According to Dr. Kirtane, the biggest concerns with aspirin are gastrointestinal bleeding and bleeding in other areas of the body, including bleeding in the brain, which can lead to a certain type of stroke. “Although aspirin has a protective effect against clotting-related (ischemic) strokes, it can also increase the risk of bleeding-related (hemorrhagic) strokes,” he says.
The guidelines suggest that people in their 40s and 50s should not start aspirin to prevent heart attacks and strokes as they might have in the past. “Even in higher-risk patients, like those with diabetes whose cardiovascular risk we would normally be very concerned about, it turns out that the protective effect of aspirin in preventing a first cardiac event was not so pronounced and the bleeding risk is always present,” says Dr. Kirtane, who is also a professor of medicine at Columbia University Vagelos College of Physicians and Surgeons.
Around age 60, the risk of bleeding complications rises further. The new guidelines more strongly discourage starting aspirin in older patients for prevention of first cardiac events, although there may be exceptions for those with “extraordinarily high cardiovascular risks,” says Dr. Kirtane. “At the end of the day, these decisions have to be individualized,” he says.