My post last week created much confusion and worry.  I received many emails asking “What about me?  Should I keep taking aspirin or not?”

Let me clarify the issue by explaining what we already knew before last week’s study in the British Medical Journal.  We knew that aspirin is valuable in:

• patients who have had a stroke
• patients who have had a heart attack
• patients who have had bypass surgery or angioplasty
• patients with angina (chest pain or discomfort caused by narrowing of coronary arteries)
• patients with claudication (calf pain caused by narrowing of leg arteries)

So patients in the above groups should take aspirin unless they have had an adverse reaction from aspirin.  Last week’s study was not about those patients.

Last week’s study was about patients with multiple risk factors for heart attack but who had not had a heart attack or a stroke.  Risk factors for heart attack and stroke are:

• age (men over 45, women over 55)
• smoking
• high blood pressure
• high cholesterol
• diabetes
• a parent or sibling with a heart attack early in life (male relative before age 55, female relative before age 65)

The US Preventive Services Task Force (USPSTF) and the American Heart Association (AHA) currently recommend aspirin to prevent a first heart attack or stroke for patients with multiple risk factors for heart attack and stroke.  Last week’s study disagreed with those recommendations, suggesting that aspirin does not prevent a first heart attack in high-risk patients.

My friend and colleague, Dr. Yaron Elad, emailed me arguing that I should not change my practice based on a single study.  He and I dug through the studies supporting the USPSTF and AHA recommendations and decided that he was right.  There is still a lot of evidence that aspirin helps prevent a first heart attack in patients at high risk of heart attacks.  So I retract my conclusions last week, and I’m grateful for Dr. Elad’s input.

Finally, and most importantly, talk to your doctor before making a decision.

Learn more:

My post from last week: Aspirin Doesn’t Prevent Heart Attacks in Patients with Diabetes

The US Preventive Services Task Force recommendation: Aspirin for the Primary Prevention of Cardiovascular Events

American Heart Association recommendation: Aspirin in Heart Attack and Stroke Prevention

Aspirin has been a mainstay in the treatment and prevention of cardiovascular disease for decades.

We know that in patients who have had a heart attack in the past aspirin prevents a second heart attack, and during a heart attack aspirin is life-saving.  We also know that in patients with a prior stroke aspirin prevents further strokes.  And in patients with symptomatic narrowing of the arteries, that is chest pressure with exertion (angina) or calf pain with walking (claudication), aspirin prevents strokes and heart attacks.

So on that solid base of evidence, doctors have extended aspirin therapy to many other patients who don’t fit the above criteria but have risk factors for heart attack and stroke, risk factors such as diabetes, smoking, high blood pressure and high cholesterol.  Practice guidelines have been formed recommending aspirin for such patients, despite the lack of evidence that it helps them.  I’ve urged many patients with diabetes, high blood pressure and high cholesterol to start taking daily aspirin.

Well, there’s nothing like a good study to show us that we’ve been doing the wrong thing.  The British Medical Journal published a study this week in which 1276 patients with diabetes and mild, asymptomatic narrowing of the arteries were randomized to receive daily aspirin or placebo.  They were followed for over 6 years to assess differences in the rates of heart attack, stroke, amputations and death.  The surprising result was that the aspirin group did no better than the placebo group.  Aspirin didn’t help.

(By the way, the study also randomized patients to receive antioxidants or placebo, and the antioxidants didn’t help either.)

So to summarize, aspirin should be taken by patients who have had a previous stroke or heart attack, or have symptoms of artery narrowing, such as angina, claudication, or a prior angioplasty or bypass surgery.  Patients taking aspirin because of risk factors for heart disease who have no symptoms of artery narrowing (even though I urged some of you to start aspirin!) should stop.

(Thanks to my colleague and pal, Dr. Rubencio Quintana, for showing me the British Medical Journal article.)

