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 did it without thinking twice. But the science has changed. Aspirin is no longer recommended for most healthy adults as a routine preventive measure. In fact, for many, continuing daily aspirin could be doing more harm than good.

Why the Big Shift?

Back in the 1980s and 90s, studies showed aspirin reduced heart attacks in men and strokes in women. It seemed like a no-brainer: pop a pill, lower your risk. By 2016, nearly 25% of U.S. adults aged 40-79 were taking aspirin daily for primary prevention-meaning they had no history of heart disease or stroke.

But newer, larger studies revealed something troubling. While aspirin did slightly lower the chance of a first heart attack, it also raised the risk of serious bleeding. And that risk didn’t stay small-it grew with age. For people over 60, the bleeding risk started to clearly outweigh the benefits. In 2022, the U.S. Preventive Services Task Force (USPSTF) reversed its earlier advice. Now, they say: don’t start aspirin for primary prevention if you’re 60 or older.

The American College of Cardiology and American Heart Association followed suit. Their 2019 guidelines already warned against routine use. By 2024, prescriptions for aspirin in healthy adults had dropped by more than half compared to 2018. This isn’t just a guideline change-it’s a cultural shift in how doctors think about prevention.

Who Should Definitely Skip Aspirin

You should avoid daily aspirin if you fall into any of these groups:

• Age 60 or older-This is the clearest cutoff. The USPSTF gives a Grade D recommendation: do not start. For every 1,000 people over 60 taking aspirin for 10 years, about 1.6 will have a major bleeding event, while only 0.9 will avoid a heart attack. The math doesn’t work.
• History of stomach ulcers or GI bleeding-About 4% of U.S. adults have had a peptic ulcer. If you’ve had one, aspirin can bring it back-and fast. Even if it was years ago, your risk remains higher.
• Taking blood thinners like warfarin, apixaban, or rivaroxaban-Combining these with aspirin multiplies bleeding risk. It’s not a 1+1 situation-it’s more like 1+3.
• Using NSAIDs regularly-Ibuprofen, naproxen, even over-the-counter doses taken several times a week, raise bleeding risk. If you’re popping Advil for arthritis or back pain, aspirin is not a safe add-on.
• High risk of falls or bleeding disorders-If you’re prone to bruising easily, have low platelets, or are at risk for head injuries (like older adults with balance issues), aspirin increases the danger of intracranial bleeding.

What About People in Their 40s and 50s?

This is where things get messy. For people aged 40-59, the picture isn’t black and white. The USPSTF says you might consider aspirin if:

• Your 10-year risk of heart attack or stroke is 10% or higher
• You have no increased bleeding risk
• You’re willing to take it for at least 10 years

To find your 10-year risk, doctors use the Pooled Cohort Equations. It’s not guesswork-it’s a calculator that uses your age, sex, race, cholesterol, blood pressure, diabetes status, and smoking habits. If your score is below 10%, aspirin won’t help. If it’s above 10%, you still need to check your bleeding risk.

But here’s the catch: even if your risk is 12%, your doctor might still say no. Why? Because bleeding risk isn’t just about medical history. It’s also about lifestyle. Heavy alcohol use? That increases stomach bleeding. Taking steroids? That too. Some people have silent bleeding risks-like undiagnosed colon polyps or kidney disease-that aren’t obvious until it’s too late.

What About Diabetes?

People with diabetes are often told they’re at higher risk for heart disease. That’s true. But does that mean they need aspirin? Not automatically.

The 2025 AHA/ACC guideline for diabetes says aspirin might be considered only if:

• You’re 40-70 years old
• Your 10-year ASCVD risk is 15% or higher
• You have no bleeding risk factors

Even then, it’s a weak recommendation (Class IIb). A 2024 meta-analysis found aspirin only helped diabetic patients with a specific genetic marker-Lp(a) above 50 mg/dL. If your Lp(a) is normal, aspirin gives you no protection. Most doctors don’t test for Lp(a) routinely, so this becomes a gamble.

Why Do So Many People Still Take It?

Despite the guidelines, nearly 1 in 6 adults over 60 still take aspirin daily. Why?

• Fear-Many believe “if it was good before, it must still be good.” They don’t want to stop something that might protect them.
• Confusion-They don’t understand the difference between primary and secondary prevention. If they had a stent or bypass surgery, aspirin is still essential. But if they’ve never had a heart event, it’s a different story.
• Doctor disagreement-A 2023 JAMA study found 57% of patients got conflicting advice. Cardiologists are more likely to keep prescribing than primary care doctors. One patient on Reddit wrote: “My cardiologist says keep taking it. My PCP says stop. Who do I trust?”

The emotional weight of this decision is real. For decades, doctors told people to take aspirin. Now they’re saying the opposite. It’s no wonder people feel lost.

What If You’re Already Taking It?

If you’re on daily aspirin and you’re over 60-or have any of the bleeding risk factors listed above-don’t stop cold turkey. Talk to your doctor.

Stopping aspirin suddenly can cause a rebound effect, slightly increasing your short-term risk of clotting. But that risk is tiny compared to the long-term bleeding danger. Your doctor can help you taper off safely if needed.

If you’re under 60 and unsure, ask for a risk calculation. Use the ACC’s free online tool or ask your provider to run your numbers. If your risk is below 10%, you’re better off without it.

What Should You Do Instead?

Aspirin was never the best tool for prevention-it was the easiest. The real game-changers are things that don’t cost a dime and have no bleeding risk:

• Don’t smoke-This is the single biggest thing you can do to cut heart disease risk.
• Move more-150 minutes of brisk walking a week cuts risk by 30%.
• Eat real food-More vegetables, whole grains, nuts, fish. Less processed meat, sugar, and fried food.
• Control blood pressure-Even if you’re not on meds, keeping it under 120/80 helps more than aspirin ever could.
• Manage cholesterol-Statins are far more effective than aspirin at preventing first events in high-risk people.

These steps don’t just prevent heart attacks-they prevent cancer, dementia, and diabetes too. Aspirin? It only helps one thing, and only for a small group.

The Future: Personalized Prevention

The next wave of prevention isn’t about age or one-size-fits-all pills. It’s about precision.

Researchers are now studying:

• Coronary calcium scores-A CT scan that shows plaque buildup. If your score is over 100, you might still benefit from aspirin-even if you’re over 60.
• Genetic testing-Some people metabolize aspirin poorly. Others have genes that make them more prone to bleeding. Future guidelines may require genetic screening before prescribing.
• Lp(a) testing-A blood test that identifies a hidden genetic risk for heart disease. If your Lp(a) is high, aspirin might still help.

A major NIH trial called ASPRIN is currently enrolling 15,000 people with high calcium scores to see if aspirin helps them specifically. Results won’t come until 2028. But the direction is clear: we’re moving away from blanket recommendations toward individualized decisions.

Final Takeaway

Aspirin isn’t evil. It’s not useless. But for most healthy people, it’s not the right tool anymore. The days of popping a baby aspirin every morning as a default are over.

If you’re under 40: skip it. You’re not at risk.

If you’re 40-59: get your 10-year risk calculated. If it’s below 10%, don’t take it. If it’s above 10%, talk to your doctor about bleeding risk.

If you’re 60+: unless you have a very specific, high-risk profile (like a calcium score over 300 and no bleeding history), you should stop. The harms outweigh the benefits.

And if you’re unsure? Ask your doctor: “Based on my numbers, does aspirin still make sense for me?” Don’t accept vague answers. Push for the numbers. Your heart-and your stomach-will thank you.