Should You Take a Daily Aspirin? Primary Prevention in 2026 | Philadelphia

TL;DR30-second take

For most people who have never had a heart attack or stroke, a daily low-dose aspirin is no longer recommended. Large trials, above all the ASPREE study in healthy older adults, found that aspirin did not prevent heart attacks or strokes in this group, while it clearly raised the risk of serious bleeding. Modern guidelines now advise against routinely starting aspirin for primary prevention, and specifically against starting it after age 60. This is different for people who have already had a heart attack, stroke, or stent, where aspirin still saves lives and should be continued. If you take a daily aspirin, do not stop on your own; talk with your doctor first.

TL;DR: For most people who have never had a heart attack or stroke, the advice on daily low-dose aspirin has reversed. For decades it was a routine recommendation; now major guidelines advise against starting it for primary prevention, and specifically against starting it after age 60. The reason is a set of large modern trials, led by the ASPREE study in healthy older adults, which found that aspirin did not lower the rate of heart attacks or strokes in people without heart disease, while it clearly raised the risk of serious bleeding. Crucially, this reversal applies only to primary prevention. If you have already had a heart attack, stroke, stent, or bypass, aspirin still protects you and should be continued. And if you currently take a daily aspirin, the right move is to talk with your doctor rather than to stop on your own.

The short answer, and the one distinction that matters most

Whether a daily aspirin makes sense comes down to a single question: have you already had a cardiovascular event?

For secondary prevention, meaning people who have already had a heart attack, an ischemic stroke, a stent, or a bypass, aspirin still clearly reduces the risk of another event, and the recommendation to take it has not changed. This article is not about you, except to say: keep taking it unless your doctor tells you otherwise.

For primary prevention, meaning people with no known heart disease who take aspirin hoping to prevent a first event, the advice has reversed. The modern evidence shows that for most such people, the small benefit in preventing clots is cancelled out, or outweighed, by the added risk of bleeding. That is the change this article explains.

What changed the advice?

For years, the case for aspirin rested on older trials from an era before widespread statins and blood-pressure treatment. Three large trials published in 2018 reexamined the question in the modern era, and together they rewrote the guidance.

The most important was ASPREE, a trial of more than 19,000 healthy adults aged 70 and older, who took either low-dose aspirin or a placebo.¹ Over nearly 5 years, aspirin did not reduce heart attacks, strokes, or deaths from cardiovascular causes. It did, however, significantly increase serious bleeding. A companion analysis found a small increase in overall deaths on aspirin, driven mostly by cancer, an unexpected finding that remains unexplained, has not been reproduced in other aspirin trials, and faded on a longer follow-up of the same participants completed in 2025, so it is best read as a caution rather than proof that aspirin causes cancer.²

The other two trials fit the same picture. ASCEND studied people with diabetes but no heart disease and found that aspirin reduced serious vascular events by about 12%, but that this benefit was largely counterbalanced by an increase in major bleeding of similar absolute size.³ ARRIVE studied people estimated to be at moderate risk and found no significant cardiovascular benefit at all, in part because the participants, on modern prevention, turned out to be at lower risk than intended.⁴

The thread connecting them is what some call diminishing returns. Aspirin prevents clots, but statins, blood-pressure control, and not smoking already prevent most of the clot-driven events in people without heart disease. That leaves aspirin a smaller problem to solve, while its bleeding risk stays the same, so the math that once favored it no longer does.

What do the guidelines say now?

The US Preventive Services Task Force, whose recommendations shape primary care, updated its guidance in 2022.⁵ For adults aged 40 to 59 whose 10-year cardiovascular risk is 10% or higher, it calls the decision to start aspirin an individual one, with only a small net benefit, best reserved for those who are not prone to bleeding and who value the small gain. For adults 60 and older, it recommends against starting aspirin for primary prevention at all, because the bleeding risk outweighs the benefit.

Cardiology guidelines agree. The American College of Cardiology and American Heart Association say aspirin may be considered for select higher-risk adults aged 40 to 70 who are not at increased bleeding risk, but should not be used routinely in anyone over 70, where it is judged to cause net harm. A 2024 stroke-prevention guideline reached the same conclusion for preventing a first stroke. Across the board, the message is the same: routine aspirin for primary prevention is out; a careful, individual decision in select younger higher-risk people is what remains.

