Asprin and Heart Disease

“Approximately 25 percent of the reduction in the rate of death from coronary artery disease that has occurred during the past 30 years may be explained by the practice of primary prevention,” says Dr. Michael Lauer, of Cleveland Clinic Foundation, in an article in the New England Journal of Medicine (NEJM).

What is primary prevention?

Primary prevention involves a deliberate treatment of a person with established risk factors for heart disease although the person has no clinical symptoms or other evidence of heart disease. The purpose is to prevent cardiac events like heart attack.

What are the risk factors for heart disease which can be target of primary prevention?

There are several of them: high blood pressure, smoking, high cholesterol level, sedentary (much sitting and little exercise) life style, platelet activity (a type of blood cell which can stick together and block coronary arteries) and inflammation.

Family history of heart disease is a risk factor as well but there is not much you can do to change that!

What is the role of aspirin in primary prevention?

Aspirin has both anti-platelet and anti-inflammatory effects. In 1970s, studies suggested regular aspirin use could reduce the risk of heart attack and death from coronary artery disease, says the NEJM article. More recent studies have confirmed this although many aspects of aspirin use are uncertain.

The article’s conclusions are:

-Aspirin use probably reduces the risk of heart attack in men over the age 50 years. It is unclear whether women have the same sort of benefit as men.
-The decision to initiate aspirin therapy should be based on assessment of absolute risk of a heart attack.
-For prevention of heart attack, low doses of aspirin (100 mg per day or less) are adequate. For prevention of stroke, low-dose aspirin is just as effective as high-dose therapy.
-Observational studies have suggested that aspirin may prevent cancer of the colon, esophagus, stomach, and rectum. But this has not been confirmed.
-Aspirin use can cause bleeding. Most common site of major bleeding (bleeding leading to death, transfusion, or surgery) was the gastrointestinal tract. It can cause minor bleeding like nose bleeds and bruising as well.

Aspirin is also called Acetylsalicylic Acid, derivative of salicylic acid that is a mild, non-narcotic pain killer useful in the relief of headache and muscle and joint aches. Aspirin is also effective in reducing fever, inflammation, and swelling and thus has been used for treatment of rheumatoid arthritis, rheumatic fever, and mild infection.

German chemical and pharmaceutical company founded in 1863 by a chemical salesman, Friedrich Bayer (1825-80), and now operating plants in Germany and more than 30 other countries was the first developer and marketer of aspirin (1899), says Encyclopædia Britannica

Aspirin has been with us for over hundred years. It is cheap and universally available. It has many health benefits. But it is not completely safe. So, before you start taking aspirin, talk to your doctor. See if it is safe for you. And don’t forget other risk factors which require your attention. Help your doctor keep you healthy!

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Irregular Heart Rhythm

What is atrial fibrillation? Why does one get it? How can it be prevented?

Atrial fibrillation is a condition in which the heart rhythm is irregular. Normally, the heart beats on an average 72 times a minute and has a very regular rhythm.

Each heartbeat normally starts in the upper right chamber of the heart from where an electric impulse travels to the lower chambers to complete the heartbeat. When there is disturbance in the initiation and/or transmission of the electrical impulse, the heartbeat goes haywire and irregular. This is called arrhythmia.

There are many types of arrhythmias affecting the upper and lower chambers of the heart. Atrial fibrillation is one of the common ones requiring treatment. It affects five percent of people older than 65 years. It accounts for up to 36 percent of all strokes in elderly people. The symptoms of atrial fibrillation are palpitation, shortness of breath, and fatigue.

Atrial fibrillation can be paroxysmal (episodic) or persistent. Some times the paroxysmal form occurs in healthy persons for no reason. It can also occur in individuals who develop acute infections, or in patients who have rheumatic heart disease, heart attack or have some other medical conditions.

Usually, paroxysmal attacks occur few times before permanent atrial fibrillation gets established. The episodic attacks may last from few seconds to few days. The onset and offset of atrial fibrillation can sometimes be quite abrupt. Permanent atrial fibrillation is almost always (with few exceptions) associated with some heart problem or other medical conditions like overactive thyroid gland.

The human heart beats 100,000 times each day. About 2000 gallons of blood is pumped out of the heart each day into the blood vessels. Irregular rhythm can impair this function. As a result, a person can go into heart failure, get a heart attack or stroke.

The most effective way to minimise the increased risk of stroke is to return the heart rhythm to sinus (regular) by electrical or chemical (medications) cardioversion. Cardioversion is a process by which the heart is returned to sinus rhythm. Cardioversion is safe, says an editorial in the British Medical Journal, with an estimated risk of stroke of less than one percent even among those at highest risk. If the atrial fibrillation has been present for more than 48 hours then the patient should receive blood thinners before and after the cardioversion to minimise the risk of stroke.

The editorial says that large series have shown initial success rates for cardioversion of around 75 to 91 percent of patients of all ages. It says that restoration and maintenance of sinus rhythm after successful cardioversion maybe enhanced by the use of medications, though optimal drug therapy has yet to be determined.

If it is difficult to sustain sinus rhythm, then the patient should receive blood thinners (like warfarin) on regular basis to reduce the risk of stroke by 70 percent. The editorial says that many physicians are reluctant to use blood thinners in the elderly due to associated risk of internal bleeding and prefer to keep them on aspirin. Aspirin does not do the job.

The editorial concludes by saying: In practice, even though the ideal may be unachievable, many elderly patents with atrial fibrillation remain suboptimally treated.

