Should you take asprin to prevent heart attack

Well should you
Thiw will downlaod a pdf file

Statins again.

Talk given by Uffe Ravnskov in Sidney August 2006


Malcolm Kendrick. Short but interesting. WHO data

Aborigines have the highest rate of cardiovascular disease (CVD) - lowest cholesterol
Swiss have highest cholesterol and lowest CVD.

Evidence for Caution: Women and statin use A meticulous 36-pages report about the senseless and dangerous use of statins in women.

Are Statins Overused?, by Malcolm Kendrick

The above all come from here

Here is Ellison's E Book The hidden truth about cholesterol

According to Ellison, studies have consistently linked high cholesterol to lower mortality. For example:

Low cholesterol is associated with heart arrhythmia.

The European Heart Journal published a 3-year study of 11,500 patients finding those with low cholesterol to have a risk of all-cause death 2.27 times higher than those with high cholesterol.

The Journal of Cardiac Failure published an analysis of 1134 patients with heart disease and found low cholesterol to be associated with the worst outcomes in heart failure patients and impaired survival, while high cholesterol improved survival rates.

The American Geriatrics Society reported in 2003 that, in patients over the age of 65, even cholesterol levels up to 417 mg/dL were associated with lower mortality compared to levels under 189 mg/dL.

Read this book - Overdosed America

It's a very eloquent read re the depressing direction modern medicine is going in - it's written by an ex academic family doctor. In particular if you want a clear picture of the cholesterol saga, it's in this book.

Betablockers post MI - NICE guidelines

• early after an acute MI, all patients without left ventricular systolic dysfunction or with left ventricular systolic dysfunction (symptomatic or asymptomatic) should be offered treatment with a beta-blocker
• for patients after an MI with left ventricular systolic dysfunction, who are being offered treatment with a beta-blocker, clinicians may prefer to consider treatment with a beta-blocker licensed for use in heart failure
• beta-blockers should be continued indefinitely after an acute MI
• after a proven MI in the past, all patients with left ventricular systolic dysfunction should be offered treatment with a beta-blocker whether or not they have symptoms, and those with heart failure plus left ventricular systolic dysfunction should be managed in line with 'Chronic heart failure' guidance
• after a proven MI in the past, patients with preserved left ventricular function who are asymptomatic should not be routinely offered treatment with a beta-blocker, unless they are identified to be at increased risk of further cardiovascular events, or there are other compelling indications for beta-blocker treatment
• beta-blockers should be initiated as soon as possible when the patient is clinically stable and titrated upwards to the maximum tolerated dose.

Fitness

CONCLUSIONS: Low fitness is an important precursor of mortality. The protective effect of fitness held for smokers and nonsmokers, those with and without elevated cholesterol levels or elevated blood pressure, and unhealthy and healthy persons. Moderate fitness seems to protect against the influence of these other predictors on mortality. Physicians should encourage sedentary patients to become physically active and thereby reduce the risk of premature mortality. (Zillions of references here to do with fitness)

Dieting - increases your CVD risk - bloody hell.

Dr. Reubin Andres of the National Institute on Aging admitted that weight loss can improve blood sugar levels, blood pressure and cholesterol in the short term. “The only problem is that when you look at mortality rates,” he said, “they don’t look good. Fat people who are subject to weight loss have a higher mortality rate than those who remain fat.”

Statistics are like a girls bikini - they show a lot but hide the vital parts. Truth is an illusive ideal. Sloganeering the easy option!

Where is the epidemic?

The emperor's new crisis!

In fact, Blair and colleagues are renowned for decades of research showing weight is not a significant predictor of mortality, it's fitness........

Sticky platelets

Antiplatelet Chemoprevention of Occlusive Vascular Events and Death

Conclusions

SECONDARY PREVENTION:

1. ASA, 80 -325 mg/day, is proven effective for the prevention of vascular occlusive events for patients with established disease. There is little evidence of benefit beyond a maximum dose of ASA of 325 mg/day.

2. Other antiplatelet drugs should be used for patients allergic to or intolerant of ASA.

3. Patient characteristics, benefits, harm and cost should be considered when selecting an agent other than ASA.

4. Combination of ASA with other antiplatelet agents requires further study.

PRIMARY PREVENTION:

Benefit of platelet prevention has not been shown to exceed harm in patients without proven vascular occlusive disease.

Stable angina - surgery or pills

Stents and things

Early Invasive Therapy or Conservative Management for Unstable Angina or NSTEMI?

