Many people see aspirin as a panacea for common physical ailments. For headache, muscle ache, or fever, it’s what people casually take for relief. Its effectiveness as an analgesic/antipyretic offers respite from these common maladies. In addition to its pain relieving and anti-inflammatory abilities, many people have believed for years that an aspirin a day, usually a “baby aspirin: (81 mg), wards off heart attack and stroke.
People believe that baby aspirin is harmless, and they often self-medicate with it. They think there are many benefits and they don’t understand that aspirin poses real risks. The view that aspirin is an innocuous medication is exacerbated because it can be purchased over the counter, along with herbal supplements, vitamins, and minerals. Yet when patients, including dental patients, are asked what medications they take, they often omit their self-prescribed aspirin a day, thinking it is safe and will guard them against heart disease.1
The mindset that aspirin can prevent a first heart attack was promoted and supported by the medical profession in the 1980s and ’90s, but it’s being refuted in current studies.2 The result is new recommendations that are reversing long-standing practices. As dental health-care professionals, we need to let our patients know that the benefits of an aspirin a day are no longer supported. Evidence suggests that one should always be under the care of a physician when taking aspirin or ibuprofen on a regular basis.2
Roger S. Blumenthal, MD, FACC, cochair of the 2019 American College of Cardiology and American Heart Association Guidelines, said in a press statement, “Aspirin should be limited to people at the highest risk of cardiovascular disease and a very low risk of bleeding.”2
Nonsteroidal anti-inflammatory drugs (NSAIDs) in relation to heart disease
Aspirin is a type of NSAID, and common brand names include Bayer, Ecotrin, and Bufferin.3 As the new guidelines point out, there are times when a physician may prescribe daily aspirin intake, but consultation with a doctor is always recommended.
Other NSAIDs, such as ibuprofen (Motrin, Advil, etc.) and naproxen (Aleve, etc.), carry much greater dangers of heart attack or stroke. Those with cardiovascular disease (CVD) or other high risks should be informed about the use of NSAIDs and the possibility they could cause gastrointestinal bleeding. Up to 20,000 people die annually in the US because of GI bleeding.4 Even those who are not at risk of CVD should ingest the lowest doses for relief of pain and inflammation and only for short periods of time.5 But even without high risk of CVD, those who consume NSAIDs regularly may be at increased risk of a heart attack, and regular alcohol consumption elevates the risks.6
How aspirin works
Aspirin is heralded as helping to “thin blood.” In actuality, aspirin interacts with the platelets in blood, helping prevent the buildup of blood clots by disrupting platelet aggregation.7 Platelets are the body’s clotting cells that stop bleeding at a wound site. Aspirin and other antiplatelet drugs stop platelets from forming clots and thus slow down wound healing.
But when people have atherosclerosis (narrow vessels caused by fatty buildup on the walls), blockages can occur to the heart, which can result in a myocardial infarction (heart attack) or ischemia (brain stroke). Aspirin’s role is to reduce the clumping ability of the platelets and hopefully prevent a heart attack or stroke by reducing the risk of vasoconstriction of the blood vessels. NSAIDs affect the way platelets work and might interfere with normal blood clotting.8
When can aspirin be prescribed by a physician?7
- When someone has had a myocardial infarction (MI; heart attack)
- When someone between the ages of 40–70 is at high risk of MI
- When someone has compromised cerebral blood flow
- When someone is a diabetic with at least one other high-risk factor for cardiovascular disease
- When someone has one or more heart stents7
Contraindications for aspirin2
The guidelines no longer recommend that even a low dose of aspirin be given routinely to people over 70 years of age.2
- Patients with conditions that are sodium-retentive (congestive heart and/or renal failure) should avoid high-sodium buffered aspirin. It can increase bleeding or reduce renal function. (Effects can increase when taken in conjunction with other nonsteroidal anti-inflammatory drugs.)9
- Patients who have allergies to NSAIDS or have asthma, rhinitis, or nasal polyps should not ingest aspirin. These patients may suffer from a number of reactions, including anaphylaxis, which can range from a mild allergic reaction to death.10
- Pregnant and lactating women may experience excessive bleeding during childbirth because of aspirin usage. Additionally, aspirin passes through the placenta and may affect platelet formation in babies. Some babies may be allergic, which could result in a serious reaction that could be potentially fatal to the infant. Lactating women also need to understand that aspirin passes to the baby through breast milk.11
- Patients with compromised liver function should avoid aspirin.11
- People who have bleeding or other disorders, including stomach ulcers, are at a higher risk of GI bleeding if they regularly use NSAIDS. Those who have a history of a peptic ulcer or hypertension, who take corticosteroids, who have a low platelet count, or have liver or kidney disease are at a high risk of GI bleeding. They should seek their physicians’ advice about all of the drugs they take, including aspirin.1
- People who are undergoing even simple medical or dental procedures need to be asked about their medications, including aspirin. Warfarin (Coumadin) is a common blood anticoagulant that inhibits the function of vitamin K, which aids in the coagulation of the blood.12 Warfarin and aspirin both decrease the body’s ability to form blood clots, thus increasing the time it takes to form a blood clot. Therefore, warfarin and the use of daily aspirin may be suspended for some dental procedures such as extractions, where coagulation is needed to stop the bleeding. The dentist and patient’s physician will need to be consulted about how to safely meet the needs of the patient.
