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 protect your heart-especially if you were over 50. But that advice has changed. Aspirin is no longer recommended for most healthy adults as a routine preventive measure. In fact, for many people, taking it daily does more harm than good.

Why the Rules Changed

Back in the 1990s, studies showed aspirin could lower the chance of a first heart attack. That led to millions of people popping a pill every day, even if they had no heart disease. But newer, larger studies-like the ASPREE trial published in 2018 and updated analyses through 2023-revealed a troubling truth: the benefits were tiny, and the risks were real.

The biggest danger? Bleeding. Aspirin thins your blood. That helps prevent clots that cause heart attacks and strokes. But it also means you’re more likely to have serious internal bleeding-especially in the stomach or brain. For people without existing heart disease, the math doesn’t add up. The number of people who avoid a heart attack by taking aspirin is almost the same as the number who suffer a dangerous bleed.

In 2022, the U.S. Preventive Services Task Force (USPSTF) flipped its recommendation. They now say: do not start daily aspirin if you’re 60 or older. For people between 40 and 59, it’s not a blanket yes or no-it’s a personal decision, based on your specific risks.

Who Should Definitely Skip Aspirin

If you fall into any of these groups, you should not take daily aspirin for heart protection:

• Age 60 and older-This is the clearest group. For every 1,000 people over 60 taking aspirin for 10 years, about 1.6 will have a major bleed, but only 0.9 will avoid a heart attack. The harm outweighs the help.
• History of stomach ulcers or GI bleeding-If you’ve had a bleeding ulcer, or even frequent heartburn that required treatment, aspirin can trigger another episode. About 4% of U.S. adults have a history of ulcers.
• Taking other blood thinners-If you’re on warfarin, apixaban, rivaroxaban, or even regular NSAIDs like ibuprofen or naproxen, adding aspirin increases your bleeding risk by up to 3 times.
• High risk of falls or frailty-Older adults who are unsteady, have balance issues, or live alone are at higher risk of head injuries. A minor bump can turn into a brain bleed when you’re on aspirin.
• Known bleeding disorders-Conditions like hemophilia or von Willebrand disease make aspirin dangerous, regardless of age.

Who Might Still Benefit (But Only With Care)

There’s a small group where aspirin might still make sense-but only after careful testing and discussion with your doctor.

• Adults 40-59 with 10% or higher 10-year heart disease risk-This is calculated using tools like the Pooled Cohort Equations. If your risk is below 10%, aspirin won’t help. If it’s above 10%, you and your doctor need to weigh the bleeding risk.
• People with very high coronary calcium scores (CAC > 100)-A CAC scan shows how much plaque is in your heart arteries. If your score is over 300, your risk is high enough that aspirin might tip the balance toward benefit. Some cardiologists still recommend it in these cases, despite general guidelines.
• People with type 2 diabetes and high ASCVD risk (≥15%)-New 2025 guidelines say aspirin might be considered for diabetic adults aged 40-70 if their 10-year risk is high and bleeding risk is low.

Even in these cases, aspirin isn’t automatic. You need a full risk assessment-no shortcuts.

What About Diabetes? It’s Complicated

Diabetes increases heart disease risk, so it’s tempting to assume aspirin helps. But studies show mixed results. A 2024 meta-analysis found aspirin reduced heart events by 19% in diabetics with high Lp(a)-a genetic cholesterol particle linked to plaque buildup. But for diabetics with normal Lp(a), there was no benefit at all.

That means: not all diabetics are the same. If you have diabetes, don’t assume aspirin is right for you. Ask for an Lp(a) blood test and a CAC scan. If both are high, and you’re under 70 with no bleeding history, aspirin might be worth discussing. Otherwise, skip it.

Why So Much Confusion Among Doctors?

You’ve probably heard conflicting advice. One doctor says stop. Another says keep going. That’s because guidelines changed fast, and not everyone caught up.

A 2023 survey of 1,500 patients found 41% of adults 60+ were still taking aspirin daily-even after the 2022 guidelines. Why? Fear. Many people believe, “I’ve been taking it for 10 years, what if I stop and have a heart attack?”

The truth? If you’ve never had a heart attack or stroke, and you’re over 60, stopping aspirin won’t suddenly put you at risk. In fact, the risk of bleeding goes down immediately after you stop.

Cardiologists are more likely to continue aspirin than primary care doctors. One reason: cardiologists see patients who already have advanced plaque. They’re more likely to think, “This person is at high risk, so I’ll err on the side of caution.” But the data doesn’t support that approach for primary prevention.

How to Know If You Should Stop

If you’re on daily aspirin and unsure whether to keep going, here’s what to do:

1. Check your age-If you’re 60 or older, the answer is almost certainly no.
2. Review your bleeding history-Have you ever had a stomach bleed, black stools, or needed a blood transfusion?
3. Look at your medications-Are you on NSAIDs, blood thinners, or steroids? That raises your risk.
4. Ask for your 10-year CVD risk score-Ask your doctor to run the Pooled Cohort Equations. If it’s under 10%, aspirin isn’t helping.
5. Consider a CAC scan-If you’re 40-59 and your risk is borderline, a calcium scan can clarify your true heart disease risk.

If all signs point to high bleeding risk or low heart risk, talk to your doctor about stopping. Don’t quit cold turkey without advice-but don’t keep taking it out of habit either.

The Bottom Line

Aspirin isn’t a magic bullet for heart health. For most people, it’s a drug with risks that outweigh its benefits. The days of “take one a day” as a blanket recommendation are over.

If you’re under 40, don’t start. If you’re 60+, stop-unless your doctor has a very strong, personalized reason to keep you on it. If you’re between 40 and 59, get tested. Know your numbers. Don’t guess.

The real heart-healthy habits? Eating vegetables, walking daily, controlling blood pressure, not smoking, and managing cholesterol. Those things work. Aspirin? It only helps in rare, specific cases-and even then, only if the risks are low.

Frequently Asked Questions