Aspirin for Primary Prevention: Who Should Skip Daily Doses

For years, taking a daily low-dose aspirin was seen as a simple, cheap way to prevent a first heart attack or stroke. Many people over 50 popped one every morning, thinking they were protecting their heart. But the science has changed. Aspirin is no longer recommended for most healthy adults as a routine preventive measure. In fact, for many, it’s doing more harm than good.

Why the Change? The Risks Outweigh the Benefits

The idea behind daily aspirin was simple: aspirin thins the blood, so it might stop clots from forming in arteries and causing heart attacks or strokes. Early studies in the 1980s and 90s showed a small benefit. But those studies didn’t fully account for the bleeding risks - and we now know those risks are real, serious, and grow with age.

Today, the data is clear. For people without existing heart disease, the chance of avoiding a heart attack with aspirin is tiny - about 1 in 1,000 people per year. Meanwhile, the risk of a major bleed - like a stomach ulcer that won’t stop bleeding or a brain hemorrhage - is higher than that. In adults over 60, for every 1,000 people taking aspirin daily for a year, you get about 0.9 fewer heart attacks but 1.6 more major bleeds. That’s not a trade-off worth making.

The U.S. Preventive Services Task Force (USPSTF) updated its guidelines in 2022 and now says: do not start aspirin for primary prevention if you’re 60 or older. The American Heart Association and American College of Cardiology agree. Even in younger adults, it’s not a blanket recommendation. It’s a personal decision - and only if you’re at high enough risk of heart disease and low enough risk of bleeding.

Who Should Absolutely Skip Daily Aspirin?

Not everyone is at equal risk. Some people should never take daily aspirin - even if they’re young and healthy.

• Anyone over 60 without known heart disease. This is the clearest group. The bleeding risk climbs sharply after 60. Your stomach lining gets thinner. Blood vessels become more fragile. The small benefit of preventing a heart attack doesn’t balance the high chance of a life-threatening bleed.
• People with a history of stomach ulcers or GI bleeding. Aspirin irritates the stomach lining. If you’ve had a bleeding ulcer before, taking aspirin again raises your risk of another bleed by up to 40%. Even if you’ve never had one, if you’ve had persistent heartburn or use NSAIDs like ibuprofen regularly, you’re at higher risk.
• People taking blood thinners like warfarin, apixaban, or rivaroxaban. Combining aspirin with these drugs multiplies your bleeding risk. You’re not adding protection - you’re adding danger.
• People with uncontrolled high blood pressure. High blood pressure weakens blood vessel walls. Add aspirin, and you increase the chance of a brain bleed. Controlling blood pressure comes first - not aspirin.
• People with liver or kidney disease. These organs help process and clear aspirin from your body. If they’re not working well, aspirin builds up, increasing side effects and bleeding risk.
• Anyone allergic to aspirin or with asthma triggered by NSAIDs. This isn’t just a rash. It can cause severe breathing problems or anaphylaxis.

Who Might Still Consider It? (And Only After a Deep Talk With Your Doctor)

There are exceptions - but they’re narrow. Aspirin might be considered for adults aged 40 to 59 only if all these conditions are true:

• You have a 10% or higher risk of having a heart attack or stroke in the next 10 years.
• You have no increased risk of bleeding.
• You’re willing to take it daily for at least 10 years.
• You’ve discussed it with your doctor and understand the trade-offs.

How do you know your 10-year risk? Your doctor can calculate it using the Pooled Cohort Equations, which look at your age, sex, race, cholesterol, blood pressure, diabetes status, and smoking habits. If your score is below 10%, aspirin won’t help you.

Some people with high calcium scores in their heart arteries (CAC > 100) may benefit even if their overall risk is borderline. But this isn’t automatic. A 2023 study in JAMA Internal Medicine found that among people with CAC scores over 300, those who stopped aspirin after the new guidelines had a 12% higher chance of having their first heart attack. That’s why some cardiologists still recommend it in these specific cases - but only after careful review.

People with type 2 diabetes aged 40-70 and a 10-year ASCVD risk of 15% or higher may also be candidates. But even here, bleeding risk must be low. A 2024 meta-analysis showed aspirin only helped diabetic patients with high Lp(a) levels - a genetic risk factor for heart disease. If your Lp(a) is normal, aspirin likely won’t help.

What About People Who’ve Been Taking It for Years?

Many people - especially those over 60 - have been taking aspirin for 10, 15, or even 20 years. They’re scared to stop. They think, “What if I have a heart attack tomorrow?”

That fear is understandable. But the data says: if you’re over 60 and healthy, stopping aspirin won’t suddenly make you more likely to have a heart attack. In fact, you’re likely reducing your risk of a dangerous bleed.

A 2023 Mayo Clinic survey found 41% of adults 60+ were still taking aspirin for prevention - even after the guidelines changed. Why? Fear. Confusion. And doctors giving mixed messages.

Don’t stop cold turkey. Talk to your doctor. If you’re on a low dose (81 mg), they might suggest tapering off slowly. Stopping abruptly can, in rare cases, trigger a rebound clotting effect. But for most people, stopping is safe and beneficial.

Why Are Doctors Still Confused?

Here’s the messy part: not all doctors are on the same page. Cardiologists are more likely to continue aspirin for high-risk patients than primary care doctors. A 2023 study in JAMA Internal Medicine found that 57% of patients reported getting conflicting advice from different doctors.

Some cardiologists still follow older guidelines or rely on individual cases - like a patient with a CAC score of 500 or a family history of early heart attacks. Others point to the ASPREE trial, which showed no net benefit in seniors, but had high dropout rates and was criticized for its methods.

Meanwhile, primary care doctors are under pressure to make quick decisions. It takes over 7 minutes to properly calculate CVD risk and bleeding risk - and most visits are 10-15 minutes long. So many just keep prescribing aspirin because it’s easier than having a complex conversation.

What Should You Do Instead?

If you’re not taking aspirin for primary prevention, what should you do to protect your heart?

• Know your numbers. Check your blood pressure, cholesterol, and blood sugar. High numbers mean higher risk - and you can fix them.
• Move more. Just 150 minutes of brisk walking a week cuts heart disease risk by 30%.
• Quit smoking. Smoking is the single biggest preventable cause of heart attacks. Quitting cuts your risk in half within a year.
• Eat better. Focus on vegetables, whole grains, nuts, fish, and olive oil. Reduce processed foods, sugar, and salt.
• Maintain a healthy weight. Losing 5-10% of your body weight can dramatically improve blood pressure and cholesterol.
• Ask about Lp(a) testing. If you have a strong family history of early heart disease, ask your doctor if you should get tested. High Lp(a) is genetic and not affected by diet or statins - but it tells you your risk is higher than your cholesterol numbers suggest.

These steps work better than aspirin. They don’t cause bleeding. They don’t cost money. And they help your whole body - not just your heart.

Final Takeaway: Aspirin Isn’t a Magic Bullet

Aspirin was once seen as a wonder drug for the heart. Now we know it’s a tool - and a risky one. For most people, especially those over 60, it’s not worth the danger. The real heart protection comes from lifestyle, not pills.

If you’re unsure whether you should be on aspirin, don’t guess. Don’t rely on old habits. Talk to your doctor. Ask: “What’s my 10-year risk? What’s my bleeding risk? Does the math still work for me?”

There’s no one-size-fits-all answer. But for the vast majority of healthy adults, skipping daily aspirin is the smarter, safer choice.