In their nested case-control study on aspirin use and mortality in women within the Nurses Health Study, Chan et al1 conclude that aspirin use is associated with a decreased mortality. The reported effect is clearly stronger than results of previous randomized controlled trials suggested. The effect of aspirin in this study may be overestimated for 2 reasons that are remediable.
The comparison between women taking aspirin and women not taking aspirin may not be straightforward for reasons other than the known difference in risk factors between these groups. Women taking aspirin regularly for preventive reasons may have a healthier lifestyle and may be more compliant users of medications, factors that are known to lead to too optimistic estimates of effects.2 It would therefore be interesting to evaluate the effect of aspirin on all-cause as well as cardiovascular- and malignancy-related mortality in patients taking aspirin for chronic headaches or musculoskeletal pain. In this subgroup, the use of aspirin is a necessity dictated by pain, which leads to regular intake, and its use is not related to a desire for general cardiovascular prevention among health-conscious persons. Because in this subgroup the reason for aspirin exposure was not related to the outcome of interest, the effect of aspirin may be more properly estimated.
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