- People who regularly take aspirin and consume alcohol have a much higher incidence of stomach bleeding.
The consequences of stopping aspirin
Like any other drug, aspirin can lead to consequences if there is a sudden absence of the drug in one’s body. Patients who have had stents placed in one or more heart arteries, or someone who has suffered a heart attack, may be risking a fatal heart attack if they stop using this “innocuous” drug, aspirin.7
The benefit-risk question
The Federal Drug Administration (FDA) provides a clear explanation of the manner in which prescribers must weigh the benefits to use a medication against its potential risk. The FDA stresses that aspirin retains its dangers despite its nonprescription status.
The consequences of daily aspirin intake without the supervision of a doctor can be life-threatening. As dental personnel, we can help alert people about the new guidelines that debunk the old beliefs that an aspirin a day will keep the heart doctor away. The lowly aspirin is a drug, and as with all drugs, it can be harmful if it’s not used in a healthy manner.
The risk of hemorrhage is now being shown to far outweigh the benefits to someone who has not had a heart attack or stroke, or to someone who is at a high risk. People die every year because of misconceptions about commonly used drugs. As health professionals in the dental arena, we not only have the opportunity—but in this author’s view—we have the obligation to inform our patients of the potential consequences of taking an aspirin a day without the supervision of a doctor. You just might save someone’s life!
References
1. Gifford-Jones W. Ten vital facts to know about ‘baby aspirin.’ Toronto Sun website. https://torontosun.com/2017/10/05/ten-vital-facts-to-know-about-baby-aspirin/wcm/fa589eeb-2d11-4fec-8b41-7bfff5f499c5. Published October 5, 2017. Updated Octiber 5, 2017. Accessed April 15, 2019.
2. Abell A. New guidelines reverse long-standing recommendation to take aspirin for heart disease and stroke prevention. American Pharmacists Association website. https://pharmacist.com/article/new-guidelines-reverse-long-standing-recommendation-take-aspirin-heart-disease-and-stroke. Accessed April 12, 2019.
3. Cunha JP. Aspirin vs. ibuprofen (Advil, Motrin). RxList website. https://www.rxlist.com/aspirin_vs_ibuprofen_advil_motrin/drugs-condition.htm.
4. El-Tawil AM. Trends on gastrointestinal bleeding and mortality: Where are we standing? World J Gastroenterol. 2012;18(11):1154-1158. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3309903/. Accessed April 12, 2019.
5. Mankad R. NSAIDs: Do they increase my risk of heart attack or stroke? Mayo Clinic website. https://www.mayoclinic.org/diseases-conditions/heart-attack/expert-answers/nsaids-heart-attack-stroke/faq-20147557. Accessed April 15, 2019.
6. Editorial staff. Lautieri A, ed. Mixing alcohol with NSAIDS or acetaminophen? Alcohol.org. https://www.alcohol.org/mixing-with/nonsteroidal-anti-inflammatory/. Published January 11, 2019. Updated June 5, 2019.
7. Mayo Clinic staff. Daily aspirin therapy: Understand the benefits and risks. Mayo Clinic website. https://www.mayoclinic.org/diseases-conditions/heart-disease/in-depth/daily-aspirin-therapy/art-20046797. Published January 9, 2019. Accessed April 13, 2019.
8. Bad mix: Blood thinners and NSAIDs. Harvard Health Publishing website. https://www.health.harvard.edu/diseases-and-conditions/bad-mix-blood-thinners-and-nsaids. Published October 2013. Accessed April 12, 2019.
9. Riegger GA, Kahles HW, Elsner D, Kromer EP, Kochsiek K. Effects of acetylsalicylic acid on renal function in patients with chronic heart failure. Am J Med. 1991;90(5):571-575.
10. Anaphylaxis overview. American Academy of Allergy Asthma & Immunology website. https://www.aaaai.org/conditions-and-treatments/allergies/anaphylaxis.
11. Pray WS, Pray GE. Benefits and risks of daily aspirin use. U.S. Pharmacist website. https://www.uspharmacist.com/article/benefits-and-risks-of-daily-aspirin-use. Published February 20, 2013. Accessed April 11, 2019.
12. Aspirin vs. warfarin (Coumadin). RxList website. https://www.rxlist.com/aspirin_vs_warfarin_coumadin/drugs-condition.htm. Updated September 5, 2018. Accessed April 11, 2019.
Dorothy Garlough, MPA, RDH, is a conscious change facilitator, leading strategy sessions and forums to orchestrate conscious change within the dental environment. As a change agent and international speaker and writer, Garlough trains others to broaden their skill sets to include recognition of limiting mental models, creativity, collaborative innovation, and mindfulness. She recognizes that engagement is the outcome when mechanisms are put in place to drive new innovations. The result is lasting change. Contact her at [email protected].