The authors conclude that an early invasive strategy is preferable to a conservative management strategy in the treatment of patients with UA or NSTEMI; however, the absolute difference between strategies in long-term mortality was not large. Forty-three people would need to be treated with an early invasive strategy to prevent one death at two to five years (i.e., number needed to treat [NNT] = 43), and a comparable number of patients will experience bleeding or procedure-related myocardial infarction (number needed to harm [NNH] = 36 and 35, respectively). However, there was a clear benefit with early invasive treatment in preventing rehospitalization during the first year (NNT = 10).

Hypertension - aspirin

Since the magnitude of benefit from the reduction in cardiovascular events was similar to the magnitude of harm of an increased risk of haemorrhagic events, the Cochrane review concluded that antiplatelet therapy with aspirin cannot be recommended in uncomplicated hypertension as primary prevention per se due to the narrow balance between benefit and harm.

QT prolongation - drugs

Drugs that Prolong the QT Interval and/or Induce Torsades de Pointes Ventricular Arrhythmia

Black box warning antidepressants

Depression is the real killer, not antidepressants, say commentators

How effective are they anyway


counter argument

hypertension

Mild Hypertension - An approach to using evidence in the decision making process

The key pooled outcomes from these 5 trials reveal the following: Would you take the pill?
1. Total mortality, RR 0.95 [0.71 - 1.11] - no real difference between taking or not aking.
2. Total serious adverse events were not reported in any of the trials.
3. Total cardiovascular events (fatal and non-fatal strokes plus fatal and non-fatal coronary heart disease) were reduced from 4.0% to 3.2%, RR 0.81 [0.71 - 0.92], ARR 0.8%,
Number Needed to Treat is 125 people for 5 years for one person to benefit.
4. Withdrawals due to adverse events, RR 4.8 [4.2 - 5.6], ARI 9%, NNH 11 for 5 years.

You now feel you are in a position to explain the benefits and harms to your patient.

Treatment of Hypertension

Aiming for a target diastolic BP of lower than 90 mm Hg provides no therapeutic advantage for most hypertensive patients.

The two groups with lower bp might be expected to have fewer cardiovascular events but this was not seen

ALLHAT STUDY

• Total mortality, coronary heart disease and end-stage renal disease are similar for first-line thiazides (diuretic), CCBs (Calcium channel blockers) and ACEIs (Angiotensin-Converting Enzyme).

• Heart failure is increased with first-line CCBs as compared to thiazides or ACEIs.

• Stroke is reduced with first-line thiazides as compared to ACEIs.

• BP control and tolerability are better with first-line thiazides as compared to ACEIs.

• Cost is substantially less for thiazides as compared to beta-blockers, ACEIs, CCBs, alpha blockers, and angiotensin receptor blockers.

Drugs of Choice in the Treatment of Hypertension

After review of the long term hypertension studies, including the epidemiologic and randomized placebo controlled drug trials, certain clinically important facts stand out:

• Risk of cardiovascular events correlates better with systolic than diastolic blood pressure.(1)

• Risk correlates better with blood pressures taken outside the doctor's office than with office blood pressures.(2)

• Blood pressure consistently decreases with placebo treatment (10/8 mm Hg).(3)

• The average additional blood pressure fall in the active treatment group is modest (11/6 mm Hg).(3), (4)

• The average blood pressure fall with treatment in trials using low doses of just one drug (7-9.5/46.5mm Hg) (5), (6) is similar to that obtained from an overview of trials using high doses of multiple drugs (11/6 mm Hg).(3), (4)

These facts suggest the following ways to assist in managing your patients with hypertension:

• Put more emphasis on systolic and home blood pressures when making treatment decisions.

• Appreciate that some of the blood pressure lowering effect seen in the office is due to the placebo effect. In other words, no matter what you are prescribing, it is likely to appear efficacious.

• Realize that pushing the dose seldom improves the antihypertensive effect. Likewise, the dose can frequently be lowered in patients receiving high doses of antihypertensive drugs without changing the antihypertensive effect.

Can blood pressure be lowered by a change in diet? Evidence from the DASH trials

Substantial BP lowering can be achieved by a reduced dietary sodium intake, the DASH diet, or a combination of the two. This approach is applicable to those patients consuming an average North American diet who are motivated to make a change.

