This week’s blog discusses aspirin or other blood thinners. Blood thinner use is a far bigger topic than it seems. Aspirin is a blood thinner, but it’s different from other blood thinners, like Xarelto, Eliquis, or Coumadin. Xarelto & Eliquis are examples of NOACs or Novel Oral Anti-Coagulants. Even though this article will touch on several subtopics, there are many blood thinner topics we won’t cover, like Coumadin, heparin, warfarin, Brilinta(ticagrelor), or Plavix(clopidogrel).
In addition to being a large & complicated topic, this issue is essential to CV event prevention. Most clotting problems can involve life-or-death complications. So there is a lot of emotion. A YouTube viewer once said: “Yikes, I have an autoimmune clotting condition. That sounds like a death sentence.” That’s not exactly the case. Let me give you a little more background. As we know, knowledge has a way of replacing fear. And even though a topic might be very complicated, you know what they say, “one step at a time”. Let’s get started.
EVEN THE PANDEMIC HAS RAISED CLOTTING ISSUES AGAIN
Doctors often protect patients with severe COVID infection with blood thinners. That’s because cytokine storm, like many serious disease processes, results in the body losing control over clotting processes.
BUT THERE ARE FAR MORE COMMON REASONS FOR BLOOD THINNERS. I’M ON A NOAC
I’m already on a NOAC (Novel Oral Anti-Coagulant). Why? I have atrial fibrillation. Atrial fibrillation is by far the most common cardiac dysrhythmia.
ATRIAL FIBRILLATION IS IMPORTANT. LET’S DISCUSS IT
(Dysrhythmia is a problem with the heart’s regular beating. Dysrhythmia is also what people used to call arrhythmia. But arrhythmia means no rhythm. You technically wouldn’t be alive if you had no heart rhythm.)
The problem with atrial fibrillation is stroke risk. We used to think that most strokes were cryptic. The term cryptic meant the cause of the stroke was not known. The vast majority of strokes were cryptic – or of unknown origin.
But now, we’re beginning to find out critical information. With this new information, we can prevent many strokes. Stroke is the #1 cause of permanent disability. So this is a significant opportunity to prevent devastation in many lives.
We’re discovering that these cryptic strokes are due to undiagnosed atrial fib. We’re also finding out that atrial fib (or atrial fibrillation) is far more common than we thought. We already knew that atrial fib was the #1 cardiac dysrhythmia. But now we’re finding that most atrial fib is undiagnosed.
IN THIS WAY, ATRIAL FIB IS LIKE PREDIABETES
Atrial fib is like prediabetes. It’s a disease process that causes significant risk. We knew it was prevalent (common). Now we’re discovering it is far more common than we knew. And it’s becoming clear that most people with it have no clue. And it’s the 3rd leading cause of death and the leading cause of disability. If more doctors & patients look for undiagnosed atrial fib – & treat it with a NOAC – we can save many lives.
As mentioned above, I have paroxysmal atrial fibrillation, which means my heart usually beats with a regular rhythm. But occasionally, it will go into short runs (like 15 seconds) of atrial fibrillation. Sometimes I notice these runs; sometimes, I don’t. They cause increased stroke risk whether you feel them or not.
These runs of atrial fib appear to be enough to cause clots to form in parts of the atria (the upper chamber of the heart.) These clots appear to be the cause of those “cryptic” strokes.
WHY NOT TAKE ASPIRIN? ASPIRIN DOESN’T WORK FOR ATRIAL FIBRILLATION & STROKE PREVENTION
If you have paroxysmal atrial fibrillation, you probably don’t know it. It’s just like 90% of people with prediabetes don’t know it. If you have atrial fib, your stroke probability is multiplied by 5 to 7 times.
You may have atrial fib. Most that have it don’t know it. If you’re a boomer, consider screening or monitoring for atrial fib. If you occasionally feel a fluttering in your chest, consider screening for it.
SCREENING FOR ATRIAL FIB
Screening for atrial fib is a whole different topic. I suspected mine for a couple of reasons. Every few months, I’d feel that flutter in my chest. And I knew from working in the human genetics lab that I had 4q25 (the atrial fib gene). So I got a simple atrial fib detection device from Amazon. There are many. The rhythm strip monitor I got is called iKardia. I now have an Apple watch with cardiac screening. Should you get screened? Probably. Should you get an Apple cardio watch? Maybe. I covered the issue in the following video.
SHOULD YOU BE ON A BLOOD THINNER?
