Does aspirin protect healthy patients from heart attacks?

A new large study published in the recent issue of the Lancet brings this into question.

I believe that the press is misreporting on the findings. What the researchers found that YES aspirin did prevent nonfatal heart attacks. However, patients who took aspirin were also more prone to develope gastrointestinal bleedings.

When aspirin is given to patients for primary prevention, it could be expected to prevent five nonfatal heart attacks but cause three extra gastrointestinal bleeds per 10,000 people treated per year.

In my experience as a Interventional Cardiologist ("heart attack doctor"), most patients that I meet having a heart attack are not on a daily aspirin. Even if they are on a daily aspirin, when they do have a heart attack, its never the "big one" but a small non-life treatening one.

Yes, patients on aspirin do blled more than patients not taking aspirin.

There is no doubt that a daily aspirin is highly protective in patients with established heart and vascular disease.

So what do I take from this.

1. Asprin is highly effective in patients with established heart or vascular disease
2. Aspirin does protect "healthy" patients from heart attacks
3. Patients who take aspirin bleed more than patients who do not
4. Therefore, the risk/benefit ratio needs to be analyzed very carefully for each patient. If a patient has a high risk of GI bleeding with low risk of heart disease, I would recommend staying away from aspirin. If a patient has a high risk of heart disease but low risk of bleeding, I would definitely recommend using aspirin. If the patient has a high risk of bleeding and a high risk of heart disease, I would recommend treating the patient with aspirin but ensure that the patient understands the increased risk of bleeding.

Very Cool!!!! Atherosclerosis Vaccine

A Vienna-based company, AFFiRiS AG, has recently announced it has secured funding for development of a vaccine that may help fight atherosclerosis.

For years, we have had medications (most notably statins - Zocor, Crestor, Lipitor, Pravacol) that are extremely efficacious in lowering the low density lipoproteins (LDLs - I call them the "lousy" ones) which dramatically reduces the incidence of heart attacks in primary and secondary prevention.

Yet, we still do not have a good medication to raise the high density lipoproteins (HDLs - I call them the "healthy" ones). The HDLs are responsible for bringing cholesterol from the tissue (plaque) back to the liver for processing.

This new vaccine would be aimed at the cholesteryl ester transfer protein (CETP), which is an enzyme responsible for transferring cholesterol esters from HDL to LDL - therefore reding the "healthy" HDL. Over time, the vaccine should reduce the activity of this enzyme.

This is very cool.

It is still totally unproven and previous such vaccines have failed. Yet this current company successfully bio-engineered vaccines for Alzheimer's and Parkinson's disease already.

I look forward to hearing how this program progresses.

Twitter

You can now follow me on twitter (http://twitter.com/drportnay). I have placed a permanent link on right of the blog. I look forward to tweeting with you

Safety of non inflammatory drugs in patients with heart disease

For some time now, there has been concern regarding the safety of non inflammatory drugs (NSAIDS) in patient with heart disease. Some of the medications seemed to lead to increased incidence of heart disease (Vioxx and Celebrex) and some NSAIDS seem to interfere with aspirin (ibuprofen).

Now, reasearchers are reporting in the May 2009 issue of Circulation: Cardiovascular Quality and Outcomes, that naproxen (Alleve) is clearly safer than the other NSAIDS with fewer heart attacks, strokes and cardiac related deaths.

For now, I encourage all my patients to try and see if they can control their pain with acetaminophen (Tylenol). If this does not control their pain, I recommend Alleve for pain control.

So Scary - where are we heading!!!!!

A new study published in the American Journal of Medicine reveals that less Americans are engaging in "healthy lifestyle" as compared with 2 decades ago.

The researchers are reporting the only 8% of today's patients engage in all five healthy behaviors -- maintaining a healthy weight, eating fruits and vegetables, drinking alcohol in moderation, exercising, and not smoking -- compared with 15% in 1988.

Enough said!!!!!

"subscribe to"

I've added the ability to subscribe to my blog. If you chose to do so, you will be emailed every time I make a new blog posting. Right now, the sign up is at the bottom of the blog. I'm hoping I can find someone who can write HTML and help me move this to the left side of the blog to make it more convenient.

Safety of Acid Reflux Drugs

Today's New York Times is reporting on a new study where patients who take proton pump inhibitors to prevent acid reflux are at higher risk for pneumonia than those who do not.

Proton Pump Inhibitors (PPIs) are amazing drugs that dramatically reduce the acid content of the stomach. This therapy has proven vital in the treatment of gastric and duodenal ulcers as well as severe cases of gastroesophageal reflux disease (GERD).

However, there have been more and more recent data regarding the safety of this medication. Not only for higher rates of pneumonia but also for cardiac reasons. There is some data that these medications have the potential to counteract the effects of plavix and there is data that patients taken both plavix and PPIs have higher rates of heart attacks than patients taking plavix without PPIs.

This raises to two important issues.

1. All the data so far on safety of PPI and plavix is retrospective. This means that researchers go back and look to see what happens in different groups of patients. This form of research is excellent for hypothesis generating but is unable to prove causality. For tis we need prospective randomized controlled trials. I have a hunch that what researchers have seen so far is that compared with patients on just plavix, patients on both Plavix and PPIs are sicker at baseline and therefore more prone to have heart attacks because of their overall health status not because of their PPI use. In my practice, I have not seen PPIs leading to heart attacks.
2. PPI are probably being used too much. They work so well, it is easier for a physician to just got to the most potent medication instead of trying a less potent medication to see if this works first.

Until this all plays out, I will be following the recommendations of the Society of Angiography and Intervention: "SCAI believes more research is needed on this topic. However, given the thousands of patients who receive stents each year, coupled with the significant risks demonstrated in this study, SCAI recommends the use of alternative medications for GI symptoms in patients with stents when appropriate. Other effective treatments for heartburn and ulcers include histaminergic (H2) blockers (Zantac [ranitidine, Boehringer Ingelheim], Tagamet [cimetidine, GlaxoSmithKline]) or antacids. In some patients the use of PPIs may still be warranted, based on the patient's medical problems, and should be taken at the direction of the patient's cardiologist, gastroenterologist, or primary physician."

I recommend you talk to your physician if you are on a PPI and plavix prior to stopping or changing your therapy based on this discussion.