BMJ  2005;330 (18 June), doi:10.1136/bmj.330.7505.0-g

Editor's choice

Make up your own minds

Hands up if you are over 50 and take an aspirin a day, or if you advise your older patients and friends to do this. It may seem a harmless and effective precaution against potentially devastating vascular events. But do the benefits outweigh the risks? Should it be offered as primary prevention to everyone over 50, or just to those at increased risk?

This week, two commentators explore the evidence for and against aspirin for everyone over 50 (pp 1440, 1442). In favour of such a policy, Peter Elwood and colleagues argue that about 80% of men and 50% of women in the United Kingdom aged 50 or older are already deemed to be at increased risk—defined as being at a 3% or greater risk of having a vascular event (myocardial infarction or stroke) in the next five years. Current practice is to target these people for primary prevention, but efforts to identify and engage them have proved unsuccessful. Elwood also argues that the risks of serious harm from low dose aspirin in people without contraindications are small, and the benefits include, as well as protection from vascular events, the possibility (not yet proved in randomised controlled trials) of protection against cancer and dementia.

Against this, Colin Baigent says that the expected benefits among unselected people younger than 60 do not exceed the expected risk of major gastrointestinal bleed, while for older people the benefits are uncertain and the risks too high. We should, he says, await the results of further large randomised controlled trials before putting people unnecessarily at risk.

How much of this decision can be handed over to patients? All of it, argues Elwood. Doctors, he says, should not be asked to predict the risk of bleeding in people who don't have obvious contraindications. Faced with such a request from patients, they will tend to advise against treatment as being the safest option in terms of liability. "The general public should be well informed and the final decision should lie with each person."

But as this BMJ debate shows, the evidence on the risks is complex and open to interpretation. Is it sufficient simply to add up the expected number of vascular events and major bleeds when such events are likely to impact differently on people's lives? I'm afraid that, like your patients, you will have to make up your own minds.

We can, however, give you definitive news on another approach to primary prevention—the polymeal. Last Christmas, Franco and colleagues presented an evidence based menu that they estimated could reduce cardiovascular disease by more than 75% ( BMJ 2004;329: 1447-50[Abstract/Free Full Text]). A BMJ competition to find the best recipe for such a polymeal has now, with the help of celebrity chef Raymond Blanc, come up with a winner. The winning recipe, including all the necessary elements of wine, fish, dark chocolate, fruits, vegetables, garlic, and almonds, is published this week (p 1422). We will be asking our editorial board, some of whom are over 50, to sample it. Randomised trials will follow.