Aspirin for Primary Prevention: Who Should Skip Daily Doses

For years, taking a daily aspirin was as routine as brushing your teeth-if you were over 50 and wanted to avoid a heart attack. Doctors handed out the recommendation like candy. But things have changed. Today, the science says aspirin isn’t for everyone. In fact, for many people, it’s doing more harm than good.

Why the Big Shift?

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’d never had a heart problem. But those early studies didn’t fully account for the risks. Over time, bigger, longer trials revealed a troubling pattern: the bleeding dangers of daily aspirin often outweigh the tiny benefit of preventing a first heart attack or stroke.

The U.S. Preventive Services Task Force (USPSTF) updated its guidelines in 2022, and the message was clear: Don’t start aspirin for primary prevention if you’re 60 or older. The American College of Cardiology and American Heart Association followed suit. They now say aspirin should only be considered in very specific cases-and even then, only after careful discussion with your doctor.

Who Definitely Should Skip Daily Aspirin

If you’re 60 or older and have never had a heart attack, stroke, stent, or bypass, you should probably stop or never start daily aspirin. Here’s why:

• Major bleeding risk goes up with age. After 60, your stomach lining becomes more fragile. Blood vessels in the brain weaken. Aspirin thins your blood. That combo means a higher chance of dangerous internal bleeding. Studies show for every 1,000 people over 60 taking aspirin daily for 10 years, about 1.6 more will have a major bleed-like a stomach ulcer or brain hemorrhage-than those not taking it.
• The benefit is tiny. In the same group, only about 0.9 fewer heart attacks happen. That’s less than one person per 1,000. The math just doesn’t work.
• Other medications make it worse. If you’re already on blood thinners like warfarin, apixaban, or rivaroxaban-or even regular NSAIDs like ibuprofen or naproxen-your bleeding risk shoots up. Many older adults take these for arthritis or pain. Adding aspirin is a recipe for trouble.

Who Might Still Benefit (But Only With Caution)

There’s a small group-mostly people in their 40s and 50s-who might still get a net benefit. But it’s not automatic. You need to meet all these conditions:

• You’re between 40 and 59 years old.
• Your 10-year risk of heart attack or stroke is 10% or higher. That’s calculated using the Pooled Cohort Equations, which factor in your age, sex, race, blood pressure, cholesterol, diabetes status, and smoking.
• You have no history of stomach ulcers, bleeding disorders, or liver disease.
• You’re not taking other blood thinners or NSAIDs regularly.
• You’re willing to stick with it long-term-because the benefit only shows up after years of use.

Even then, it’s not a yes-or-no decision. It’s a conversation. Some people with high calcium scores in their heart arteries (CAC >100) or elevated Lp(a) levels might still benefit. But that’s not something you can guess. You need blood tests and imaging to know.

The Diabetes Dilemma

People with diabetes have higher heart disease risk. That’s why many assumed they should be on aspirin. But the 2025 AHA/ACC guidelines changed that too. Now, aspirin is only considered for diabetics aged 40-70 if their 10-year risk is 15% or higher and they have no bleeding risk. For most diabetics under 60 without other major risk factors, aspirin isn’t recommended.

One exception? Diabetics with Lp(a) over 50 mg/dL. A 2024 study showed aspirin cut their heart events by nearly 20%. But testing for Lp(a) isn’t routine. If you have diabetes and a family history of early heart disease, ask your doctor about this test.

What About the People Who’ve Been on Aspirin for Years?

If you’re over 60 and have been taking aspirin daily for 10 years because your doctor told you to, you’re not alone. A 2023 Mayo Clinic survey found 41% of people 60+ kept taking it even after the new guidelines came out. Why? Fear.

“I’ve been on it since I was 55. I’m scared to stop,” one patient told a researcher. But stopping isn’t dangerous. Unlike blood pressure or cholesterol meds, aspirin doesn’t cause rebound effects. Your body doesn’t suddenly go into overdrive without it.

If you’re unsure, talk to your doctor. Don’t quit cold turkey if you’re also on other meds-but don’t keep taking it just because “it’s always been there.” Your risk profile has changed since you started.

Why Do Doctors Give Conflicting Advice?

You’re not imagining it. One doctor says stop. Another says keep going. That’s because guidelines are broad. Real people are messy.

Cardiologists, who see patients with advanced disease, are more likely to stick with aspirin for high-risk cases-even if guidelines say no. Primary care doctors, who see the big picture, are more likely to follow the new rules.

Plus, not every doctor has time to run the risk calculators. A 2023 study found 63% of primary care visits didn’t include a formal CVD risk assessment. Many still rely on age or “family history” as a shortcut.

What Should You Do Instead?

Aspirin was never a magic bullet. The real winners in heart disease prevention are the basics:

• Don’t smoke.
• Move your body-150 minutes a week of walking, cycling, or swimming.
• Control your blood pressure. Aim for under 120/80.
• Manage your cholesterol. If your LDL is over 100, diet and exercise come first.
• Keep your blood sugar in check, especially if you have prediabetes.

If you’re still unsure, use the AHA’s free “Know Your Risk” calculator. It takes five minutes. Or ask your doctor to run the Pooled Cohort Equations. Don’t guess your risk. Measure it.

The Bottom Line

Daily aspirin for heart health isn’t dead-but it’s not for most people anymore. If you’re under 40, skip it. If you’re 60+, don’t start it. If you’re 40-59 and have high risk and low bleeding risk, talk to your doctor. But don’t assume it’s right for you just because your neighbor takes it.

The goal isn’t to take more pills. It’s to live longer, healthier, and without a hospital stay from a bleed you didn’t need.