of discussion in the press and a lot of discussion among cardiologists just in the last year about aspirin and raising questions about the value of aspirin, but not for people who already have coronary disease or other types of vascular disease. It’s still really important for those people.
But basically, aspirin is still aspirin. It’s still a great drug but only in the right person that really needs the aspirin.
Host: So, it kind of goes back and forth as you mentioned there’s some discussion among the press and among cardiologists and so, it used to be that they were recommending it for everybody at one point to help protect against certain events. But now as you say, it certainly is limited. How is thing changing Dr. Miller and why did it change?
Dr. Miller: Yeah. it’s such a great question because as long as aspirin has been around, you’d think that we would have really figured all this stuff out by now and there really wouldn’t be any changes in the recommendations about aspirin. But actually that’s not true. And the reason that this has become kind of an issue again and discussed quite a bit in articles written in newspapers about this, is that in the last year, three major important studies have been published on the value of aspirin for preventing a first event, a first heart attack or stroke or other cardiovascular event and they are important studies. They were very well done. And they were published in very authoritative journals.
So, they have clearly affected our thinking about this and again, not for people that already have disease, have had a heart attack, stent, bypass surgery, whatever; those people still need to be on aspirin. This is for people who have never had a problem in the past. So, the different studies looked at different populations. One of them looked at people who are at intermediate risk for heart attack; so these are usually people with a couple of risk factors so middle aged with hypertension and smoking or middle aged with high cholesterol and a very potent family history of heart disease. Something like that. People at risk. One of the studies was in healthy people, men and women over the age of 70 and the third study was among diabetic patients who have not had a history of cardiovascular disease.
The study on the intermediate risk patients and the study on the healthy men and women over the age of 70; they studied aspirin versus placebo, and they were huge studies with thousands of patients, and they were negative. There was no benefit in terms of reducing the risk of heart attack or stroke or cardiovascular death but there was definitely an increase in the bleeding risk. So, these were negative studies. So, this was a surprise because there’s a lot of people who believed that if you could pick out people who were at high enough risk of a heart attack; those people should benefit from being on an aspirin. And that really in this case turned out not to be true.
The third study was a little different because that involved people with diabetes who are always at higher risk of cardiovascular disease and in those people and there were over 15,000 people enrolled in this study and they were studied for over seven years. so, it’s a very powerful study. And in that study, they did demonstrate that there was a reduction in the risk of major cardiovascular events like heart attack, stroke and cardiovascular death. It was fairly modest, but it was significant. But the cost for that benefit was an increase in the bleeding risk.
So, it really helps us understand how to target aspirin therapy for prevention and it’s clearly not for everybody. And it’s I think in my practice, at least, I think most of my cardiology colleagues would agree; most healthy people over the age of 70 probably should not be taking an aspirin and most middle aged people at average risk of heart disease should probably not be taking an aspirin. It can be a little complicated and I think it’s always worth discussing this issue with your doctor because it is an individualized decision and if your risk is high enough; maybe that’s something you’d want to do.
Host: What a great explanation Dr. Miller, that was excellent. So, when we are assessing the risk versus benefit, in someone in that high risk category, some of those side effects you were talking about bleeding, but there’s also skin bruising and even I as an exercise physiologist see with my clients all the time, this major bruising and then the risk of hemorrhagic stroke, all of these other kinds of things. How do you as a cardiologist weigh that and when you are looking at maybe an elderly patient of yours and saying well yes, you should be taking aspirin and then their arms are covered with bruises. Does that change that risk benefit assessment?
Dr. Miller: I think that’s a great question and I think it’s important to keep in mind that aspirin just like any drug can hurt people and you have to weigh that into the equation. People think of aspirin, you can buy it over-the-counter, it doesn’t seem like that big of a deal. What’s the harm in an aspirin. And the truth is, the risk of major bleeding is still really quite low but if you treat enough people, you are going to really hurt some people and there really are people that have life threatening bleeding complications simply of being on an aspirin. And if you can’t prove a benefit of being on an aspirin, why would you want to expose yourself to that risk.