If you have CV (CardioVascular) plaque, you should. How do you know if you have CV plaque? That is a big topic as well. I’ve done a series on CV plaque detection & measurement. Here’s a quick summary followed by a link to a video. The typical ways of CV plaque detection (like Framingham, stress test, & cardiac cath) have significant problems, like leading to unnecessary surgery. There are better ways, like calcium score, CIMT, & CT angiogram.
“I THOUGHT THE RECOMMENDATION IS NO LONGER TO TAKE ASPIRIN. IS THAT WRONG?”
Several medical standards committees have recently stated we should no longer take aspirin – but only for primary prevention. If you have CV plaque, it’s no longer primary prevention. We’ll cover this in more detail later. And we have several videos on it. Here’s a 1-minute video on the topic:
Most boomers should learn more about blood thinners. If we have CV plaque, we should at least take a baby aspirin daily. And as mentioned, atrial fib screening is essential, especially if you ever have that fluttering feeling in your chest. And again, if you have atrial fib, baby aspirin isn’t enough. If you have atrial fib, you need to be on one of the NOACs- Novel Oral Anti-Coagulants. The most common ones are Rivaroxaban (Xarelto) and Eliquis.
This is a video about paroxysmal atrial fibrillation:
If that quick mention of the aspirin issue left you wondering, you’re not alone. The distinctions between primary and secondary prevention are subtle but essential. Most doctors don’t understand them. Let’s go a little deeper into the aspirin issue.
Medical researchers published the ASPREE trial in the New England Journal of Medicine on September 16th, 2018.
ASPREE was a large study with 19,114 participants. They lived in two countries: Australia and the US. In Australia, it was a Caucasian group. In the US, the participants were African Americans and Hispanics.
The researchers published two different studies. There were several surprises. The first surprise was that the aspirin for this study group did not improve the participants’ health. The researchers saw something different- an increase in deaths related to cancer. There was a signal in terms of increased cancer rates. Please be very careful and don’t over-interpret this outcome. For example, I’d still be taking baby aspirin if I weren’t taking Xarelto. The other thing the authors said was that it was right in lockstep with other studies until you reached three and a half years of treatment.
Some reacted to the ASPREE trial by reversing their recommendation for preventive aspirin based on age alone. I haven’t recommended aspirin based on age alone for decades. The confusion here is one of primary prevention (based on age) vs secondary prevention (based on the presence of CV plaque). We’ll touch on this again.
If you look at other images in this part of the study, they didn’t see a significant increase in major hemorrhagic stroke. They published another analysis of this in the same journal and did see some growth, but it wasn’t enough to be significant.
If you’re over 70 and you’ve been taking baby aspirin for a few years, or if you’ve been taking baby aspirin and you’re worried about these results, consider whether or not you want to continue taking the aspirin.
Why are so many doctors misinterpreting this? Doctors tend to practice prevention from this perspective: they are a doctor first (they diagnose & treat disease). Preventing illness is secondary. So they get their preventive aspirin guidelines from headlines in the New York Times. (New York Times articles on medicine are often good. But this one was wrong, as were most lay press headlines.)
NOTHING IN LIFE IS RISK-FREE. THAT INCLUDES ASPIRIN
I have my arguments with the FDA. I testified once for the FDA on a vaccine issue. They listened & changed their regulation. I wish they’d change their rules on metformin, the Freestyle Libre, & aspirin. I’m not alone in saying that aspirin has more risk than either metformin or the Freestyle Libre. Yet the FDA requires a doctor’s prescription for the latter two. And it doesn’t require a prescription for aspirin.
They showed in the ASPREE trial that the benefits for people taking baby aspirin were not as high anymore. Although heart attack and stroke are still the biggest causes of death and disability, even during the COVID pandemic, we’ve made progress.
We manage CV risk better than we did decades ago when we did the original baby aspirin studies. The ASPREE trials showed that the benefit had declined as we improved at preventing heart attacks. So the benefits/risk balance for preventive baby aspirin changed. Many misinterpreted that to mean baby aspirin was no longer worth it. That was a mistake.
I know what they’re thinking, but I can’t entirely agree with them. The standards committees in the past said if you turn age 50, you should start taking baby aspirin. I understand why they said that. You start getting into the risk age for heart attack and stroke.
But what about the people that have no plaque? Why would you need to take baby aspirin if you have no plaque?
Too many doctors & patients make similar assumptions about LDL cholesterol. They think if you have an LDL level over 70, you need to take a statin.