One point these guidelines share deserves emphasis: they are about whether to START aspirin, and they do not tell people already taking it to stop. That decision is separate, and it belongs with your doctor.

If you already take a daily aspirin, should you stop?

Not on your own, and maybe not at all. This is the most important safety point in the article.

If you take aspirin for secondary prevention, because you have had a heart attack, stroke, stent, or bypass, you should almost certainly keep taking it. For you the benefit is proven and outweighs the bleeding risk, and stopping abruptly can be dangerous, raising the risk of a clot, which is a heightened concern after a stent. Do not stop without a clear plan from your cardiologist.

If you take aspirin for primary prevention, started years ago when it was routine, the newer evidence may mean it is no longer the right choice for you, particularly if you are over 60 or have any bleeding risk. But that is a conversation to have with your doctor, who can weigh your heart risk against your bleeding risk and decide with you. The point is not to panic or to make the change yourself; it is to raise the question at your next visit.

Who might still benefit from aspirin?

The reversal is about routine use rather than a blanket ban, and a few groups sit in the gray zone where aspirin can still make sense as an individual decision.

The clearest is a person in their forties or fifties with a high cardiovascular risk, driven by factors like strong family history or diabetes, who has a low risk of bleeding and a clear-eyed understanding of the trade-off. For that person, the guidelines leave room for aspirin as a shared decision. The key is that it is chosen deliberately, weighing their own numbers, rather than taken by default.

One area of active study is lipoprotein(a), or Lp(a), the inherited particle that raises cardiovascular risk. Some observational data suggest people with high Lp(a) might get more benefit from aspirin than others, which has led a few clinicians to consider it in that setting. But this comes from observational studies rather than randomized trials, and no guideline recommends aspirin on the basis of Lp(a) yet. It is a hypothesis under study, and a reasonable thing to discuss with a preventive cardiologist, rather than an established reason to start.

Guidance from the Clinic

"This is one of the clearest examples of medicine correcting itself, and I spend serious time on it with patients. Half of what I do here is get people to stop a daily aspirin they started a decade ago on old advice, because for a healthy person over 60 the bleeding risk has come to outweigh a benefit that modern prevention has already shrunk. The other half is making sure I never say that to the wrong person. If you have had a heart attack, a stent, or a stroke, your aspirin is doing its job, and I want you to keep taking it. So my rule is simple: never start or stop aspirin on your own. Bring me the bottle, tell me your history, and we will decide together whether it earns its place for you. It is a cheap, humble pill that helps a specific group and can harm another, and telling those two groups apart is the whole game."

Key Takeaways

For most people without heart disease, daily low-dose aspirin is no longer recommended to prevent a first heart attack or stroke, a reversal from decades of routine advice.
Modern trials, led by ASPREE in healthy older adults, found aspirin did not prevent cardiovascular events in this group while it raised serious bleeding; guidelines now advise against starting it after age 60.
This applies only to primary prevention. People who have had a heart attack, stroke, stent, or bypass should keep taking aspirin, where it still saves lives.
If you take a daily aspirin, do not stop on your own; the decision to continue or stop belongs with your doctor, and stopping abruptly can be risky for secondary-prevention patients.
Aspirin can still be a reasonable individual choice for select higher-risk adults in their forties and fifties with low bleeding risk, and remains standard emergency advice during a suspected heart attack.

Stroke Prevention - preventing a first or repeat stroke
What Is a Preventive Cardiologist? - how these individual decisions get made
Low-Dose Colchicine for Cardiovascular Prevention - the anti-inflammatory approach to residual risk
ApoB and Heart Health - the cholesterol particle count that drives risk
Lp(a): The Genetic Risk Most Panels Miss - the inherited risk sometimes linked to aspirin benefit

Scientific References

McNeil JJ, et al. "Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly." New England Journal of Medicine. 2018;379(16):1509-1518.
McNeil JJ, et al. "Effect of Aspirin on All-Cause Mortality in the Healthy Elderly." New England Journal of Medicine. 2018;379(16):1519-1528.
ASCEND Study Collaborative Group. "Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus." New England Journal of Medicine. 2018;379(16):1529-1539.
Gaziano JM, et al. "Use of Aspirin to Reduce Risk of Initial Vascular Events in Patients at Moderate Risk of Cardiovascular Disease (ARRIVE): a Randomised, Double-Blind, Placebo-Controlled Trial." Lancet. 2018;392(10152):1036-1046.
US Preventive Services Task Force. "Aspirin Use to Prevent Cardiovascular Disease: US Preventive Services Task Force Recommendation Statement." JAMA. 2022;327(16):1577-1584.

