Does Dairy Deserve Designation as Heart Healthy?

In 1977 an advertising campaign was launched featuring the first American commercials produced in the Soviet Union.  The ads depicted older individuals from Soviet Georgia, several of whom were over 100 years old, eating yogurt.  One scene showed an 89-year-old man eating yogurt. Beside him was his 114-year-old mother who was looking quite pleased with his dietary choice. The obvious implication is that yogurt was responsible for the spectacular longevity in these Georgians. The ads were quite memorable and very successful, launching a little known yogurt company to prominence and starting the yogurt consumption craze in the US.

Dairy products are a good source for essential vitamins (A and B12), minerals (such as calcium and potassium) and high quality protein. On the other hand, dairy products are a leading source of saturated fat, cholesterol and sodium, all of which are detrimental to heart health. The American Heart Association/American College of Cardiology, the DASH (Dietary Approach to Stop Hypertension) Diet and Mediterranean Diet all recommend avoiding full fat dairy products and substituting fat free or low fat sources of dairy. What is the recent data on milk, yogurt and cheese and heart disease?

The PURE study evaluated 136,000 people from 21 countries and five continents.  The study showed that those who consumed 2 or more dairy products (milk, yogurt and cheese) per day had a lower risk for dying and lower risk for cardiovascular death than those who did not eat dairy. Even in those who consumed only high fat dairy, there was a lower risk for dying, which seemingly contradicts all of the previous dietary recommendations. Another large analysis of several dairy trials confirmed these findings concluding that high fat milk did not increase heart disease or mortality.  So it seems that dairy fat may not increase the risk for heart disease and death.  The lesson from theses studies is the importance of evaluating dairy products not just on their fat content, but on their total nutritional value. 

What about yogurt, can it prevent heart disease? One study evaluated 1900 middle-aged men without heart disease and followed them for 20 years. The study found that consuming yogurt cut the risk for heart attack in these men.  It has also been shown that higher intake of yogurt decreases the risk for type 2 diabetes.  In choosing a yogurt, it is important to choose a sugar free or low sugar product as many yogurts have added sugar. 

Next up is cheese. Can eating a small amount of cheese every day benefit heart health?  A major study of 200,000 participants sought to answer this question. The enrollees were monitored for 10 years and most did not have heart disease. The study showed that eating around 1.4 ounces of cheese every day lowered the risk for heart disease, heart deaths and stroke.  However, not all cheeses are equal. For example, feta cheese is a low fat low calorie cheese favored in the Mediterranean diet. One ounce of feta is lower in fat (6 grams) and calories (74) than one ounce of cheddar or parmesan cheese (110 calories and 7 grams of fat).  Skim mozzarella is another low calorie cheese (72).  High calorie cheeses include gouda (101), swiss (111) provolone (98) and brie (95).  

One thing to keep in mind is that the research supplying all of this data is not the strongest.  Many of the studies are observational (they can observe an effect but not prove cause and effect) and many are sponsored by the dairy industry (so bias cannot be excluded). Despite this, a couple of things are clear. One is that eating a yogurt a day will not guarantee that you will live to one hundred. The other is that, in general, dairy is quite healthy. Dairy products provide significant nutritional value and may reduce the risk for cardiovascular disease and dying. It seems prudent to follow the guidelines of the Mediterranean diet and consume two servings of low fat dairy per day. This should come mostly from low fat or fat free milk, low fat yogurt and cheese. Low fat cheese should be limited to 3 servings per week, but choose your cheese carefully!

Can Jellyfish Ward off Dementia?

Hearing the word dementia has a devastating effect on those who have had a family member suffer with it. What is dementia and can it be prevented? Dementia isn’t a specific disease, but an umbrella term for a set of symptoms that affects memory, thinking, personality, and activities of daily living.  In addition, there is confusion, disorientation, and difficulty in finding words and problem solving.  Alzheimer’s disease is the most common cause of dementia, occurring in two thirds of all cases.  Vascular dementia is the second most common type, occurring as a result of damage to the blood supply to the brain. This damage may be from a stroke, diabetes or high blood pressure, putting heart patients at risk.  While dementia is not a normal part of aging, the older we get, the higher the risk for dementia.  Genetics play a big part; those with a family history of dementia are at higher risk. Other risk factors include, heavy alcohol use, smoking, high blood pressure, depression and diabetes. 