Atenolol

If you on this maybe you'd be better off on something else

Hypertension

1995 drugs for BP part one Part two

These two parts emphasized choosing antihypertensive drugs primarily based on the results of randomized controlled trials measuring morbidity and mortality. The evidence at the present time demonstrates that low dose thiazides are effective in reducing the incidence of myocardial infarction, stroke, and overall mortality in patients with mild to severe hypertension. The amount of evidence in favor of beta blockers is less and we have little data on what dose is optimal or whether cardioselectivity and partial agonist activity are beneficial. There are no randomized controlled trials in hypertension measuring morbidity and mortality associated with ACE inhibitors and calcium channel blockers.The case control study which we referred to in Letter 8 has now been published.(6) This study shows that for the treatment of hypertension calcium channel blockers (verapamil, diltiazem, and nifedipine) are each associated with a 60% increased risk of myocardial infarction (MI) compared with thiazides and beta blockers. When the dose response relationship was evaluated, higher doses of calcium channel blockers increased the risk of MI compared with beta blockers where higher doses decreased the risk. Another interesting observation from this study is that ACE inhibitors alone were associated with an MI risk similar to diuretics and beta blockers.

Diet and hypertension

Asprin and hypertension

Which class was best at reducing mortality and morbidity? 2003

The combined major outcomes from these 2 trials plus all other RCTs comparing first-line thiazides to CCBs^4-7 are shown in the Table. Total mortality, coronary heart disease and end-stage renal disease were not different for the different classes. The most convincing morbidity difference was that CCBs increased the incidence of heart failure (events leading to death or hospitalization) over 5 years as compared to thiazides (ARI 1.7%, NNH = 61) or ACEIs (ARI 1.2%, NNH = 83). In addition, thiazides reduced the incidence of stroke as compared to ACEIs (ARR 0.5%, NNT = 200). Contrary to common opinion, in ALLHAT the thiazide was similar to the ACEI and CCB in preventing end-stage renal disease, and in a large subgroup of patients with diabetes (12,063) none of the pre-specified subgroup outcomes favored the ACEI or CCB as compared to the thiazide.¹

Low dose asprin

Clinical implications: The indications for low dose ASA (e.g. 80 mg.) to prevent cardiovascular events are the same for patients with normal and elevated blood pressure; low dose ASA is recommended in patients with proven cardiovascular disease (secondary prevention), but not in those without cardiovascular disease (primary prevention).⁷

Pulmonary embolus - tricky diagnosis

Massive PE with no obvious cause after extensive testing - see if you can guess the diagnosis before getting to the end of this story.

Drug-Eluting Stents in the News

You're going to be hearing a lot about drug-eluting stents over the next week in the run-up to the Food and Drug Administration's advisory committee hearing weighing evidence about their safety. Here's a Reuthers report on the latest study from the Cleveland Clinic suggesting these tiny devices inserted in heart arteries to maintain adequate blood flow actually increase the risk of severe clots leading to heart attacks and strokes.

Heart Operations all they are cracked up to be?

The two studies also indicate that an outmoded understanding of heart disease still dominates the way it is treated. According to the so-called new view of heart disease, a major constriction in the coronary artery is not where a future heart attack will occur. “There’s lots of data to show that opening a narrowed artery will not reduce your chances of having a heart attack,” said Dr. Waters, citing the one exception. “If, however, a person is having a heart attack, and that person has an artery-opening procedure while having the heart attack, there is good evidence that this will reduce the risk of dying of that heart attack.” In other words, the procedure will have no effect on future heart attacks.

High cholesterol GOOD!!!!

The Benefits of High Cholesterol

A study of elderly French women living in a nursing home showed that those with the highest cholesterol levels lived the longest (The Lancet, 4/22/89). The death rate was more than five times higher for women with very low cholesterol. Several other studies have shown similar results. Ironically, Dr. Ravnskov noted that in his practice it was usually the elderly women who were most worried about their cholesterol levels.

Cholesterol and risk of stroke

Yet data from Japan directly contradicts Ebrahim et al's conclusions. From 1958 to 1995 fat consumption increased from 5% to 20% of the total daily energy consumption, and cholesterol concentrations rose from 3.9 mmol/l to 5.0 mmol/l.² During this period the rate of stroke (combined) fell from 1344/100 000/year to 205/100 000/year in those aged 60-69. This is a 6.5-fold reduction in the rate of stroke.³ (There was also a decrease in death rate from coronary heart disease.)

Cholesterol

HOW WE CAME TO BELIEVE THAT THE LOW-FAT DIET IS GOOD AND CHOLESTEROL IS BAD

By Maryann Napoli
(February 2003)

Despite decades of effort and many thousands of people randomized [into clinical trials], there is still only limited and inconclusive evidence of the effects of modification of total, saturated, monounsaturated, or polyunsaturated fats on cardiovascular morbidity and mortality.

British Medical Journal, March 31, 2001