If you have irregular heart rhythm then get yourself checked out. If you think your condition is suboptimally treated then get a second opinion. It may save your life!

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Heart Disease

Recent newspaper headline says that heart and blood vessel disease kills more women than breast cancer. Are you surprised? Well, you shouldn’t be!

We know that heart and blood vessel (cardio-vascular) disease is a number one killer of all adults, irrespective of gender. Over the years, and from time to time, our doctors and our media, remind us about the known risk factors associated with cardio-vascular disease. But how many of us have the ability to remember and recall these risk factors?

Now, if you are one of those Canadians who can remember and recite these risk factors before each meal then you run the risk of being left alone to eat your own breakfast, lunch and dinner. You will be a social outcast!

And if you are a physician, sitting with non-physicians who enjoy extra salt, a blood soaked 20-oz steak cooked in butter, and double size cheesecake with extra whipping cream then you better keep your mouth shut! And you better keep your mouth shut, if you are a non-physician sitting with physicians who smoke and eat just like “normal” human beings!

In any case, how can we change our eating habits if we are to stay healthy? Is it by keeping our mouth shut or by being a social outcast? Before you start your meal, would rather say “grace” or recite the innumerable commandments of healthy eating?

While you are struggling to make up your mind, lets look at recent articles in Canadian Medical Association Journal that say that in order for a person to change his behaviour, he has to rely on his knowledge or have access to information to make sound judgement on what is good for his health. They also believe that monitoring the population’s knowledge of risk factors can help guide public health programs.

Here is a test for you! In the next 60 seconds, name the six risk factors for cardiovascular disease. Now compare yourself with how 23,000 Canadians aged 17 to 74 did in a survey conducted by Canadian Heart Health Research Group between 1986 and 1992.

Overall, the percentage of Canadians who identified the six important risk factors for cardio-vascular disease is: fat in food (60 percent), smoking (52 percent), lack of exercise (41 percent), excess weight (32 percent), elevated cholesterol (27 percent), and high blood pressure (22 percent). So, how did you do? Never mind, must be that mental block!

The researchers found that the behaviour related risk factors – fat consumption, smoking and exercise – were mentioned more often than physiologic ones – high blood pressure and raised cholesterol level. They also found that all segments of the Canadian population are missing some information about the different cardio-vascular risk factors.

Their findings suggest that health promotion campaigns should consider individual differences and include distinct messages for subgroups of the population, at least those defined by age and education level. And not to forget the disadvantaged segments of our population.

Now, can you recall the six important risk factors for cardio-vascular disease?

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Chest Pain

You are relaxing or doing some activity at home. Suddenly, you experience chest pain and shortness of breath. What is your immediate reaction? Dial 911 and call an ambulance? Get in your car and drive yourself to emergency department (ER)? Have a family member drive you to ER? Or pop some antacid pills in your mouth and wait?

Well, while you are scratching your head for an answer, let us ask the question to Dr. Hal Canham, ER Physician at Medicine Hat Regional Hospital (MHRH) and Medical Director of Medicine Hat Ambulance Service.

“As a physician, I may be able to judge if my chest pain is of cardiac (heart) or non-cardiac origin. If I am not sure, then I will dial 911 and ask for an ambulance. My advice to people in general is to call 911 immediately if they experience chest pain. There may not be time for self-diagnosis,” says Dr. Canham.

Each year, close to half a million people in Canada come to ER with chest pain. Some have acute life threatening illness. Others may have nothing seriously wrong with them. Some may have history of coronary heart disease. Others may not.

What about Medicine Hat?

In an 18 month period (June/97 to Dec/98), the ER Department at MHRH sees 53,548 patients. Out of these, 50 patients are confirmed to have heart attack and are eligible for thrombolytic (clot busting) therapy.

Dr. Canham studied these 50 cases. What did he find? “A major concern became apparent immediately. Of the 50 patients with diagnosis of heart attack, only 15 had called for an ambulance! This confirmed our impression that there is underutilization of the ambulance service for chest pain patients in our community.”

Why call an ambulance? Isn’t it faster for me to jump in my car and rush to ER?

If your chest pain is due to heart attack then the outcome of your illness may be dictated by: 1) the speed and mode of transportation to ER, 2) your previous history of cardiac problems, 3) rapid evaluation of your condition by ER physician, 4) the use of “clot busting” drugs in a timely fashion.

In 1997, the Medicine Hat Ambulance Service purchased new cardiac monitors and defibrillators. The aim is to speed up the delivery of “clot busting” drug to eligible cardiac patients.

Our paramedics are now able to do 12-lead cardiac monitoring in patient’s own home immediately on arrival. This test is transmitted “live” to ER physician to diagnose heart attack before the patient arrives. The ER physician is then ready with “clot busting” drug if the diagnoses are confirmed.

There is also another important reason to call 911. Early in the course of a heart attack, patients are at risk of having the heart stop (cardiac arrest). The chance of surviving this is better in an ambulance with paramedics at hand then in your own vehicle.

Dr. Canham, what is your message to the people of our region?

“The Medicine Hat Ambulance Service is truly an extension of our ER Department and rarely is this more apparent then when you are experiencing chest pain or shortness of breath. Be aware of symptoms suggestive of a heart attack and call 911 early!”

Pain is the most frequent presenting symptom. It is deep in the chest, described as “heavy”, “squeezing”, and “crushing”. The pain may radiate to the neck or the arms. There may be weakness, sweating, vomiting or giddiness. Symptoms may vary. So do not waste time on self-diagnoses. One telephone call may save your life!

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!