And it is absolutely true that the older you get, the higher your risk of having all of those bleeding complications. And in fact, I would point out in the study, that was done on healthy elderly people over the age of 70; they actually had an increase in all cause mortality in people who were taking aspirin versus placebo. So, this is not a benign drug. And we should take it seriously when we are making decisions about whether to take it or not. And this is exactly the reason that when one of the major producers of aspirin went to the FDA to ask them if they could put on their over-the-counter aspirin label some language about good for heart health or something like that. They said no, you can’t do that and it’s because it’s not for everybody. And it is a very individualized decision.
And I think one thing that’s helpful maybe to help people think about this, why this has seemingly changed is that the answer to the question of whether aspirin is beneficial actually probably is a different answer now than it was 20 or 30 years ago. And the reason is that people’s risk factors are being treated differently now than they were before. So, in a middle aged person or even an elderly person whose cholesterol is already being well managed and whose blood pressure is already being well managed; there probably is no additional benefit of being on an aspirin and that’s probably, at least that’s been speculated to be one of the reasons that the results now on an aspirin look different than the results did three decades ago when they studied it initially.
So, a lot of people trying to kind of filter it and understand this data and try to incorporate it into our practice have thought well maybe this is good evidence that risk factor management really does matter and that controlling risk factors like high cholesterol, high blood pressure, smoking and diabetes is actually more important than taking an aspirin. And if you are controlling those risk factors well; aspirin doesn’t provide extra benefit, but it may actually hurt you.
Host: Well taken. What a great point. So, before we wrap up here, when people are looking at aspirin, and talking with their physicians about it; what is the best dose that you recommend. I mean people see baby aspirin and then they see regular aspirin. Do you have a preference, or can you explain very briefly to us the difference?
Dr. Miller: If you have had a good discussion with your doctor about your overall risk and have made a decision that maybe aspirin is appropriate for you; for the most part a baby aspirin is adequate. If you are just doing primary prevention. Now for people that have had a stent, or some kind of other cardiovascular event, maybe they have had a stroke or a mini stroke; those recommendations may change, and they may change over time for a patient that’s had a stent for example. But for most people, who are stable and we’re just trying to protect them chronically from events like that; a baby aspirin is fine. And there’s been really no evidence that a higher dose is better. But a higher dose definitely increases the bleeding risk. So, baby aspirin for most people.
And I guess I would just say at the bottom of it all; I think it’s worth having a conversation with your doctor if you are not sure because if you do have some risk factors; that could come into play. Or let’s say you have very high cholesterol and you smoke, and you are not able to take a cholesterol medicine because of side effects; all those things go into the discussion and your risk might be higher than some of the people that were studied in these studies. So, maybe it is appropriate for some people. But it’s a very individualized decision.
Host: Well it certainly is and thank you so much Dr. Miller for coming on and clearing up questions that so many people have aboutaspirin to help cardioprotective mechanisms and really explaining it so very well for us. And thanks to our Bryan Foundation partner, Union Bank & Trust. That wraps up this episode of Bryan Health Podcast. Head on over to our website at www.bryanheart.org for more informationand to get connected with one of our providers. If you found this podcast as informative as I did; please share on social medial, share with your friends and family because I’m sure you have friends and family that are either on aspirin or have questions about it and this way, we can learn from the experts at Bryan Health together. And be sure not to miss all the other interesting podcasts in our library. Until next time, I’m Melanie Cole.
Aspirin & Your Heart: Get the Facts
Melanie Cole (Host): We hear so much today about aspirin and its uses to help prevent cardiovascular disease but how do you know what to believe? Should you take an aspirin? Is there a certain age that you should? Or risk factor? We’re going to find out and clear some of that up today with Dr. Keith Miller. He’s a cardiologist with Bryan Heart. Dr. Miller, I’m so glad to have you with us today as this is something I’ve thought about myself being 55 and in menopause and tell us a little bit about aspirin. What’s the main function of it?
