Posts Tagged ‘coronary artery disease’

Should I be taking aspirin?

Wednesday, January 30th, 2013

I take a dose equivalent to 1/4 tablet of aspirin

One of our friends recently told my wife she’d stopped taking aspirin after a news report linked regular use of the medication to macular degeneration. We’ve both taken 81 mg of aspirin a day and, after I’d heard that people may not absorb the enteric coated form well (and I couldn’t find any other form in that size at the local drugstore), I’d ordered ten bottles of chewable orange-flavored aspirin online from Amazon.

Then I decided to read the medical reports that our friend’s recommendation had been based on. She doesn’t have a medical background and hadn’t looked at the original data, but instead had seen a warning in a newspaper article. Let’s start at The New York Times blog. On Dec 12, 2012 they published an article by Anahad O’Conner titled “Aspirin Tied To Rare Eye Disorder.”

It’s a very well-worded article written by a 31-year-old, Yale-educated Times reporter who writes a weekly science column and has published two books He notes the article he based his piece on was from JAMA with the lead author, Dr. Barbara Klein, being a professor of ophthalmology at the University of Wisconsin, Madison. Since I’m a UW graduate (BS 1963, MD 1966), I was particularly interested in her study.

It used data from the Beaver Dam Eye Study, started in 1988-1990 and concluded in 2010. O’Connor very appropriately noted this was an observational study, not a prospective, controlled research project. In other words a group of ~5,000, aged 43 to 84, agreed to have regular eye exams and reports were published after the 5-, 10-, 15- and 20-year followups.More than 300 publications have resulted from this project with data supporting a relationship of cataracts and age-related macular degeneration (AMD) to cigarette smoking.

Klein’s paper stated that an estimated 19.3% of US adults take aspirin on a regular basis. It’s commonly recommended for anyone who has had a heart attack (secondary prevention), but many   of us who’ve never had evidence of coronary vascular disease also take aspirin. This is primary prevention and is controversial with some data suggesting reduction of heart attacks in men over 45, but not women, although they may have a 17% reduction in stroke incidence.

A senior who has AMD may need a magnifying glass.

A January 21,2013 article from an Australian group reported a two-fold increase in AMD of a particular type, independent of smoking habits. Nearly a quarter of regular long-term aspirin users developed neovascular AMD, two and a half times the percentage of those who did not regularly take aspirin.

A 2001 paper in the Archives of Ophthalmology reported a randomized, double-masked, placebo-controlled study of low dose aspirin (one adult tablet every other day) plus 50 milligrams of beta carotene (a vitamin A precursor rated possibly effective in treating advanced AMD) among over 20,000 US male physicians aged 30 to 84 in 1982. The study was stopped after ~5 years due to a statistically extreme reduction (44%) in first heart attacks. There were fewer cases of AMD in those taking low-dose aspirin than in those who got the placebo.

There’s also some data supporting aspirin’s role in cancer prevention, especially in malignancies of the colon. Here the benefit was unrelated to aspirin dose (75 mg/day and up), but increased with age.

So let me look at my own risks: my dad had a large polyp in the earliest part of the colon, an area hard to see even on colonoscopy. It was initially felt to be benign, but later had some areas of low-grade malignancy. He also had macular degeneration in his remaining eye  diagnosed at age 90+ (the other eye having been removed nearly sixty years previously after a bad cut and a subsequent infection). My brother died of a heart attack at age 57 and my mother had a heart attack at age 74 with a cardiac arrest; (Dad resuscitated her and she lived to age 90).

The editorial that accompanied the recent JAMA article is thoughtful and impressive. Its title was “Relationship of Aspirin Use With Age-Related Macular Degeneration: Association or Causation?” and it concludes “From a purely science-of-medicine perspective, the strength of evidence is not sufficiently robust to be clinically directive.” It then switches to a different viewpoint, the art-of-medicine perspective, saying maintaining the status quo is currently the most prudent approach, especially in secondary prevention (someone who has already had a cardiovascular event). For those of us who haven’t, the risks versus benefits should be individualized based on our own medical history and value judgement.

I’m going to discuss this with my own physician but not stop taking a chewable 81 mg aspirin daily until I do.

Heart attacks Part 2: Prevention: risk factors & our kids

Wednesday, May 23rd, 2012

Here's a risk factor you can eliminate

This post pings off the April 17, 2012 article in The Wall Street Journal, “The Guide to Beating a Heart Attack.” I initially wrote about surviving a heart attack (myocardial infarction {MI} is the medical term). Next I wanted to turn toward the prevention side.

I first found the Interheart study’s article from 2004, “Nine modifiable risk factors predict 90% of acute MI.” The study followed 29,000 people from 262 sites in 52 countries and concluded that the common belief that half of heart attacks can be predicted was clearly an underestimate.

