Aspirin & Heart Disease Prevention Recommendations

In the 1950’s a research paper based on work done at a Veterans Administration Hospital found that men 45 years of age who took a daily aspirin tended to have fewer heart attacks and strokes. The VA patients were mostly male WWII and Korean War Veterans. That was the basis for most of the men in my Baby Boomer generation to take a daily aspirin.

Yes, we knew that aspirin gives us an increased risk of bleeding from our stomach and intestine. And we knew that if we hit our head while on aspirin the amount of bleeding on the brain would be much greater. It was a tradeoff – benefits versus risks.

Over the years the science has advanced to now distinguish those taking aspirin to prevent developing heart disease, cerebrovascular disease or primary prevention and those seeking to prevent an additional health event such as a second heart attack or stroke. To my knowledge there are no studies that examine what happens to someone in their 60a or 70s who has been taking an aspirin for 40 plus years daily and suddenly stops. It’s a question that should be answered before electively stopping daily aspirin.

Over the last few years researchers have hinted that the daily aspirin may protect against developing colorectal cancer and certain aggressive skin cancers. The downside to taking the aspirin has always been the bleeding risk. This data is now being questioned by the USPTF looking for more “evidence.”

The US Preventive Services Task Force was formed in 1984 with the encouragement of employers, private insurers selling managed health care plans and members of Congress to try and save money in healthcare. It is comprised of volunteer physicians and researchers who are supposed to match evidence with medical procedures to ensure that we are receiving high value procedures only.

In 1998 Congress mandated that they convene annually. Under their direction, recommendations were made to stop taking routine chest x rays on adult smokers because it didn’t save or prolong life and it took $200,000 of X Rays to save one life. They reversed their opinion decades later deciding that the math on that study wasn’t quite right and now recommend CT scans on smokers of a certain age and duration of tobacco use. I point this out to emphasize why I am not quite as excited today about their change in aspirin guidelines as the newspaper and media outlet stations seem to be.

I am a never smoker, frequently exercising adult with high blood pressure controlled with medication, high cholesterol controlled with medication and recently diagnosed non obstructive coronary artery disease. What does that mean? At age 45 my CT Scan of my coronary arteries showed almost no calcium in the walls. 26 years later there is enough Calcium seen to increase my risk of a cardiac event to > 10% over the next ten years. I took a nuclear stress test and ran at level 5 with no evidence of a blockage on EKG or films. The calcium in the walls of the arteries however indicates that cholesterol laden foam cells living in the walls of my coronary arteries and moving towards the lumen to rupture and cause a heart attack were thwarted and calcified preventing that heart attack or stroke. I am certainly not going to stop my aspirin.

My thin healthy friend who works out harder than I do told me he doesn’t have heart disease and is going to stop his baby aspirin. I asked him what about his three stents keeping several coronary arteries open? He told me he had heart disease before he got the stents but now he doesn’t. I suggested he talk to his internist or cardiologist prior to stopping the aspirin.

I may take a different path in starting adults on aspirin for cardiovascular and cerebrovascular event protection. I am certainly not going to withdraw aspirin from patients taking it for years unless they are high risk for falls and head trauma or bleeding. I suggest you ask your doctor before considering changing any of your medications.

Try an exercise by writing down all the prescription medicines and next to them list what condition you take them for. Once you have established that information, set up an appointment and talk about it with your physician. The decision-making is much more complicated than the USPTF and headline hungry media discussed and reported.

Some Health Issues Should Not Be Evaluated in the Office

I received a phone call from an elderly gentleman who was closer to ninety years of age than 80, was taking an aspirin and had just suffered a fall and hit his head. He did not know why or how he fell. He asked for an appointment the same day to “check me out.” 

My staff asked all the pertinent questions and immediately brought the information to me.  After reviewing it, I felt for his safety his best course of action was to immediately call 911 (or have us do it) and go to our local emergency department for evaluation. The patient takes daily aspirins to prevent a second heart attack or stroke.

The antiplatelet action of the aspirin, plus his age and the head trauma necessitate an immediate and thorough evaluation with imaging. I do not have an X Ray unit, CT Scan unit or MRI unit in my internal medicine office. If I bring this gentleman into my office, he must transport himself, wait until I have time later in the day and probably will then have to wait to be scheduled by an imaging facility for a non-contrast CT scan of the brain to make sure doesn’t have a bleed between his brain and skull or a bleed in the brain. The delay in evaluation can threaten his survival and recovery. 

