Aspirin: Quitting cold turkey could be dangerous

Studies have linked aspirin withdrawal to heart attacks.

(This article was first printed in the October 2005 issue of the Harvard Heart Letter. For more information or to order, please go to www.health.harvard.edu/health.)

Patients are sometimes told to stop taking aspirin before surgery and dental treatments because aspirin is believed to increase the risk for serious bleeding. But many doctors are now giving just the opposite advice, telling patients to stay on their aspirin. Research has shown that abruptly quitting aspirin after taking it regularly may increase the risk of having a heart attack or stroke. And for most operations there now seems little reason to worry about aspirin causing extra bleeding.

Doubly good

Aspirin protects against heart disease for two reasons. First, it makes platelets in the blood less “sticky,” so blood clots are less likely to form. This is the flip side to the bleeding risk. Second, it’s anti-inflammatory, so it may help cool off the processes that lead to atherosclerosis, plaque rupture, and blockage of arteries.

The drug is so cardioprotective that everybody who has had a heart attack is supposed to take a low dose (325 mg or less) every day. Current guidelines also recommend aspirin for people at elevated risk for a first heart attack. Fam­ily history, cholesterol levels, and other factors determine that. If you think you might fall into the high-risk category, be sure to talk to your doctor about it.

Quitters didn’t prosper

Emile Ferrari, a cardiologist in Nice, France, sounded the alarm about the dangers of aspirin withdrawal at a meeting of the American College of Chest Physicians. Combing the medical records of over 1,000 patients hospitalized for heart problems (heart attacks, unstable angina, and so on) at his hospital, he found 51 who had quit taking aspirin within the month preceding their heart trouble. Those cases constituted about 4% of all coronary patients admitted to the hospital and 13% of the patients with recurrent heart disease.

Early in 2005, Ferrari and his colleagues published an update in the Journal of the American College of Cardiology. Probably the most interesting bit of news was that 10 of the 51 cases he originally identified were patients who had had uncoated stents inserted after angioplasty.

Other research has supplied variations on Ferrari’s theme. For example, a study in the Archives of Internal Medicine in 2004 analyzed a huge database of British patients and concluded that people who stopped taking nonsteroidal anti-inflammatory drugs (NSAIDs) were 50% more likely to have a heart attack during the month right after they quit than people who kept on taking their NSAIDs. The NSAIDs include ibuprofen (Advil, Motrin, other brands), naproxen (Aleve, Naprosyn, other brands), and several less familiar prescription drugs. The risk was especially high for people with rheumatoid arthritis or lupus.

Brain surgery is an exception

As for bleeding problems in surgical patients, most of them are apparently minor. In a review published in 2003, Dutch researchers examined all the studies of bleeding complications from aspirin published from 1996 to 2002. Their conclusion: Aspirin caused no “clinically relevant” bleeding complications in cardiovascular, vascular, or orthopedic surgical patients. They didn’t find enough studies of cataract, dermatologic, gynecologic, or abdominal surgery to draw any conclusions.

Dr. Donald T. Reilly, a member of the Harvard Health Letter editorial board and an orthopedic surgeon at New England Baptist Hospital in Boston who performs many hip and knee replacement operations, starts his patients on aspirin three days before sur­gery and keeps them on it for four weeks afterward. Dr. Reilly says blood clots are a bigger worry than bleeding because they can lead to deep vein thrombosis and other problems (see “Deep trouble,” above).

Dr. Richard Hodin, another member of the Harvard Health Letter editorial board and a surgeon at Massachusetts General Hospital, says he tells his patients who are taking aspirin to keep on taking it. For the operations he does, says Dr. Hodin, there’s little risk of extra bleeding.

The exception that Dr. Hodin and others mention is brain surgery. The smallest bleeding problem in the brain can permanently damage brain tissue.

Aspirin withdrawal is center stage here because recent study results are provocative. But it’s a bad idea to stop taking most medications abruptly. You could trigger a rebound effect, in which the problem that the drug was designed to treat comes back, maybe worse than ever. Many medications work by holding back chemical reactions in the body; if you stop suddenly, it’s as if a dam has burst.

(This article was first printed in the October 2005 issue of the Harvard Heart Letter. For more information or to order, please go to www.health.harvard.edu/health.)

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