If you don’t have plaque, you don’t need to take a statin. And you also don’t need to take a baby aspirin. If you rewrite those standards and say unless you have plaque, you don’t take that or baby Aspirin, then suddenly, most statin prescriptions would disappear. The majority of preventive aspirin prescriptions would also disappear.
The people who are left are the people that have known CV plaque. If you have known plaque, your risk for heart attack and stroke is much higher than for somebody that doesn’t.
The bottom line is this: people with plaque need to be on a low-dose baby aspirin (or a NOAC if atrial fib is present).
You’re also in the risk category of other chronic diseases like high blood pressure and unrecognized paroxysmal atrial fibrillation. It would be best if you ruled these out.
There was a focus on people 70 and older with the ASPREE trial. So please share this with them if you have friends that age.
AREN’T OMEGA 3 OILS BLOOD THINNERS?
We have a few studies that came out recently that appear to be washing out the impact of Omega-3 oils – at least omega-3s in lower doses. If you look up Omega 3s in Wikipedia, the statement is that Omega 3s don’t work. Wikipedia is like the NY Times; it’s often correct -but not always. This time it isn’t.
Now, let’s go a little bit deeper regarding the adverse effects of aspirin; what you typically see with the addition of Aspirin is Gastrointestinal (GI) bleeds, a little bit of bleeding from the stomach, and ulcer kind of effects.
Aspirin cardiovascular disease benefits appear within the first 1-2 years of administration. The bleeding harms begin soon after aspirin initiation.
When you start considering the other side of this, you go down this path. You may think- it’s a baby aspirin; what’s the big deal?
Once you learn the details, it becomes a big deal. We’re talking about GI bleeding or stroke. There has been a lot of coverage in the New York Times headline: “Aspirin Used to Prevent First Heart Attack or Stroke Should Be Curtailed.”
The USPSTF says that was a misinterpretation. I agree. It’s not what they said. What they said is for people that have no cardiovascular disease. That’s not the same as the first heart attack or stroke.
Here’s the point that is skipped over in headlines: they said it is people that do not have pre-existing cardiovascular disease.
We’ve talked about the importance of plaque. If you have a plaque in your arteries, you have pre-existing cardiovascular disease.
Look at guys like me, and I’m not alone; listen to Brad Bale and Amy Doneen talk about the Bale/Doneen community. They talk about this issue often.
We confuse primary prevention with secondary prevention. We assume that the only people that have pre-existing cardiovascular disease are people like you see in this headline.
Unfortunately, doctors often assume that only professionals should understand this concept.
If you have plaque, you don’t need to have had a heart attack or a stroke if you already have pre-existing cardiovascular disease.
This is what came out of the New York Times article. Doctors should no longer routinely start people at high risk of heart disease on a low-dose aspirin regimen.
There was a significant misinterpretation. The US task force also wants to strongly discourage anyone 60 years or older from starting a low-dose aspirin regimen.
Go back to the previous interpretation and look at the last quote. “Preventive recommendation age 60 or older”. A lot of previous ones were age 55 and older. A few years ago, it went from 55 up
to 60. Now they’re saying again, if you’re thinking about that old guideline, 60 or older, take a baby aspirin. Don’t do that based on age alone.
Go to the Bale/Doneen community. We never said age alone. We said if you have plaque if you have a pre-existing disease.
Why are they backing off exciting concerns about the heightened age-related risk for life-threatening bleeding, strokes, and GI bleeding?
The proposed guidelines would not apply to those already taking aspirin; those who already had a heart attack and those who have pre-existing disease
I mentioned the ASPREE trial. This was one of the first trials to wonder whether we should start every 60-year-old on baby aspirin whether they have plaque,
When we introduced the topic of blood thinners, we said it is a big topic. We’ve focused mostly on atrial fib, NOACS, aspirin, & primary vs. secondary prevention. We did promise to mention another very common blood thinner – warfarin (or Coumadin). The following video compares warfarin with the NOACS for stroke prevention:
HOW DO BLOOD THINNERS WORK?
As you see, this has been a long article. It still doesn’t detail things like separate mechanisms for blood thinners. We’ll leave it with a few examples, including:
Decrease of platelet function (aspirin, Plavix (clopidogrel), Brilinta (ticagrelor)
Decrease in clotting factor function due to Vitamin K antagonism (warfarin, Coumadin)
Decrease the function of specific clotting factors (IX, Xa, & thrombin) (rivaroxaban, (Xarelto), apixaban (Eliquis))
We’ll cover other topics later, like the use of DAPT (Dual Anti-Platelet Therapy), a comparison of NOACs, & more detailed discussion of mechanisms.
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