Aspirin for Primary Prevention- Revisited in 2019
When we speak of preventing heart attack and stroke events there are two categories: Primary and Secondary prevention. Secondary prevention means an individual has already experienced symptomatic vascular disease. In this group, daily aspirin lowers odds of an event by 22%. The benefit in general outweighs risk. Primary prevention is a treatment intervention recommendation before an event. Who should be considered for primary prevention depends upon their personal health risk factors for premature vascular events.
Many patients have been asking about whether they should be taking 81 mg aspirin daily for heart attack and stroke prevention. In 2018, three additional studies were reported as it relates to taking aspirin for prevention of an initial cardiovascular event. In January of this year, the Journal of the American Medicine Association (JAMA) published a summary study (meta-analysis) which added the data of these more recent studies. The information didn't significantly alter what we know about risks and benefits.
What is coming out of this study and discussion among physicians is that the benefits for lowering events is small on an absolute basis. 265 people need to be treated to avoid one nonfatal heart attack, stroke or cardiovascular mortality event. If we look at significant major bleeding event risk in this same group, 210 individuals need to be exposed to treatment for one event. I will continue to review the appropriateness of aspirin on a case by case basis. I would advise my patients not to change therapy without us reviewing your particular risk factors and health situation.
Non-HDL Cholesterol Reduction In Persons With High Triglycerides Benefit As Much as LDL Reduction in Persons Without Elevated Triglycerides.
A recent JAMA article looked at the reduction of heart attack rate in individuals with elevated triglycerides. What they concluded was that the lowering of triglycerides as a target lowered particles of non-HDL cholesterol which includes particles known as VLDL, IDL and LDL (bad cholesterol). Regardless of the source of non-HDL (good) cholesterol that is lowered there is an equal amount of benefit as it relates to heart attack reduction.
Statins, which are the main therapeutic medication for lowering heart attack risks, don't lower non-LDL (VLDL and IDL) particles of cholesterol that are associated with high triglycerides. Diets lower in simple carbohydrates, eating fish and fish oil lower triglycerides and non-HDL cholesterol very well. The point is if your triglycerides are elevated it isn't the triglycerides that are harming you, it is a set of particles called VLDL and IDL that are increasing heart attack risk. Lowering triglycerides with fish oil and prescription variants promote a drop in these VLDL particles. Diet modifies these particles strongly as well. Lowering these particles is as helpful and necessary as lowering the LDL. Many of my patients know that we use fish oil when triglycerides are high. They also know we discuss the plate-building/Mediterranean style of eating as an important lifestyle move. Exercise including walking drops triglycerides and hence the other particles as well.
Traditional Office Blood Pressure Measurements Are Falling to the Wayside
A
systemic review that incorporated several similar study protocols (this is called meta-analysis) has shown that instead of the traditional office manual blood pressure reading performed by the physician or nurse, we should be averaging 3 automated inflated cuff pressures. The caveat is that these measurements are averaged and should be measured with the patient resting alone and in a quiet place. Conversation is the most common reason for white coat phenomenon.
The corollary to this is that home automated blood pressure recordings can feasibly be performed at home allowing the quiet, alone person to record their blood pressure. This is why I ask my patients who are under treatment or suspected of having high blood pressure to invest in a home blood pressure cuff to collect data that won't be under the "white coat" cloud.
Some ACP Commentary Reports On Marijuana Highlight The Downside of "Medical Marijuana"
From the Annals of Internal Medicine January 8, 2019 journal:
Dr's Heard, Monte and Hoyte indicate that 90,000 residents of Colorado have medical cannabis cards and 1/3 use it daily. Prior to 2009, very few children were hospitalized for marijuana exposure in Colorado. From 2005-2009 the largest pediatric hospital had no children hospitalized. Now they see several a month, a few cases required ICU admission and resulted in expensive work-ups including invasive procedures. There has been a dramatic increase in ER visits for excess vomiting- from virtually none to 100 per year in their hospital. Death has resulted due to severe dehydration and metabolic acidosis. There was also a five-fold increase in ER visits attributable to cannabis coded as related to mental health disorders as well.
Dr. Eli Adashi MD documented the National Survey on Drug Use and Health has documented as high a rate as 8.5% of marijuana use in pregnant women. Many are using it to manage nausea in the first trimester. Marijuana readily crosses the placenta and blood-brain barrier in fetuses and neonates. This is very troubling as we know in adolescents the use of marijuana affects learning and IQ development.
Dr. Good et al comment on the concerns including lack of clinical evidence, good trials and the lack of product control in the use of
marijuana for pain management.
|
