Key Points on low dose aspirin

Yesterday some of my more well informed and alert patients and friends drew my attention to a newspaper report of the US preventive task force’s latest recommendation about low dose aspirin. This short write up is pertaining to the same so that there is clarity in minds of people.

1.       Clotting and bleeding are opposite phenomena. Agents which prevent clotting can cause bleeding. Aspirin is one such agent.

2.       There are two groups of people for whom preventive therapy with low dose (LD) aspirin is applicable.(Low dose which is less than 100mg has been shown to have same benefits as full dose of 325 mg, but with the benefit of less bleeding.)

3.       One group is composed of those who already have evidence of arterial disease such as a heart attack, angina, angioplasty, bypass surgery, ischemic brain stroke or arterial disease of the limbs.

4.       For these people, life-long LD aspirin (or another antiplatelet drug like clopidogrel) is HIGHLY advisable because the benefit in terms of preventing another clotting event like a heart attack far outweighs the risk of bleeding in the gut or the brain-the most important risk with aspirin. This is called secondary prevention.

5.       The other group of people is composed of those who are apparently healthy and wish to prevent heart attacks or strokes in future, which is called primary prevention.

6.       Some years back, the popular notion was that LD aspirin should be given to all above 40 years to prevent a heart attack. This was not based on scientific evidence, but from observation and impression gathered from population.

7.       In the last few years came hard evidence in form of placebo controlled, randomized trials with aspirin which showed that for primary prevention, the risk of bleeding may outweigh the benefit with LD aspirin.

8.       Hence in 2019 American College of Cardiology & American Heart Association recommended that LD aspirin for PRIMARY PREVENTION is not advisable for people above age 70 or ANYONE at high bleeding risk.

9.       But they said LD aspirin MAY BE advisable for primary prevention in people between ages of 40 and 70 who are at high cardiovascular disease risk (such as people with family history of premature heart disease, people with hypertension, diabetes, high cholesterol, smokers, obese etc) and low bleeding risk, to prevent heart attacks and colorectal cancer. It may also be recommended for people who already are on LD aspirin without side effects.

10.   The current US task force’s recommendation is almost the same as the 2019 recommendation by ACC-AHA except that the upper age limit is brought down to 60 and prevention of colorectal cancer is no longer a reason for preventive therapy with LD aspirin. 

11.   These are general recommendations for the population. At the individual level, shared decision making with your cardiologist is recommended after weighing your probability of benefit against your risk of bleeding with LD aspirin.

12.   Lastly, one group of patients that is not covered by the above scientific bodies is people without any symptoms but with fatty deposits in their heart, brain or leg arteries as shown by tests like coronary artery calcium score, coronary CT angiography, doppler showing plaques in carotid arteries or BP in legs lower than that in arms.

13.   Such people (for example with coronary artery calcium score more than 100 and) at high risk may be well advised LD aspirin for prevention. Again, shared decision making with your cardiologist is advisable after discussing the risk-benefit issues.

 

Doc, are pills prescribed for BP and cholesterol, habit forming? Is it true 

that once started they cannot be stopped?

Well, the answer is that they are not habit forming (in the sense some drugs acting on the mind are), although if they benefit you in the long term helping you to prevent heart attacks and brain strokes, they are a good “habit” to form!

If BP and cholesterol levels are not at desirable levels as per your risk profile, and if your cardiologist feels you that in addition to the lifestyle changes you have instituted, pills are also required to control their levels to reduce the risk of heart attack or brain strokes, then it may be advisable to take them as long as your cardiologist feels you should take them, which in many cases could be lifelong. But that will drastically cut your risk of heart attack or brain strokes in future, if taken as advised.

About stopping them once started? Well it depends on your risk of having heart attacks in future (which depends on your lifestyle and risk factors like family history, presence of hypertension, diabetes, cholesterol etc.), and your response to changes in lifestyle and drugs.

For example, if your BP comes down with lifestyle measures such as weight reduction, salt and alcohol restriction, doing regular exercise, sleeping well and increasing fruits and vegetables in diet, your pills can be tapered gradually over weeks and months keeping a watch over your BP, lest it should go up again.

If it remains normal on repeated checking despite tapering and stopping pills, one can do away with the BP pills. If after tapering and stopping pills, BP rises again, then the pills will have to be reinstituted.

In case of cholesterol pills, commonest of which are called statins, research has found tremendous benefits with their use in people at high risk, for example people who are known to have coronary artery disease or people with multiple risk factors alluded above.

But again, in people with low or intermediate risk, if cholesterol levels plummet with intensive lifestyle changes, these pills can be stopped, and lipid levels checked again at regular intervals to see if they remain low. If they rise again, one may have to reinstitute the drugs at the advice of one’s cardiologist after a risk-benefit discussion.

One caveat to all the above is that there are certain drugs which are dangerous to stop suddenly. For example, a class of drugs called betablockers or a drug like clonidine, if stopped suddenly can cause rebound hypertension (to levels higher than those before drug was started) and rarely even cause heart attacks. Hence if they are to be stopped, it should only be done gradually under the guidance of your cardiologist.

As far as cholesterol lowering drugs (like statins) are concerned, stopping them suddenly in a person having underlying coronary disease may increase his/her risk of worsening his/her condition. Hence again, if one wants to stop or alter them, it should be done under a cardiologist’s guidance.

Thus, BP drugs and Cholesterol drugs are a good “habit” to form if they are required to control your BP and cholesterol levels which will benefit you in the long term to prevent heart attacks and brain strokes. If you are at low or intermediate risk and if BP and cholesterol are well controlled with healthy lifestyle and habits, then stopping or altering drugs is possible but not without medical guidance.

 

 

 

 

 

 Purpose in life, sleep and walking speed

A page from my book “Romancing the Heart” (available on Amazon)

·         There is a curious relationship between having a purpose in life, your walking speed and your sleep.

·         Not only are they inter-related, but they all also independently impact health.

·         This is especially important for those above 55 or 60 years of age, when both walking speed and sleep start being affected, commonly.

·         Studies have found that if you have a higher purpose in life, a pet project or an exciting reason to get up in the morning, you are more likely to have better sleep. Also, in that case, your walking speed does not diminish as you age and you may stay more physically fit.

·         Now the interesting thing is that although a higher purpose in life improves walking speed and sleep, both these latter are also affect each other: if you walk better, you sleep better and if you sleep better you can walk better.

·         To top it all, the three, each by independent mechanisms, impact health, for example walking speed by cardiorespiratory fitness, purpose in life by psycho-neuro-immune pathways and cell repair with better sleep.

·         Finally, the silver lining is that both can change for the better. Walking speed can be improved with practice and purpose in life can be cultivated. These measures can improve sleep and overall health.

·         Volunteering, learning new things, cultivating relationships and hobbies and interests can be important ways for increasing one’s sense of meaning in life. This protects against many negative health and psychological outcomes, especially of older age.

·         Hence, don’t wait. Increase your walking speed, but first better find out something exciting to do which fills a need and fulfils yourself! It will help you sleep better, walk faster.