Mild cognitive impairment is an intermediate stage, where there are changes in thinking that exceed normal aging (benign forgetfulness), but not as severe as full-blown dementia (malignant forgetfulness).  One passes through the mild cognitive impairment stage on the way to dementia. 

Neither mild cognitive impairment nor dementia can be cured. There are many medications which help with the symptoms, but they don’t alter the course of the disease. Can dementia be prevented?  There are many over the counter products being sold that claim to prevent dementia. These include supplements, vitamins, ginkgo biloba, jellyfish proteins, green tea extract, St John’s wort and others. However, when rigorously tested, none of these compounds have been shown to slow the progression to dementia, despite their advertising claims. In February 2019, the Food and Drug Administration cracked down on the sale of unapproved products claiming to prevent, treat or cure Alzheimer’s disease sending warning letters to 17 companies selling these supplements.  Since this approach doesn’t work, what can prevent dementia? In 2017, a National Academy of Sciences panel reviewed all of the published prevention studies and suggested three interventions to slow cognitive decline: increased physical activity, blood pressure control and being mentally active. 

Controlling high blood pressure as a measure to prevent dementia is an appealing concept.  The brain seems to be very vulnerable to sustained high blood pressure. Hypertension changes the structure of the small blood vessels of the brain, leading to vascular dementia. In addition, hypertension is a well-known risk factor for stroke. Can lowering blood pressure reduce the stress on the blood vessels and delay the progression of dementia? This hypothesis was tested in two large trials. In the HOPE trial, lowering blood pressure did not delay cognitive decline. This trial only included patients older than 70 years old. The SPRINT trial enrolled 9000 hypertensive patients with an average age of 68 and followed them for 5 years.  The risk for dementia was not reduced by intense blood pressure lowering (a blood pressure goal less than120) compared to a blood pressure goal less than 140.  However, the intense treatment group had a lower risk for mild cognitive impairment.  Unfortunately neither trial was able to prove that lowering blood pressure prevented dementia, but there are signals that we may be on the right path.  Both trials may be limited as the patients were older and followed for only a few years. Perhaps patients have to be followed for many years to see an effect and perhaps blood pressure control should start at an earlier age (for example, starting medications when patients are in their 40’s). 

Thousands of studies have been conducted looking at exercise and brain function. In general, exercise is felt to be beneficial.  Exercise may be helpful in a variety of ways including lowering blood pressure and promoting neurogenesis (the generation of new brain cells).  A large recent study evaluated all of the clinical trials on exercise and brain function and concluded the following. Exercise significantly improved cognitive function in adults over 50 years old, even if mild cognitive impairment or dementia were already present. Since some patients may begin to show signs of dementia as early as 45 years old, it is never too early or too late to start exercising.  Aerobic exercise and resistance training were similarly effective. To achieve improvement in cognitive function, exercising for a minimum of 45 minutes at moderate to vigorous intensity, on as many days of the week as possible is recommended.

There is a lot we don’t know about preventing dementia. We do know that taking brain supplements and substances found in jellyfish do not work. Lowering blood pressure may be helpful but even if it isn’t, there is no downside. Controlling blood pressure is always beneficial for overall health and there is little risk. Similarly, exercise may or may not help prevent dementia but it is good for overall health and there are no side effects. So skip the supplements and walk away from dementia. 

A Spoonful of Medicine Helps the Sugar Go Down

Diabetes mellitus is one of the most common chronic conditions in the world and a significant risk factor for heart disease.  It is a major contributor to global morbidity and mortality. What is diabetes and how can it be controlled to reduce the burden of heart disease and cardiac death? Diabetes is a disease characterized by high blood sugar.  Type I diabetes starts at an early age and occurs because the body does not produce enough insulin (insulin is a hormone secreted by the pancreas and is responsible for regulating the sugar in the body). Type II diabetes occurs in adults, accounts for 90% of the cases of diabetes, and is the result of the body resisting the effects of insulin.  The prevalence of Type II diabetes keeps rising, paralleling the obesity epidemic. It has been estimated that 13% of all U.S. adults have diabetes.  Diabetes is diagnosed by a single blood draw, looking at two tests, glucose (blood sugar) and hemoglobin A1C (a three-month average of the blood sugar). Diabetes is present if hemoglobin A1C is greater than 6.5% or the fasting blood sugar is greater than 126 mg/dl or the nonfasting blood sugar is greater than 200 mg/dl.