Keith Miller, MD, PhD, FACC (Guest): It’s a great topic. It’s such a basic and such a fundamental but it has been a little bit of a moving target, so, I’m really happy to have a chance to talk about aspirin. It’s kind of at the core of what we do in cardiology.
Aspirin has been around forever as you know. And it’s been an important part of taking care of cardiology patients for a long time. It helps prevent blood clots. We think it has an anti-inflammatory effect and we know that it protects people from heart attack in the right setting. And I think one of the most important things to remember is that for people that have already been diagnosed with a coronary problem; so they’ve had a heart attack or an unstable coronary syndrome or they’ve gotten a coronary stent, or they’ve had a bypass surgery; aspirin is still important. And I emphasize that because there’s been a lot of discussion in the press and a lot of discussion among cardiologists just in the last year about aspirin and raising questions about the value of aspirin, but not for people who already have coronary disease or other types of vascular disease. It’s still really important for those people.
But basically, aspirin is still aspirin. It’s still a great drug but only in the right person that really needs the aspirin.
Host: So, it kind of goes back and forth as you mentioned there’s some discussion among the press and among cardiologists and so, it used to be that they were recommending it for everybody at one point to help protect against certain events. But now as you say, it certainly is limited. How is thing changing Dr. Miller and why did it change?
Dr. Miller: Yeah. it’s such a great question because as long as aspirin has been around, you’d think that we would have really figured all this stuff out by now and there really wouldn’t be any changes in the recommendations about aspirin. But actually that’s not true. And the reason that this has become kind of an issue again and discussed quite a bit in articles written in newspapers about this, is that in the last year, three major important studies have been published on the value of aspirin for preventing a first event, a first heart attack or stroke or other cardiovascular event and they are important studies. They were very well done. And they were published in very authoritative journals.
So, they have clearly affected our thinking about this and again, not for people that already have disease, have had a heart attack, stent, bypass surgery, whatever; those people still need to be on aspirin. This is for people who have never had a problem in the past. So, the different studies looked at different populations. One of them looked at people who are at intermediate risk for heart attack; so these are usually people with a couple of risk factors so middle aged with hypertension and smoking or middle aged with high cholesterol and a very potent family history of heart disease. Something like that. People at risk. One of the studies was in healthy people, men and women over the age of 70 and the third study was among diabetic patients who have not had a history of cardiovascular disease.
The study on the intermediate risk patients and the study on the healthy men and women over the age of 70; they studied aspirin versus placebo, and they were huge studies with thousands of patients, and they were negative. There was no benefit in terms of reducing the risk of heart attack or stroke or cardiovascular death but there was definitely an increase in the bleeding risk. So, these were negative studies. So, this was a surprise because there’s a lot of people who believed that if you could pick out people who were at high enough risk of a heart attack; those people should benefit from being on an aspirin. And that really in this case turned out not to be true.
The third study was a little different because that involved people with diabetes who are always at higher risk of cardiovascular disease and in those people and there were over 15,000 people enrolled in this study and they were studied for over seven years. so, it’s a very powerful study. And in that study, they did demonstrate that there was a reduction in the risk of major cardiovascular events like heart attack, stroke and cardiovascular death. It was fairly modest, but it was significant. But the cost for that benefit was an increase in the bleeding risk.
So, it really helps us understand how to target aspirin therapy for prevention and it’s clearly not for everybody. And it’s I think in my practice, at least, I think most of my cardiology colleagues would agree; most healthy people over the age of 70 probably should not be taking an aspirin and most middle aged people at average risk of heart disease should probably not be taking an aspirin. It can be a little complicated and I think it’s always worth discussing this issue with your doctor because it is an individualized decision and if your risk is high enough; maybe that’s something you’d want to do.
Host: What a great explanation Dr. Miller, that was excellent. So, when we are assessing the risk versus benefit, in someone in that high risk category, some of those side effects you were talking about bleeding, but there’s also skin bruising and even I as an exercise physiologist see with my clients all the time, this major bruising and then the risk of hemorrhagic stroke, all of these other kinds of things. How do you as a cardiologist weigh that and when you are looking at maybe an elderly patient of yours and saying well yes, you should be taking aspirin and then their arms are covered with bruises. Does that change that risk benefit assessment?