The patient was quite angry at the suggestion – quoting my concierge practice contract that says we will bring you in for a visit same day for an acute condition. The non-stated content is that we will bring you in same day for a condition that is appropriate for evaluation in an office setting. The same can be said for someone calling with acute substernal chest pain which could be a heart attack or sudden inability to breathe.  Add in excessive bleeding that does not respond to compression or loss of consciousness as conditions that are best evaluated and treated in an emergency department. These are all conditions that require a call to EMS via 911 and an immediate evaluation in an Emergency Department where the equipment exists to quickly evaluate and treat these problems safely. 

The patient was worried about the wait in the ED and COVID-19 exposure. Both concerns are understandable despite little transmission of Covid recorded in ED visits or in patient hospitalizations.

This patient has emailed me twice now demanding a full refund of his membership fee due to violation of the contract. The reasoning and concern have been explained to him several times already. My concern is that his new onset short temper and grumpy demeanor are the result of the fall and head trauma which still has not been evaluated.

Patients need to know that there are times a health issue requires evaluation and treatment in an emergency department.  It has nothing to do with a contract.  It has everything to do with making the right clinical recommendation for the patient.

Diagnostic X-rays: A Source of Potential Danger?

Last week a patient of mine complaining of cold like symptoms demanded a CT scan of the sinuses. She had been caring for her preschool age grandchild who attended day care and was now experiencing her fifth upper respiratory tract infection in the last 12 months. Her nasal congestion, sore throat, minimally productive cough, aches and pains and overall malaise were typical of the common cold caused by a host of viral agents seen frequently in crowded daycare center classes.  She had no tooth, jaw or facial pain.  We discussed why she did not need an antibiotic at this point and why exposing her to ionizing x- irradiation made no sense.

“How much radiation is safe to receive?” she asked.  According to most experts, there is no safe level of radiation to receive. Different tissues take up and store different amounts of radiation and it all depends on the size of the dose, the distance from the source of radiation and the time of exposure. Most expert panels suggest that we do not receive more than 0.05 mSv per year above our normal annual exposure.  Yes we do receive about 3 mSv per year from naturally occurring sources including cosmic radiation from outer space and radon in the ground and basement of our homes.  People living at higher altitudes receive even more annual natural exposure, with those living in the plateaus of Colorado and New Mexico getting 1.5 mSv more per year than those at sea level. As our radiation exposure increases, the chance of ill effects and ultimate malignancy increase as well.

Recent research data shows that the number of diagnostic and surveillance medical x-rays including CT scans has increased dramatically in the last decade especially in the pediatric age group which is very susceptible to the cumulative radiation doses. A simple chest x-ray exposes you to 0.1 mSv of radiation which is comparable to the natural exposure we receive from 10 days of exposure in our natural surroundings.  Compare that with a chest CT scan which provides 7 mSV of exposure or the equivalent of 2 years worth of natural exposure.  A CT scan of the head, done routinely in ER visits for minor head trauma, fainting or severe headache provides 4 mSv or 16 months worth of natural radiation exposure and is considered a “ low” risk of causing fatal cancer.   The patient who shows up in the ER with lower abdominal pain and gets a CT scan of the abdomen and pelvis with and without contrast receives up to 30 mSv of radiation which is comparable to 10 years of natural exposure.  Now think of the type of exposure cancer victims are receiving routinely to monitor the effectiveness of their treatment and disease progress.

In the hands of skilled technicians and experienced radiologists, obtaining medically necessary studies remains safe.  What may be needed is a realization by all involved that the more exposure we have the more risk we experience. For this reason, I will be giving my patients a radiation exposure history tracking card for their wallets. Each time they have a medical x- ray I will be asking them to record the date and type of procedure.  This will include dental x-rays (0.005mSv or 1 day’s natural exposure level) and all other procedures so we can track annual exposure and consider alternative diagnostic options in those with large exposure numbers.

As the country considers the new health care reform proposals and opponents speak about rationing to save money and “death panels”, remember that some of the reductions proposed are designed to spare us excessive and unnecessary ionizing radiation exposure.

For more information about radiation, visit the web sites listed below.

American College of Radiology – http://www.acr.org/

Radiology Info – http://www.radiologyinfo.org/

Effective Radiation Dose / Exposure – Chart