Scientific Reports, Media Reports and Ambiguity

Last week I read an article in a peer reviewed journal citing the benefits of a few eggs per week as part of a low carbohydrate dietary intervention for Type II Diabetes.  The information was so meaningful about a controversial food source of protein that I decided to write about it in my blog and pass it along to my patients.  Three days later the American Heart Association and American College of Cardiology discussed the increased risk of cardiovascular events and mortality in individuals consuming three or more eggs regularly. They talked about the detrimental cholesterol being concentrated in the yolk making egg white omelets look healthier than traditional omelets.

In the early 1970’s a VA study was published showing that veterans over 45 years of age who took an aspirin a day had fewer heart attacks and strokes and survived them better than those who don’t.  Fast forward almost 50 years and we have different recommendations for people who have never had an MI or CVA or evidence of cardiovascular disease compared to secondary prevention in individuals who have known coronary artery disease, cerebrovascular disease or diabetes. Throw in the controversial discussions of aspirin preventing colorectal adenomas from developing, aspirin preventing certain types of skin cancers and today’s report that suggests it may prevent liver cancer. Now three studies suggest that in older individuals (70 or greater) the risk of bleeding negates the benefits of cardio and cerebrovascular protection and aspirin may not actually prevent heart attacks and strokes in that age group.

We then turn to statins and prevention of heart attacks and numerous articles about not prescribing them to older Americans.  I saw articles on this topic covered by CNN, the Wall Street Journal, ARP Journal, AAA magazine and in several newsletters published by major national medical centers.  In each piece they caution you to talk to your doctor before stopping that medicine.

I am that seventy year old patient they all talk about.  I have never smoked. I exercise modestly on a regular basis, getting my 10,000 or more steps five or more days a week.  I battle to keep my weight down and find it difficult to give up sweets and bread when so many other of life’s pleasures are no longer available due to age and health related suggestions.

There are clearly no studies that look at patients who took a statin for 15 years and aspirins for over 20 years, stopped them and then were followed for the remainder of their lives.   How will they fare compared to patients who never took them?

I have this discussion every day with my patient’s pointing out the current guidelines and trying to individualize the suggestions to their unique lifestyle and issues. On a personal level, I still have no idea what the correct thing is to do even after discussing it with my doctors.  How can I expect my patients to feel any differently?

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Aspirin Holiday Carries Its Risks

A recent publication in the British Medical Journal looked at the risk of stopping aspirin therapy and taking a drug holiday from it if you are taking aspirin as secondary prevention for heart disease. The study, conducted from 2000 – 2007, looked at almost 40,000 participants aged 50-84 who were taking low dose aspirin (75- 300 mg per day) for secondary prevention of cardiovascular outcomes. They followed the patients for 3.2 years.

Researchers determined that individuals who stopped aspirin for 1-6 months had significantly more myocardial infarctions (heart attacks) and cardiovascular deaths than individuals who continued the aspirin.  Most of the patients who stopped the medication just stopped it on their own for no particular reason.

The study has implications for patients who have known coronary artery disease, have had a heart attack or stent placed or have survived bypass surgery. It says that if you stop the aspirin you increase your risk of having a cardiac event.

As a physician I am always faced with phone calls from patients going for minor dental work and the dentist insists on stopping the aspirin. I have patients going for elective cosmetic procedures who are required to stop their aspirin.  The message must be “is the risk of excessive bleeding from the elective procedure greater than the risk of having a heart attack?”  This is a question you should ask your cardiologist, internist or family physician before stopping the aspirin. You and they will need to ask your dentist or surgeon the same question before you stop the aspirin.

There will be times when you will have no choice but to accept that increased risk to have work done which may be necessary.  By informing your physician of the problem, and discussing it with the surgeon or dentist, we can determine if stopping the aspirin is essential and if there are other measures we can take to prevent a cardiac event.

Non Steroidal Anti-Inflammatory Drug (NSAID) Use and Heart Attacks

Most of us weekend warriors are used to reaching for the ibuprofen , naproxen or aspirin for relief from aches and pains after some strenuous gardening, yard work or recreational exercise. It helps alleviate the pains and allows one to go on with their life and perform the normal activities of daily living.

For many individuals with advanced osteoarthritis or the more severe types of immunological arthritis such as rheumatoid arthritis or psoriatic arthritis, these medicines are liberating and allow patients to live a normal life. For many years the major concern with these medications was their effect on the stomach causing irritation, inflammation and gastrointestinal bleeding. Then experts issued warnings about long term use and liver and kidney damage.  These side effects were listed on the product insert and were not unexpected.

What was unexpected was the association of NSAID’s and acute heart attacks. Drugs like Vioxx and Bextra, which were extraordinarily effective at relieving aches and pains, were pulled from the market after being determined to dramatically increase the number of acute myocardial infarctions users suffered. The NSAID’s reduced joint pain and inflammation by inhibiting chemicals called prostaglandins. Unfortunately the same inhibition of prostaglandins that produced less inflammation and joint pain also inhibited prostaglandins that kept our coronary arteries from going into spasm and cutting off the circulation to our heart muscle. For several years now pharmaceutical manufacturers have been looking for the perfect formula that inhibits joint inflammation without increasing heart attack risks.

A recent study from Denmark indicated that their search has not yet been successful. Denmark maintains detailed records of patient hospital admissions and medication usage as well as a central national death registry.  Using these data bases, the records of 84,000 patients admitted to a hospital for treatment of a myocardial infarction from 1997-2006 were reviewed and linked to pharmacy records. Researchers found that 43.3% of the MI patients received NSAID’s post MI and there were 35,257 deaths or repeat heart attacks.

“Overall NSAID treatment was related to a significantly increased risk of death at the beginning of the treatment and the risk persisted throughout the treatment. Patients taking Celebrex had an increased risk of death when the treatment lasted two weeks to a month.  All NSAID’s increased the risk of death or recurrent MI by 45% after a week.  Naproxen increased the risk of death or recurrent MI by 76% after a week. For treatment lasting 30-90 days the increased risk was 15%.  Ibuprofen had the lowest initial risk, just 4% increase for treatments lasting seven days or less.

In practical terms, we must limit NSAID use to the absolute minimum in patients with established cardiovascular disease.  Based on this article, ibuprofen seems to be the best choice for short term use in patients with known cardiovascular disease. Patients with cardiovascular disease and known previous MI should be talking to their doctor before they reach for the over-the-counter bottle of a NSAID.