The research group found the same impact of the nine variables everywhere in the world: abnormal blood lipids (fats, like cholesterol) and smoking were at the top of their list. Then came diabetes, high blood pressure, abdominal obesity, stress & depression, exercise, diet and alcohol intake.

I was used to measuring cholesterol and its HDL (so-called good cholesterol)  and LDL (bad cholesterol) components. This study actually used a more sophisticated lipid approach.

They measured the ratios of  the proteins that bind to and carry fats, apolipoproteins A and B. APOA is associated with HDL lipids while APOB is said to unlock the door to cells and in doing so acts as an unwelcome delivery van for cholesterol. When present in high levels, APOB can lead to plaque formation in blood vessels and an increased risk of coronary heart disease (CHD).

They also found some good news: as expected, eating fruits and vegetables daily, exercising and perhaps moderate alcohol intake were associated with lower risks of CHD. Again this was true everywhere in the world.

The WSJ article mentioned that hospital admissions for heart attacks had actually decreased among the elderly; these nine factors were better predictors in younger groups. What can be done to stop the looming specter of CHD among our younger population?

The CDC examined the parameters in a recent online article titled “A Growing Problem.” One issue was “screen time.” Our kids eight to eighteen average four an a half hours a day watching TV and three more on cell phones, movies, computers and video games. I even read an article about a two-year-old whose parents think learns a lot from their iPad. Maybe so, but how much exercise does that kid (and his older compatriots) get?

The CDC feels there is a dearth of quality physical activity in our schools; as of 2009 only a third of them provided daily PE for our kids. And after they leave school or when they’re on vacation, many don’t have safe access to biking, hiking, running, playing areas and trails.

Somerville chose healthier food in their schools

One Massachusetts community, Somerville, has gotten attention for their anti-obesity integrated program, “Shape Up Sommerville”  (You can watch the thirteen minute PBS special on their community-wide progress). The Robert Wood Johnson Foundation is attempting to help similar programs get started across the country, especially focusing on childhood obesity.

Recently I heard a NPR comment that caught my attention. If we don’t do something to stop the epidemic of childhood obesity, we’ll soon be seeing CHD rates soar in people in their 20s and 30s and maybe even younger.

A French researcher said, “Mankind is doing a good job of killing himself.”

We need to try new approaches to help our kids. The Somerville plan sound like a good place to start.

 

 

 

The very high-priced spread

Saturday, February 4th, 2012

This obese teenager could be headed for trouble

I’ve been concerned about our burgeoning problem of excessive weight, so when the Journal of the American Medical Association for February 1, 2012 arrived, I was intrigued by the variety of articles touching on the subject. Let me start with a disclaimer: I have no clear-cut special competence, no magic bullet for preventing or treating obesity in our children. I do think it’s a major threat to the upcoming generations here and elsewhere in the world. I am also very aware that its opposite numbers, hunger and even starvation, threaten whole populations around the globe.

But my own background, both as a physician and as someone who has successfully fought weight issues (I weighed 218 in 1969 and 148 this morning), has made me concentrate on the American epidemic of eating to excess as a major area of my interest.

The first article dealt with kids and adolescents. A group of CDC researchers reported an update on obesity in American kids, giving data from 199 to 2010. The newest statistics show nearly ten percent of our infants and toddlers are obese and close to 17% of our kids ages two to nineteen. As the kids got older, more boys than girls were obese in this survey with over 4,000 participants.

Then there was an article titled “Weight Loss Stratagies for Adolescents,” based on a Boston Children’s Hospital Conference roughly a year ago. The MD, PhD Harvard Professor of pediatrics who discussed the issue began with the case history of a particular obese girl, a fourteen-year-old who was five foot six and weighed nearly 250 pounds (giving her a body mass index,BMI, of 40). Her adoptive parents were overweight themselves, but had to learn to “back off” in their attempts to control her diet. There is some early data that suggests that parents can help by providing health food choices in the home and facilitating enjoyable physical activity throughout the day (versus a fixed “exercise time).

I had seen an example of that with some former neighbors whose boys, in order to have their one hour of “screen time,” had to be outside playing for several hours at a time. Both youngsters were lean.

One critical point to be made is avoiding focusing on obese kids only. A large Danish study, published in the New England Journal of Medicine in December, 2007,  followed over a quarter million children born in the 1930 to 1976 time period. Denmark established a national civil register of “vital statistics” in 1968 and enrolled everyone in the country, giving them a unique number, ironically termed their CPR number. Although that had nothing to do, I gather, with cardiopulmonary resuscitation, which is what I think CPR means, the study did look at risk factors for coronary heart disease.

When your heart's on fire, it may not be from love

The results are impressive and threatening: every one point increase in BMI across the spectrum was associated with an increased risk of coronary artery disease. A child didn’t have to be fat to be at risk later on. One calculation estimated that a 13-year-old boy weighing 25 pounds more than the average had a one-third increase in the likelihood of having a heart attack before the age of sixty.

It’s time to start helping our kids live leaner and longer, healthier lives.