We were sent a question about the use of aspirin to prevent heart attacks in people with Down syndrome. We have provided some information below. Please note that this information is for educational purposes only and is not intended to serve as a substitute for a medical, psychiatric, mental health, or behavioral evaluation; diagnosis; or treatment plan by a qualified professional.
When discussing heart attack prevention, there are two groups to consider - those who do not have atherosclerotic heart disease (“hardening of the arteries”) and those that already have this hardening of the arteries (which may have become symptomatic in the form of, for example, having a heart attack or chest pain due to angina).
The two types of prevention based on those two groups are primary and secondary prevention. Primary prevention is preventing a heart attack or the onset of symptoms in those who have not yet developed evidence of atherosclerotic disease (i.e. preventing the onset or primary episode). Secondary prevention is preventing another heart attack (myocardial infarction) or progression of disease that is already present. In this resource, we will focus on primary prevention.
Aspirin has been used for many years to prevent heart attacks, both as primary and secondary prevention. In recent years, the practice of primary prevention has been questioned. The editorial below from the New England Journal of Medicine summarizes recent studies that call into question the use of aspirin for primary prevention. The authors of the studies note lack of benefit for preventing heart attacks in those who have not previously had one and also note an increase in gastrointestinal bleeding (e.g. from ulcers in the stomach or duodenum).
(Full editorial available to subscribers only)
These studies weren’t done in people with Down syndrome so how do the data apply to people with Down syndrome?
Some of the limited studies available and our experience have found that people with Down syndrome have a lower incidence of atherosclerotic disease. Therefore, the benefit of medications such as aspirin for primary prevention is likely to be lower because the rate of the disease is low already. In addition, one of the challenges of treating people with Down syndrome with aspirin is that, if they do develop ulcers or inflammation in the stomach or small intestine, they may have difficulty expressing that discomfort. Those two pieces of information suggest to us that there is no reason to go against the recommendation in the editorial to NOT use aspirin for primary prevention. In fact, those two pieces of information would suggest that there is even less benefit and more risk for the use of aspirin for primary prevention in people with Down syndrome, and, therefore, we do not recommend aspirin as primary prevention for heart attacks in people with Down syndrome.
What about statin medications?
The editorial also describes the use of a statin medication as primary prevention in certain people. This is an unanswered question for people with Down syndrome. It seems that statins are less likely to be beneficial for people with Down syndrome to prevent heart attacks because heart attacks are less common anyway. However, studies have not yet been done to know for sure. We discuss the pros and cons of statins with our patients in light of this lower incidence of heart attacks.
What about people with Down syndrome who have a history of congenital heart disease?
Some cardiologists who see individuals with Down syndrome we serve do recommend an aspirin for individuals with Down syndrome who had surgery to correct congenital heart disease and some cardiologists don’t. Aside from preventing heart attacks, there may be other benefits in those individuals such as preventing the development of blood clots within the heart. However, based on the experience of our patients with their cardiologists, there appears to be variation in treatment decisions. This variation may be partly based on limited studies, the characteristics of the individual’s heart disease, as well as the personal experience of the cardiologist. We follow the recommendation of the cardiologist in those patients
We conclude that use of aspirin to prevent heart attacks in people with Down syndrome who do not have a history of any heart disease falls within the findings of recent studies that there is no or limited benefit in preventing heart disease and potential risk for gastrointestinal bleeding. However, studies specifically in people with Down syndrome have not been done. For those individuals with Down syndrome with a history of heart disease (congenital or other), discussion with your cardiologist is recommended.
For additional reading on the use of aspirin or other medications to reduce clotting in adults with a history of congenital heart disease:
Khairy, P. (2013). Thrombosis in congenital heart disease. Expert Review of Cardiovascular Therapy, 11: 12, 1579-1582. https://www.tandfonline.com/doi/pdf/10.1586/14779072.2013.854703
Boris, J.R. & Harris, M.A. (2003). The use of anticoagulation in pediatric cardiac disease. Images in Paediatric Cardiology, 5(3), 1-35. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3232543/