Heart disease is the main cause of death among patients with diabetes. Diabetics have a twofold to fourfold increased risk for blockage in the heart arteries, a heart attack or cardiac death and a twofold to fivefold increased risk for congestive heart failure (fluid in the lungs). In addition, diabetic patients are at increased risk for stroke and blockage in the leg arteries.   Therefore the treatment goals for the diabetic patient include lowering the blood sugar, reducing the risk for complications of diabetes (for example kidney disease and blindness) and especially reducing the risk for heart disease.

Cardiovascular risk factor management in Type II diabetes starts with diet.  Patients are often referred to specialized dieticians to help with monitoring caloric intake and carbohydrate consumption. A Mediterranean-style diet can greatly reduce blood sugar.  The goal is to lower the hemoglobin A1C to < 7%. Overweight and obese patients are counseled about weight loss; even a modest reduction in weight of 3-5% can make a big difference.  For severely obese patients, weight loss surgery (for example, gastric sleeve) is often recommended. With significant weight loss, diabetic medications can be weaned down and in many cases stopped.  Diabetic patients with elevated blood pressure should be placed on medication, with a blood pressure goal between 120 and 140.  Diabetics whose LDL cholesterol is high should be prescribed a statin, with an LDL goal < 70 mg/dl. Achieving these aims is not easy.  In a large recent study of 73,000 diabetic patients, 73% met the hemoglobin A1C target, 69% met the blood pressure goal and 48% hit the LDL number. Unfortunately, however, only 21% met all three goals.

Recently, the medical management of the patient with Type II diabetes underwent a revolution.  There are twelve classes of medications (including insulin) and at least 36 individual drugs approved for the treatment of diabetes.  Picking the right drug or the right combination of drugs can be difficult. It is generally agreed that treatment start with metformin, which has been shown to lower hemoglobin A1C and reduce cardiac events.  Picking the right target for treatment is just as difficult. For the past 20 years, the medical therapy of diabetes focused on intensive control of blood sugar. However, this approach did not reduce cardiovascular events and may have increased them.  Then in 2008 the Food and Drug Administration mandated that any new diabetes drug must prove its cardiovascular safety before being approved for use.  This resulted in the discovery of new drugs which did just that; they were shown to lower the risk for major heart events and reduce cardiac deaths. This has led to a fundamental shift in diabetes management, away from lowering blood sugar and toward reducing cardiac risk.  In fact, for the first time ever, the American Diabetes Association and the American College of Cardiology have aligned their medication recommendations for treating Type II diabetes.  

The new agents fall into two classes of diabetes medications: sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor (GLP-1) agonists.  Both classes of agents substantially reduce the risk for heart attack, stroke and cardiac death. Both reduce blood pressure and promote weight loss. The best-studied SGLT2 inhibitor is empagliflozin (Jardiance), a once a day oral medication. The classic GLP-1 agonist is liraglutide (Victoza), a once weekly injection. It is felt that SGLT2 inhibitors are better for CHF patients while the GLP-1 agonists are better at reducing heart attack and stroke. 

The bottom line, according to both diabetes doctors and cardiologists, is that patients with Type II diabetes and established heart disease start treatment with lifestyle management (especially diet and weight loss).  If medication is needed, then metformin is the first line agent.  If a second line agent is necessary, then either an SGLT2 inhibitor or a GLP-1 agonist should be used, depending on patient characteristics.

Sleeping Tips to Avoid A Wake

We all could use a good night’s sleep. Sleep is an important part of the day but approximately one third of Americans do not get adequate sleep. Not getting a good night’s sleep is a health hazard and can lead to hypertension (high blood pressure), heart artery disease, atrial fibrillation (an irregular heart rhythm) and early death. What can be done to get a good night’s sleep?