Dr. Miller: I think that’s a great question and I think it’s important to keep in mind that aspirin just like any drug can hurt people and you have to weigh that into the equation. People think of aspirin, you can buy it over-the-counter, it doesn’t seem like that big of a deal. What’s the harm in an aspirin. And the truth is, the risk of major bleeding is still really quite low but if you treat enough people, you are going to really hurt some people and there really are people that have life threatening bleeding complications simply of being on an aspirin. And if you can’t prove a benefit of being on an aspirin, why would you want to expose yourself to that risk.
And it is absolutely true that the older you get, the higher your risk of having all of those bleeding complications. And in fact, I would point out in the study, that was done on healthy elderly people over the age of 70; they actually had an increase in all cause mortality in people who were taking aspirin versus placebo. So, this is not a benign drug. And we should take it seriously when we are making decisions about whether to take it or not. And this is exactly the reason that when one of the major producers of aspirin went to the FDA to ask them if they could put on their over-the-counter aspirin label some language about good for heart health or something like that. They said no, you can’t do that and it’s because it’s not for everybody. And it is a very individualized decision.
And I think one thing that’s helpful maybe to help people think about this, why this has seemingly changed is that the answer to the question of whether aspirin is beneficial actually probably is a different answer now than it was 20 or 30 years ago. And the reason is that people’s risk factors are being treated differently now than they were before. So, in a middle aged person or even an elderly person whose cholesterol is already being well managed and whose blood pressure is already being well managed; there probably is no additional benefit of being on an aspirin and that’s probably, at least that’s been speculated to be one of the reasons that the results now on an aspirin look different than the results did three decades ago when they studied it initially.
So, a lot of people trying to kind of filter it and understand this data and try to incorporate it into our practice have thought well maybe this is good evidence that risk factor management really does matter and that controlling risk factors like high cholesterol, high blood pressure, smoking and diabetes is actually more important than taking an aspirin. And if you are controlling those risk factors well; aspirin doesn’t provide extra benefit, but it may actually hurt you.
Host: Well taken. What a great point. So, before we wrap up here, when people are looking at aspirin, and talking with their physicians about it; what is the best dose that you recommend. I mean people see baby aspirin and then they see regular aspirin. Do you have a preference, or can you explain very briefly to us the difference?
Dr. Miller: If you have had a good discussion with your doctor about your overall risk and have made a decision that maybe aspirin is appropriate for you; for the most part a baby aspirin is adequate. If you are just doing primary prevention. Now for people that have had a stent, or some kind of other cardiovascular event, maybe they have had a stroke or a mini stroke; those recommendations may change, and they may change over time for a patient that’s had a stent for example. But for most people, who are stable and we’re just trying to protect them chronically from events like that; a baby aspirin is fine. And there’s been really no evidence that a higher dose is better. But a higher dose definitely increases the bleeding risk. So, baby aspirin for most people.
And I guess I would just say at the bottom of it all; I think it’s worth having a conversation with your doctor if you are not sure because if you do have some risk factors; that could come into play. Or let’s say you have very high cholesterol and you smoke, and you are not able to take a cholesterol medicine because of side effects; all those things go into the discussion and your risk might be higher than some of the people that were studied in these studies. So, maybe it is appropriate for some people. But it’s a very individualized decision.
Host: Well it certainly is and thank you so much Dr. Miller for coming on and clearing up questions that so many people have aboutaspirin to help cardioprotective mechanisms and really explaining it so very well for us. And thanks to our Bryan Foundation partner, Union Bank & Trust. That wraps up this episode of Bryan Health Podcast. Head on over to our website at www.bryanheart.org for more informationand to get connected with one of our providers. If you found this podcast as informative as I did; please share on social medial, share with your friends and family because I’m sure you have friends and family that are either on aspirin or have questions about it and this way, we can learn from the experts at Bryan Health together. And be sure not to miss all the other interesting podcasts in our library. Until next time, I’m Melanie Cole.