Aspirin for Primary Prevention: Who Should Skip Daily Doses

For years, millions of people took a daily low-dose aspirin to prevent their first heart attack or stroke. It seemed simple: one pill, one less chance of something bad happening. But the science has changed - dramatically. Today, for most healthy adults, taking aspirin every day does more harm than good. The question isn’t whether aspirin works - it’s who should skip it entirely.

Why the Rules Changed

In the 1990s, studies like the Physicians’ Health Study showed that aspirin could lower heart attack risk. By the 2000s, doctors routinely recommended it for adults over 50. But those early studies didn’t fully account for the cost: bleeding. Not just minor nosebleeds or bruising - serious, life-threatening internal bleeding in the stomach or brain.

By 2022, the U.S. Preventive Services Task Force (USPSTF) flipped its stance. Instead of recommending aspirin for people aged 50-59 with moderate heart disease risk, they now say: don’t start it if you’re 60 or older. For those between 40 and 59, it’s not a blanket yes - it’s a personal decision, only if you’re at high heart risk and low bleeding risk.

The American Heart Association and American College of Cardiology followed suit. Their 2019 guidelines already said aspirin shouldn’t be used routinely for primary prevention. Now, even the most cautious experts agree: the benefits are too small, and the risks are too real.

Who Definitely Should Skip Aspirin

If you’re 60 or older and don’t have heart disease, you should not start daily aspirin. Period. The data is clear: for every 1,000 people over 60 taking aspirin for 10 years, about 1.6 will have a major bleed - like a stomach ulcer that won’t stop bleeding or a brain hemorrhage. Meanwhile, only about 0.9 will avoid a heart attack. That’s not a win. It’s a loss.

Even if you’re younger, skip aspirin if you have any of these:

• A history of stomach ulcers or bleeding in the digestive tract
• Regular use of NSAIDs like ibuprofen or naproxen
• Taking blood thinners like warfarin, apixaban, or rivaroxaban
• Uncontrolled high blood pressure
• Kidney disease or liver disease
• A history of bleeding in the brain
• Being over 70 - even if you feel fine

These aren’t just theoretical risks. NHANES data shows 4% of U.S. adults have had a peptic ulcer. Nearly 18% of adults over 65 take NSAIDs regularly. Combine that with aspirin, and the bleeding risk shoots up.

Who Might Still Benefit - But Only After a Deep Dive

There’s a small group where aspirin might still make sense. But it’s not about age alone. It’s about precision.

You might consider aspirin if you’re 40-59, have a 10-year cardiovascular disease risk of 10% or higher (calculated using the Pooled Cohort Equations), and have no bleeding risk factors. Even then, it’s not automatic. You need to talk through it with your doctor.

Some people in this group have hidden risk markers that change the equation:

• Coronary artery calcium (CAC) score over 100 - meaning visible plaque in heart arteries
• Lipoprotein(a) levels above 50 mg/dL - a genetic risk factor for clotting
• Diabetes with additional risk factors like high blood pressure or smoking

A 2024 meta-analysis in Diabetes Care found aspirin reduced heart events by 19% in diabetic patients with high Lp(a). But for those with normal Lp(a)? No benefit at all. That’s why blanket advice doesn’t work anymore.

The Cost of Being Wrong

Many people who take aspirin daily don’t realize they’re not in the group that benefits. A 2023 Mayo Clinic survey found 41% of adults 60+ still take aspirin for prevention - even after new guidelines came out. Why? Fear.

“I was told to take it for 20 years,” one 68-year-old woman told her doctor. “I’m scared if I stop, I’ll have a heart attack.”

But stopping aspirin doesn’t cause a rebound heart attack. That’s a myth. The risk comes from continuing it when you shouldn’t. Major bleeding events cost Medicare an average of $1,200 per case. And those aren’t just financial costs - they’re hospitalizations, long recovery times, and sometimes death.

Worse, doctors are still giving mixed messages. A 2023 study in JAMA Internal Medicine found 57% of patients reported getting conflicting advice. Cardiologists are more likely to keep prescribing aspirin than primary care doctors. One reason? Cardiologists see patients who’ve already had heart problems - so they’re used to treating secondary prevention. Primary prevention is different. You’re healthy. You’re not supposed to be bleeding to stay healthy.

What to Do Instead

If you’re not taking aspirin for primary prevention, what should you do? Focus on what actually moves the needle:

• Manage blood pressure - aim for under 120/80
• Keep cholesterol in check - especially LDL
• Don’t smoke - ever
• Get 150 minutes of moderate exercise a week
• Eat more vegetables, beans, whole grains, and fish
• Control your weight - even a 5% loss helps
• Check your blood sugar - especially if you’re over 45

These aren’t optional. They’re proven. The same studies that showed aspirin’s weak benefit also showed that lifestyle changes cut heart disease risk by 80% in high-risk people.

What About Diabetes?

People with diabetes are often told to take aspirin. But the 2025 AHA/ACC guidelines updated this too. Now, aspirin may be considered only for diabetics aged 40-70 with a 10-year ASCVD risk of 15% or higher - and no bleeding risk.

That means most diabetics under 40, or over 70, should skip it. Even if you have diabetes, if your arteries are clean and your blood pressure is good, aspirin won’t help. And it might hurt.

Tools to Help You Decide

You don’t need to guess. Use these free tools:

• ACC/AHA Pooled Cohort Equations - calculates your 10-year heart disease risk
• HAS-BLED score - checks your bleeding risk (factors: high blood pressure, liver/kidney disease, stroke history, lab values, drugs, age, bleeding history)
• AHA’s ‘Know Your Risk’ calculator - simple, patient-friendly version

These aren’t magic. But they’re better than guesswork. If your doctor doesn’t use them, ask them to. You have a right to know why they’re recommending something - especially when the stakes are bleeding or a heart attack.

What If You’re Already Taking It?

If you’ve been on daily aspirin for years and you’re over 60, talk to your doctor about stopping. Don’t quit cold turkey - but don’t keep taking it just because “it’s always been part of my routine.”

A 2023 study found that patients who stopped aspirin after the 2022 guidelines had no increase in heart events - and fewer stomach problems. One Reddit user wrote: “At 62, my doctor took me off aspirin after the USPSTF update. I’ve had zero issues since.”

If you’re under 60 and have high risk markers - like a CAC score of 350 - your doctor might still recommend it. But that’s a personalized call, not a default.

The Bottom Line

Aspirin isn’t a magic bullet. It’s a tool with sharp edges. For most healthy people, especially those over 60, the edges cut deeper than the benefits. The era of “take one a day” for prevention is over.

If you’re healthy, active, and don’t have heart disease, you don’t need aspirin. You need better sleep, better food, more movement, and a clear conversation with your doctor - not a pill.

Frequently Asked Questions