First, we should understand a little about the physiology of sleep. The normal sleep cycle consists of four stages. There are three stages of non-REM (rapid eye movement) sleep, each lasting about five to fifteen minutes. Stage 3 of non-REM is the deep sleep stage where the body repairs itself. During this stage, the muscles, the tissues of the body and the brain are refreshed from the stresses of the day. In addition, bone and muscle are built and the immune system is strengthened. During the REM stage, the eyes move rapidly from side to side, the muscles are often paralyzed and the brain is more active than in stage 3. Dreaming occurs during REM sleep and a person can dream 4 to 6 times per night. 

There are a variety of sleep disorders; the most common are insomnia and sleep apnea. Insomnia is difficulty falling asleep and staying asleep. It may be due to psychological stress, excessive mental activity at bedtime, inconsistent bedtimes or caffeine or heavy alcohol intake in the evening. It may be treated through behavioral modifications (for example keeping a regular bedtime), exercise (at any time of the day), and avoiding stimulants in the evening.  Medications can be helpful, including sleeping pills and melatonin. Melatonin is a hormone produced by the pineal gland in the brain and it helps regulate the sleep-wake cycle.  It is also available as an over the counter medication used to shorten the time to sleep.  Nowadays, one of the biggest causes of insomnia is the use of light emitting electronic devices (laptop computers, tablets, cell phones and televisions) near bedtime.  It has been found that the light exposure from these devices affects the normal sleep cycle.  The light emitted suppresses the secretion of melatonin. This causes a later sleep time, increased alertness at bedtime, reduced REM sleep, and increased morning sleepiness.  This effect is especially pronounced in children and adolescents. For a better night of sleep try to avoid using these devices for at least one hour prior to bedtime. 

Sleep apnea is a condition characterized by periods of decreased breathing while sleeping (apnea means absence of breathing). Obstructive sleep apnea occurs when the upper airway collapses, air movement into the lungs ceases causing the oxygen level in the body to fall. This prompts the person to wake up and take deep breaths.  These periods of apnea disrupt the sleep cycle and prevent the person from getting enough time in the deep sleep, restorative stages of sleep.  Because the body does not get enough rest, the person feels “revved up” all the time.  Sleep apnea is often seen in obese patients and is quite common occurring in 34% of men and 17% of women.  It is associated with loud snoring, excessive daytime sleepiness, morning headaches and irritability.  Sleep apnea is also associated with significant heart problems including hypertension (especially hypertension that is difficult to treat), stroke, heart failure, blockage in the heart arteries and atrial fibrillation. It is diagnosed by a sleep study, which counts and measures the periods of apnea and low oxygen. Treatment of sleep apnea primarily involves weight loss and CPAP (continuous positive airway pressure- a mask that keeps the airway open).  Treatment with CPAP is especially useful in lowering blood pressure and preventing recurrent episodes of atrial fibrillation and congestive heart failure.  

Just as important as sleep is the process of waking up. Being jolted from a deep sleep by an alarm clock is as bad as not getting enough sleep. When one is woken suddenly and too early, there is a prolonged period between the eyes opening and being fully awake. This phenomenon is called sleep inertia, a groggy sensation somewhat like jet lag.  We feel this because we are awake, but our bodies want to keep sleeping. This is because the brain’s arousal system is activated almost immediately but the higher centers of the brain take longer to awaken. If woken abruptly, as with an alarm clock, the sleep inertia is more severe.  Sleep inertia can take anywhere from two to four hours to resolve.  Waking up naturally, by our own internal clock, is much better for us. The mismatch between our biologically optimal wake up time and the alarm clock time takes a toll on our system, leading to obesity, diabetes and heart disease.  On the other hand, in cultures known for their longevity, there are a higher percentage of people who wake naturally. 

This leads to the question, how much sleep is enough sleep? What is the optimal amount of sleep needed for a long and healthy life?  In one study examining patients between 40 and 54 years old and who were free of heart disease, those sleeping less than 6 hours or more than 8 hours per night had higher risk of plaque in the heart arteries than those sleeping 7 to 8 hours. In another study of patients over 60 years old, those who slept less than 6 hours had a 12% increased risk for death and those who slept more than 9 hours had a 30% increased risk of death.  In this population as well, 7 to 8 hours was the optimal amount of sleep time. However, very different results could be found if younger populations are studied.

So start altering those bad nighttime habits and start getting a good night’s sleep.