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Frequently Asked Questions

Common Questions

If you have never had a heart attack, stroke, or stent, probably not. Modern trials found that for people without heart disease, daily aspirin does not clearly prevent heart attacks or strokes, while it does raise the risk of serious bleeding. Guidelines now advise against routinely starting it for prevention, and against starting it at all after age 60. If you have already had a cardiovascular event, aspirin is still recommended. Either way, decide with your doctor.

Because newer, larger trials in the modern era found the benefit had shrunk while the bleeding risk had not. Older aspirin advice came from a time before widespread statins and blood-pressure treatment, when people without heart disease had more clot risk for aspirin to prevent. Today, those other tools already lower that risk, so aspirin has less to add, and its bleeding harm, mainly in the stomach and occasionally in the brain, tips the balance against routine use.

Do not stop on your own; raise it with your doctor. If you take it because you have had a heart attack, stroke, or stent, you should very likely keep taking it, since stopping can be dangerous. If you started it on your own or on older advice and have no heart disease, it may no longer be the right choice, above all if you are over 60 or bleed easily, but that is a decision to make together with your physician, not alone.

Yes, for several groups. It clearly helps people who have already had a heart attack, stroke, stent, or bypass, where it prevents repeat events and remains recommended. It may also help select younger adults, in their forties or fifties, who are at high cardiovascular risk and low bleeding risk, as an individual choice. The change in advice is narrow: it is about not starting aspirin routinely in people without heart disease, above all older adults.

The main risk is bleeding. Aspirin makes platelets less able to form clots, which is how it prevents heart attacks, but that same effect can cause bleeding, most often in the digestive tract and, less commonly but more seriously, in the brain. The bleeding risk rises with age and with other factors like ulcers, kidney disease, and other blood thinners. In people without heart disease, this bleeding risk is the main reason the balance turned against routine use.

Deep-Dive Questions

Aspirin works by making blood less likely to clot, which prevents the clots that cause most heart attacks and ischemic strokes. But the amount of benefit depends on how much clot risk a person has to begin with. Decades ago, someone without heart disease often had substantial untreated risk, from high cholesterol, high blood pressure, or smoking, and aspirin could meaningfully lower it. Today, a person on a statin, with controlled blood pressure and no cigarettes, already has much less of that risk left. Aspirin can only prevent events that would otherwise happen, so when fewer are going to happen, there is less for it to prevent, while the fixed bleeding hazard remains. The benefit shrank; the harm did not.

In ASPREE, the group taking aspirin had slightly more deaths overall than the placebo group, and the difference traced mostly to cancer deaths. This was unexpected, because earlier research had hinted that aspirin might lower cancer risk rather than raise cancer deaths. The finding has to be handled carefully. It was not seen in the other large aspirin trials, no clear biological explanation has emerged, and with longer follow-up of the same participants the signal weakened. So it is treated as a reason for humility and caution rather than as proof that aspirin causes cancer. It is a good example of why a single surprising result, even from a strong trial, is held loosely until others confirm or refute it.

It is a different situation, and the distinction can save a life. This article is about taking a daily aspirin for years to prevent a first event, which the evidence no longer supports for most people. But if someone is having symptoms of a heart attack right now, chewing an aspirin while waiting for emergency care is still standard advice, because in that moment the benefit of breaking up a forming clot is large and immediate. The routine daily-prevention question and the emergency question are separate. If you think you are having a heart attack, call emergency services, and follow their instructions, which often include chewing an aspirin.

Mostly yes, with care. People with diabetes are at higher cardiovascular risk, and for years aspirin was commonly recommended for them even without heart disease. The ASCEND trial tested this group directly and found that aspirin's benefit was largely offset by extra bleeding, so routine aspirin is no longer advised for most people with diabetes and no heart disease. Some individuals with diabetes and very high risk plus low bleeding risk may still consider it, as a shared decision. As always, someone with diabetes who has already had a cardiovascular event should keep taking aspirin.

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