Don’t Take an Aspirin and Call Me in the Morning

People are asking about the latest US Public Health Service Taskforce on Prevention (USPSTF) recommendation about the use of aspirin to prevent heart disease. It has been a long-standing recommendation for people who already have heart disease.

When I turned 50, I started taking a “baby” aspirin. That was their recommendation then. I stopped taking mine because I had several nosebleeds. “It’s not worth it for me”, I told my patients. Some time later, they changed their recommendation to men over 50 but only women over 50 with diabetes (because their risk for heart disease is four times that of non-diabetic women).

The reason their recommendation keeps changing (negative view) or evolving (positive view) is that studying what happens to large groups of people who do this, that or the other over periods of many years is difficult, expensive and fraught with technical and procedural problems.

It boils down to two numbers: the number needed to treat in order to avoid one bad event, NNT, and the number needed to harm one person. When I wrote about aspirin for heart disease prevention in 2017, the number of aspirin recommendations needed to avoid one cardiac event was about 200. I didn’t know the number needed to harm then.

The harm can be a lot worse than the nosebleeds I had. Some people get bleeding ulcers or even cerebral hemorrhages that may be partly due to their aspirin use.

So last week their recommendation was revised based on more recent data. It seems the risk is greater than the benefit for people over 60 – again, we are talking about primary prevention, people who do not yet have heart disease.

Patients often worry when we change our advice because of new scientific evidence. I understand their confusion and their calls, but I don’t worry much about this change: It doesn’t keep me up at night or on the phone with patients after hours. We need to remember the NNT. It takes 200 aspirin recommendations to prevent one heart attack. That means that roughly 0.5% of people taking aspirin will be helped by it and the rest will not – but in some subgroups the benefit is greater and in some subgroups of people there will be more harm than good.

The latest recommendation includes the patient’s ten year cardiovascular risk, so the USPSTF no longer treats all men over 50 the same. The ten year risk can be calculated from a person’s sex, age, blood pressure, smoking status, presence of diabetes and diagnosis of hypertension. The American Heart Association and the American College of Cardiology created this risk calculator/smartphone app in 2013.

Here is their latest recommendation:

The USPSTF concludes with moderate certainty that aspirin use for the primary prevention of CVD events in adults ages 40 to 59 years who have a 10% or greater 10-year CVD risk has a small net benefit.

The USPSTF concludes with moderate certainty that initiating aspirin use for the primary prevention of CVD events in adults age 60 years or older has no net benefit.

So, remember that a lot of people will still be taking aspirin for nothing. But think of it like wearing your seatbelt: as long as it doesn’t hurt you, what do you have to lose – even if you never get in an accident? But the big concern with recommendations about primary prevention is that our recommendations could end up hurting people who never had a big risk of getting the disease we are trying to prevent. Then our advice could hurt innocent people. And that is what the USPSTF is now saying about seemingly healthy 60-year olds. (More people are hurt by aspirin than by seatbelts.)

Dear Uncle Marcus (Welby):

You never knew me as a doctor. I was just a teenager when you were at the peak of your career. You would be 114 if you were alive today. But you represent something lasting, something archetypal, to me and to many of my colleagues – and also to patients who met you or heard about you.

You were passionate, caring, creative and daring.

Your were passionate about your calling as a doctor and about your principles. There was never any doubt about where you stood. Sometimes you had to process things, and many times your understanding and thinking evolved. But it was always a process grounded in your heart and soul, true to your nature.

You cared deeply for your patients. You often extended, gave of yourself, invested in them. They were not just clients or consumers of healthcare. They were your people.

Your creativity showed when you adopted new technologies to unique clinical scenarios, in your finding ways to reach closed minds or break through stalemates. Medicine was never cookbook in your practice, but an exploration of what you could do with whatever tools were available for you and your patients.

You were daring enough to speak up against injustice, closed mindedness, self pity or abuse. You took on hospital administrators and community leaders. You claimed and used the authority American physicians had in your day.

In some ways it seems being a doctor was easier in your era, but I’m not sure. Every age has its challenges. We have more treatments today to offer our patients. But I believe there is one tool we use much less than you did – ourselves.

You were fully engaged, fully invested. A doctor is what you were, who you were, through and through.

I don’t like to go to doctors, but if I had to, I’d want someone like you.

My wish is that I can be at least a little bit like you for the patients who choose me as their personal physician.

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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