The Key to The Heart: Be Nice to Your Spouse

What are the best ways to avoid heart disease and live a long, healthy life?  The answer starts with the four basic characteristics of a healthy lifestyle: get adequate exercise, maintain a healthy weight, avoid smoking and eat a prudent diet.  Essentially following these four pillars is an individual choice: whether to exercise and how much to exercise, whether to avoid smoking and keep the pounds off and what one eats is largely up to each individual. What can be done beyond the individual? Does marital status affect the heart? Does belonging to a larger community and socializing help prevent heart disease?

It turns out that being married is good for the heart. In patients who have heart disease, being married was better than not being married.  In studies it was found that unmarried participants (including divorced, separated, widowed and never-married) had a 52% higher rate of heart attack and death compared to married participants.  Married patients who had open-heart surgery or stent placement were much more likely to be alive and free from heart events than unmarried patients.  Divorce has the highest rates of heart events and cardiac death, presumably due to the stress it invokes. Fortunately, remarriage decreases some of that risk.  The risk for unmarried patients is the same for both men and women but younger patients (aged < 65 years old) had a higher risk than older patients.  Does the same relationship hold true in the general population (in people who don’t already have heart disease)? In this population as well, unmarried participants had higher rates of heart disease, stroke and death. Why is being married so protective? There are many potential reasons. Having a spouse may mean that warning symptoms are detected and acted upon sooner. Unmarried patients typically had longer delays in seeking treatment. Spouses can encourage sticking to a healthy lifestyle including eating better, having someone to walk or exercise with and providing support when quitting smoking. In addition, spouses can encourage adherence to treatment including taking medications as prescribed. Lastly, the loss of a spouse (either due to death or divorce) has detrimental physical and emotional consequences.  Stress can worsen blood pressure, raise cholesterol, worsen diabetes and accelerate the progression of blockage in the heart arteries.  Stress affects emotional well being resulting in a decreased ability to prevent, detect or treat illness.

The research noted above looked at married versus unmarried people, but it can be generalized to living with someone versus living alone. Can this be broadened further to mean that social isolation is bad for the heart? Is it better to be part of a larger community?  Studies have shown that those with few social contacts (or who are socially isolated) have about 30% higher risk for heart disease and stroke.  In addition, those with poor social connections had a 50% higher risk for death than those with better social integration. This makes the effect of social isolation as detrimental as a sedentary lifestyle or being obese.  Depth and quality of the social connections matter as well.  Having one friend beats being alone, but having a larger network is better and having true friends (as opposed to acquaintances) who can provide emotional support is better still.  Social networks can help when someone is ill, for example by helping to prepare meals or drive to a doctor’s appointment. A connected, supportive network is an antidote to the stress of daily life by providing emotional support and lowering the release of stress hormones. People who are socially isolated tend to engage in negative health behaviors such as smoking, drinking excess alcohol and not exercising or eating correctly. Social isolation also can affect the body by increasing inflammation, decreasing immune function and increasing blood pressure. Lastly, there is no down side to developing a strong social network.  

As the New Year dawns and resolutions are made to follow a healthy lifestyle, don’t forget to include a promise to be part of a healthy community as well. This can be done by joining a walking group, being part of a religious organization or playing on a sports team.  For heart patients, the individual and the community are nicely tied together in the Ornish Lifestyle Medicine Program, which has been shown to reverse the progression of heart disease. The program entails a cohort of ten people who exercise together, eat a heart healthy diet together, and learn how to reduce stress. These patients have similar heart problems so there is a strong component of socialization and social support in the group. Similarly, in cultures known for their longevity, food, exercise and socializing are tied together.  Entire towns are out walking before or after the evening meal. Both the walking and the meal are shared with others in the community. So, grab your spouse or a friend, go for a walk, meet others for dinner, catch a show or a movie and have a wonderful date night. 

How the Cardiologist Stole Holiday Treats

The holidays bring visions of sugar plum fairies dancing and tables filled with fruitcake, sugar cookies, gingerbread, red velvet cake, macaroons and chocolate yule log. These delectable holiday treats are as much a staple of the holidays as family gatherings and celebrations. Unfortunately, these sugary delights are not quite part of a heart healthy diet and can wreak havoc with cholesterol levels.  As we head into the peak holiday and treat-eating season, it’s a good time to review what is new in cholesterol management.