Learn more:

British Medical Journal article: The prevention of progression of arterial disease and diabetes (POPADAD) trial: factorial randomised placebo controlled trial of aspirin and antioxidants in patients with diabetes and asymptomatic peripheral arterial disease

UPDATE:  In a subsequent post I retracted my conclusions, offered some balance to the controversy and urged readers to talk to their doctors before changing their aspirin regimen.

I beg your indulgence this week as I ignore medical news and offer some personal reflections.

Unless you’ve been avoiding all news sources for the last few weeks, you know that a lot of people all over the world are scared.  Today’s headlines scream about the worst week ever on Wall Street, with trillions of dollars of assets evaporating.  No one is sure when the housing and credit markets will stop falling.  No one is sure whether the actions of the U.S. and other governments to keep credit flowing will work.

And this calamity did not befall an otherwise tranquil world.  Those who were paying attention had plenty of other reasons for anxiety, from a nuclear-armed Pakistan that always seems one election away from anarchy to our federal budget becoming an unworkable fantasy as the baby boom retires.

The sky really seems to be falling.

I’m not an economist, and I can’t predict when or how this will end.  I certainly won’t minimize the very real harm that’s been done.  The staggering numbers aren’t just theoretical paper losses.  They represent the vanishing of retirement plans, the loss of homes, and the destruction of years of gains.

All I can do is remind us that the world will not end.  At some price buyers will want houses again.  At some interest rate lenders will write loans again.  If governments keep their currencies stable, markets will eventually hit bottom and stabilize.  The engine for economic growth after all is that people want stuff that they don’t have, and that they are willing to work and spend for it.  That hasn’t changed.  The sun will come up tomorrow.

So to quote Douglas Adams, don’t panic.  Take a walk, preferably with someone you care about.  Listen to some music that has survived over a century.  And take a big breath.

The current issue of the Annals of Internal Medicine published a clinical practice guideline from the American College of Physician on drug treatment for low bone density.  It contains a valuable review of the known benefits and risks of the medications used for osteoporosis which I summarize below.

Bisphosphonates

This family of medicines includes Fosamax, Didronel, Boniva and Actonel.  Fosamax, Didronel, Boniva and Actonel have been proven to prevent vertebral fractures, and Fosamax and Actonel have been proven to prevent hip fractures.  Boniva has not been shown to prevent non-vertebral fractures.  The most common side effects of bisphosphonates are gastrointestinal: acid reflux, esophageal irritation, and nausea.  Bisphosphonates have also been linked to destruction of the jaw bone, a very rare but more serious side effect.

Calcitonin

Calcitonin nasal spray has been shown to prevent vertebral fractures though the evidence is less strong than for bisphosphonates.  Calcitonin does not prevent non-vertebral fractures.  It has no serious side effects.

Estrogen

There is strong evidence that estrogen prevents vertebral and non-vertebral (including hip) fractures.  But there’s also good evidence that estrogen increases the risk of blood clots and stroke.  In combination with progestin, estrogen also increases the risk of breast cancer.  Without progestin it increases the risk of uterine cancer.

Forteo

Forteo is a relatively new treatment for osteoporosis.  It is taken as a daily subcutaneous injection, making it less convenient than oral medications.  It has been shown to prevent vertebral fractures, but its effect on non-vertebral fractures isn’t clear.  It has no serious side effects.

Selective Estrogen Receptor Modulators (SERMs)

The two available SERMs are Evista and tamoxifen.  Tamoxifen is not useful for fracture prevention and is not used to treat osteoporosis.  Evista has been shown to prevent vertebral but not non-vertebral fractures.  Evista increases the risk of blood clots.

Calcium and Vitamin D

The evidence on calcium and vitamin D for fracture prevention is mixed, with the most positive studies showing modest benefit.  Calcium and vitamin D have no serious side effects.

Learn more:

Summaries for Patients:  Drug Treatment for Low Bone Density or Osteoporosis to Prevent Fractures

American College of Physicians clinical practice guidelines:  Pharmacologic Treatment of Low Bone Density or Osteoporosis to Prevent Fractures