Aspirin Therapy for Heart Disease Prevention: Who Really Needs It?

For decades, taking a daily low-dose aspirin was as common as brushing your teeth if you wanted to avoid a heart attack. Many people started it after a parent had a heart attack, or their doctor casually suggested it during a routine checkup. But today, that advice has changed - dramatically. If you’re over 60 and have never had a heart attack or stroke, aspirin therapy is no longer recommended for preventing heart disease. And if you’re under 60, it’s not automatic either. The science has caught up with the practice, and what once seemed like a simple, harmless habit is now seen as a potential risk with very limited benefits for most people.

Why Aspirin Was Once Seen as a Miracle Pill

Aspirin has been around since 1899. It was originally developed as a painkiller, but in the 1970s, scientists discovered it blocked a key enzyme involved in blood clotting. That led to the idea: if you can stop blood clots, you can stop heart attacks and strokes. And for people who already had heart disease, that turned out to be true. In secondary prevention - meaning after someone has already had a heart attack, stroke, or stent - aspirin reduces the risk of another event by about 21%. That’s why it’s still a cornerstone of treatment for those patients.

But for people without any history of heart disease? The story is very different. Large studies from the last decade - including ASPREE, ASCEND, and ARRIVE - showed something surprising: while aspirin slightly lowered the risk of nonfatal heart attacks and strokes, it also increased the chance of serious, even life-threatening bleeding by about 43%. For every 100 people taking aspirin daily for 10 years, roughly one might avoid a heart attack, but two might have a major bleed - like a stomach ulcer that requires a blood transfusion, or bleeding in the brain.

Who Might Still Benefit from Aspirin?

The current guidelines don’t say aspirin is useless for everyone. They say it’s only worth considering for a small group: adults aged 40 to 59 with a high risk of heart disease and low risk of bleeding.

To figure out if you’re in that group, doctors use a tool called the ACC/AHA Pooled Cohort Equation. It takes five pieces of information:

• Your age
• Your sex
• Your race
• Your total and HDL cholesterol levels
• Your blood pressure (whether you’re on medication or not)
• Whether you have diabetes or smoke

If that calculation shows you have a 10% or higher chance of having a heart attack or stroke in the next 10 years, then aspirin might be worth discussing. But even then, it’s not a yes-or-no decision. You also need to look at bleeding risk.

The HAS-BLED score helps with that. It checks for:

• High blood pressure
• Kidney or liver disease
• History of bleeding (like nosebleeds, stomach ulcers, or easy bruising)
• Use of other blood thinners (like warfarin or apixaban)
• Age over 65
• Drinking more than three alcoholic drinks a day

If your HAS-BLED score is 3 or higher, aspirin is generally not recommended - even if your heart risk is high.

What About Diabetes or Family History?

Many people think: “My dad had a heart attack at 55, so I should take aspirin.” But family history alone isn’t enough. What matters more is your own current risk factors. Someone with diabetes and high cholesterol has a much higher risk than someone with just a family history and normal blood pressure.

The American Diabetes Association still recommends aspirin for people with diabetes who are over 40 and have other risk factors - like smoking or high blood pressure. But even that’s changing. Recent studies show that with modern diabetes treatments and better control of cholesterol and blood pressure, the added benefit of aspirin is tiny.

And here’s something many don’t realize: having high cholesterol doesn’t automatically mean you need aspirin. Statins - medications like atorvastatin - reduce heart attack risk by 25-37%, which is far more than aspirin’s 10-15%. For most people, controlling cholesterol and blood pressure is the real game-changer.

Why Are So Many People Still Taking It?

Despite the guidelines, an estimated 29 million Americans without heart disease still take daily aspirin. About 6.6 million of them aren’t even told to by a doctor. Why?

One reason is habit. People started taking it years ago and never stopped. Another is fear. The idea of “doing something” to prevent a heart attack feels better than doing nothing - even if the science says the balance has shifted.

Social media and anecdotal stories make it worse. You see posts like: “I’ve taken baby aspirin since I was 50. I had a mild heart attack at 68 - and it didn’t kill me.” But that’s confirmation bias. People who had a heart attack and took aspirin remember it. People who bled from it and never told anyone? They don’t post about it.

A 2019 study in Circulation found that 58% of adults aged 60-75 who were taking aspirin for prevention didn’t even know the guidelines had changed. Many were told by a doctor years ago - and never re-evaluated.

What Should You Do If You’re Already Taking Aspirin?

If you’re taking aspirin daily and you’re over 60 - and you’ve never had a heart attack, stroke, stent, or bypass - you should talk to your doctor about stopping. Don’t quit cold turkey. But don’t assume you need to keep going.

If you’re under 60 and have no heart disease, ask your doctor to calculate your 10-year heart disease risk. If it’s below 10%, aspirin is unlikely to help you. If it’s above 10%, then weigh the bleeding risk. Do you have a history of stomach ulcers? Are you on NSAIDs like ibuprofen regularly? Do you drink alcohol? Are you over 60? If yes to any of those, the risks probably outweigh the benefits.

If you’re on aspirin because of diabetes, ask whether your risk factors are well-controlled. If your A1C is under 7%, your blood pressure is normal, and your LDL cholesterol is below 70, you might not need aspirin anymore.

What Are the Real Alternatives?

Aspirin isn’t the only tool - and it’s not even the most effective one for most people.

• Statins: These drugs lower LDL cholesterol and stabilize plaque in arteries. They’re proven to prevent first heart attacks in high-risk people - and they don’t increase bleeding risk.
• Blood pressure control: Keeping your systolic pressure under 130 reduces heart attack risk more than aspirin ever could.
• Quitting smoking: This single change cuts heart disease risk by half within five years.
• Exercise and diet: Walking 30 minutes a day, eating more vegetables and less processed food, and losing 5-10% of body weight can reduce your 10-year heart disease risk by 20-30%.

These changes don’t come in a pill. But they work better - and safer - than aspirin for most people.

What About Cost and Accessibility?

Yes, aspirin is cheap. A three-month supply costs $4-$6 in the U.S. That’s a big reason why it stayed popular so long. But cheap doesn’t mean safe. A bleeding event can cost tens of thousands of dollars in hospital bills - not to mention the pain, recovery time, and risk of death.

In New Zealand, aspirin is available over the counter, but it’s not free. And while the price is low, the real cost is your health. The goal isn’t to save money on pills - it’s to avoid hospitalization.

Final Thoughts: It’s Not About Aspirin - It’s About Your Risk

Aspirin therapy for heart disease prevention isn’t a one-size-fits-all solution anymore. It’s a narrow, personalized tool - and only for a small group of people who meet very specific criteria.

If you’re under 40: you don’t need it.

If you’re 40-59: calculate your risk. If it’s below 10%, skip it. If it’s above 10%, talk to your doctor about bleeding risk.

If you’re 60 or older: unless you’ve already had a heart attack or stroke, don’t start it. If you’re already taking it, talk to your doctor about stopping.

The best way to prevent heart disease isn’t a pill. It’s knowing your numbers - cholesterol, blood pressure, blood sugar - and taking action on them. That’s where real protection lies.