Who should be treated with a statin for high cholesterol in 2019? In 2013, the American Heart Association and the American College of Cardiology published a guideline to address this topic.  This guideline was just updated in November 2018, adding more nuance to the original. The guideline focuses primarily on LDL cholesterol (low density lipoprotein, “the bad cholesterol”). In general, there are four categories of patients for whom a statin should be prescribed: 

1) secondary prevention (trying to prevent a second event in patients who have already had a heart attack or stroke), 

2) diabetic patients (a high risk group) whose LDL is greater than 70 mg/dl, 

3) patients with an LDL greater than 190 mg/dl (severe familial high cholesterol).  For these three groups, especially secondary prevention, the medical literature is quite consistent in showing the benefit of statin therapy. The data for statins is less robust in the fourth group, primary prevention (trying to prevent a heart attack or stroke in a patient who has not had an event).  The 2013 guideline used a risk calculator (which can be found at: cvriskcalculator.com) to identify high-risk patients for primary prevention.  This was a controversial issue at the time and many cardiologists felt that the calculator overestimated the risk, thus exposing more people to statin therapy.  The updated guideline attempts to clarify who should be on a statin by adding risk enhancers and using coronary calcium score. If the calculator places the patient at high risk for a cardiac event over the next ten years with a score of 20% or greater, then a statin should be given.  If the patient is at low risk (a score of 5% or less), then no statin is necessary.  If the patient is at intermediate risk (a score between 5% and 20%), then risk enhancers are used.  These risk enhancers are: 

LDL > 160 mg/dl,

high-sensitivity C reactive protein level (a measure of inflammation) > 2.0 mg/L, 

triglycerides > 175 mg/dl, 

apoliprotein B level > 130 mg/dl, 

lipoprotein (a) level > 50 mg/dl, 

peripheral arterial disease, 

chronic kidney disease, 

chronic inflammatory disease (rheumatoid arthritis, psoriasis, or lupus), 

metabolic syndrome (hypertension, diabetes, high triglycerides, obesity- especially a large waist circumference), 

family history of premature heart disease, or 

premature menopause. 

With an intermediate risk score and the presence of one or more risk enhancers, a statin should be prescribed. If the patient and the doctor still are uncertain about starting a statin, then a coronary calcium score can be used. A CT scan of the heart measures the calcium score. Calcium is found in plaque in the heart arteries. The higher the amount of calcium, the more plaque is present in the heart arteries. A coronary calcium score of zero means there is no plaque and a statin can be withheld.  However, if the calcium score is 100 or more, then a statin is indicated. 

What about the other test on the standard lipid panel, triglycerides?  It is well known that patients who have heart disease and good LDL levels on statin but have elevated triglycerides are still at risk for cardiac events. It is thought that reducing triglycerides can provide an additional benefit beyond lowering the LDL. Unfortunately, this hypothesis has never been proven, until recently.  Medications that reduce triglycerides such as niacin or fenofibrate, taken with a statin, did not show a reduction in cardiac events. Omega-3 fatty acids (fish oil) are present in fatty fish and in populations with high fish intake, there is a lower risk for heart disease.  Formulations of omega-3 fatty acids contain either eicosapentaenoic aicd (EPA) alone or a combination of EPA with docosahexaenoic acid (DHA). These medications are prescribed to treat elevated triglycerides but neither the combination nor low dose EPA have been shown to reduce the risk for heart disease. More recently, a high dose, pure form of EPA was tested in patients with heart disease, statin controlled LDL levels and high triglycerides.  For the first time, the pure form EPA was shown to reduce the risk for heart attack, stroke and cardiac death by 25%.  The triglycerides were lower in patients on the medication, but it is thought that other mechanisms, such as an anti-inflammatory effect of the EPA, may also have contributed.  The results of this trial have changed the way cardiologists view and treat triglycerides in their patients with heart artery disease. Is fish oil beneficial for the primary prevention of heart disease? Two recent trials tested patients without heart disease by using a combination of EPA and DHA. Neither showed a reduction in heart attack, stroke or cardiac death. Therefore, low doses of fish oil are not beneficial for primary prevention but prescription high dose EPA is now being used for secondary prevention of heart disease. 

So, enjoy the holidays with friends and family. Have a holiday treat or two. If you want some heart healthy choices (including treats), try the recipes at heart.kumu.org. Then in the New Year, tackle those high cholesterol and triglyceride numbers.

The Gray Lady of the Medicine Cabinet

Aspirin is the gray lady of the medicine cabinet.  Aspirin, the medication that has been in use for over one hundred years, is tried, true and reliable. Aspirin has been prescribed for a variety of ailments including fever, aches and pains. Aspirin is the standard of care in the treatment of heart disease and stroke. Judging by its longevity and the extent of its use, it would seem that we know all there is to know about aspirin. That assumption would be wrong.

Aspirin’s anti-inflammatory and blood thinning properties are ideally suited for treating an acute heart attack or stroke. Aspirin is usually the first medication given in the ambulance to a patient who is having a heart attack. In addition, there is data going back decades showing that aspirin can prevent a second heart attack or stroke in patients who have already had an event. This is called secondary prevention and aspirin’s role is not controversial and well established.  What about primary prevention, trying to prevent a heart attack or stroke in a patient who has not had an event? Here aspirin’s role is much murkier and the data not as solid. A few primary prevention trials of aspirin were done many years ago and showed a small cardiovascular benefit for aspirin, even though the risk for bleeding increases with aspirin use. In 2016 the US Preventive Services Task Force recommended a low dose (81 mg) aspirin for adults aged 50 to 59 years old, who are at high risk for cardiovascular disease. What about patients who are 70 years of age or older, a population known to be at higher risk for cardiac events? Should an aspirin a day be prescribed?

Several large, well done primary prevention trials have recently been published and have added clarity. In a trial of 15,000 patients with diabetes (average age of 63), aspirin lowered the rate of cardiovascular events but increased the risk for major bleeding. There was no reduction in the death rate.  The next trial included 12,000 nondiabetic patients with the men over age 55 and the women over the age of 60.  These were patients felt to be at low risk for cardiovascular disease. Again, aspirin did not reduce mortality. There was no cardiovascular benefit for taking aspirin and the risk of bleeding was twice as high. The last trial included 17,000 patients all older than 70 years old and without cardiovascular disease. Once again, aspirin gave no benefit with respect to death, cardiovascular events, dementia or physical disability.  The risk for bleeding on aspirin was higher.  Overall these trials were consistent in showing that aspirin provided minimal benefit and significant bleeding risks. On the scale of benefit versus risk, the risk of aspirin outweighed any benefit in primary prevention.  What changed compared to previous primary prevention trials? The difference seems to be that the prevention of heart disease is much better now than in the past. Smoking is less common and the treatment of high blood pressure, high cholesterol and diabetes is better and more aggressive.

What is the correct dosage of aspirin? Even after all of these years, we still do not know for certain. Guidelines recommend a full dose (325 mg) of aspirin for at least one month after a heart attack, a cardiac stent, bypass surgery or a stroke. Then the recommendation is to lower the dose to 81 mg, with the idea that the lower dose confers the same benefit as the higher dose, but with less risk for bleeding. Now a new study questions the efficacy of 81 mg of aspirin.  It was found that low doses of aspirin, such as the 81 mg dose, were only effective in protecting against cardiovascular effects in patients weighing less than 150 pounds and had no benefit for those weighing more than 150 pounds.  This issue certainly will require further study.

All of these studies were reported in the news accompanied by headlines such as, “Aspirin Flops Big Time in Heart Study. Is it R.I.P for Aspirin?” This caused a lot of confusion among patients as to whether they should be on aspirin. To clarify, if you are having a heart attack or stroke, take an aspirin and call for help. If you have a history of heart attack, cardiac stent, bypass surgery, stroke, significant plaque in the neck (carotid) arteries, aorta or leg arteries, congestive heart failure or atrial fibrillation then the benefits of aspirin outweigh the bleeding risks.  If you do not have any of these conditions, then you should not take aspirin for primary prevention of cardiovascular disease. Instead, you should refrain from smoking, exercise regularly and take a statin and/or blood pressure medication as indicated.  Of course if there are any questions, talk over the risks and benefits of aspirin with your doctor.