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Archive for the ‘Preventive cardiology’ Category

Thousands of delegates* converge annually in glittering convention centers on a regular basis to present high quality research. It’s all about overflowing seminar halls, stunning speeches , Intense questions , adoring debates , cozy discussions in grand dinner nights . The meet continues further, as news breaks in global TV shows, spreads in non-stop handles of twitter after igniting the face books.

Finally , it ends over the week-end ! (It has to you know ! ) . . . Every one flies back, only to come back next year to ponder “almost the same issue”  all over again. (Some times the questions are left unanswered for decades ! Not getting an answer is okay , after all research is a  journey towards  truth   but sustaining a confusion or creating new one has been a norm in recent times.)

*Sorry , If am provocative , I need to be genuine in my expression.

Coming to the topic, Aspirin is one wonder drug which made a big impact on CAD risk . We know there is something great with this cheapest and humble Dual COX  blocker.The only weak point is ,it lacks the glamor quotient like that of newer antiplatelets, NOACs  and their clones.

Its my perception ,big breaking research has tried to ditch this drug for quiet a while .But ,it was all too difficult to go for the kill.So these studies circumnavigate the real issue. and end up with  suspicious conclusions  (or Inconclusions !) always trying to hide behind sinister statistics of course with a questionable caveat !

What’s new in the topic of Primary prevention of CAD ?

Two major studies were released recently in August 2018

Both studies suggest caution for Aspirin. If Aspirin is really  bad it would (and should) have buried long ago. We should be thankful even in these testing times for truth ,this humble drug is fighting  back and forth .(Digoxin is another close  cousin of Aspirin fighting for the existence  crisis in cardiology  ! ) 

So what is the role of Aspirin in primary prevention of CAD ?

This question doesn’t make sense in many clinical situations.

Primary and secondary prevention are defined with reference to manifest vascular event. We will not know how much of silent CAD exist in asymptomatic persons.Primary prevention of CAD itself could be a misnomer as most elderly do carry at-least some form of CVD. For example, If a patient with manifest peripheral arterial disease (PAD) and takes Aspirin , its  secondary prevention for PAD but becomes primary prevention for CAD . . . isn’t  ?

Final message

We know Aspirin  continues to be the flag bearer of  all DAPT regimen.I wish it remains a star in primary prevention as well. It looks like(for me)  these studies  are another attempt to pull down Aspirin in primary prevention .I think ARRIVE failed to reach the desired conclusion. Aspirin is a warrior and it will never allow that to happen and ASCEND to glory again !

Postamble

Modern drug research appears to pursue a study till the desired conclusion is reached. We need important  drugs in many vital areas of cardiology .Our energy should be focused to find new molecules. It is worrying trend(if its true !) if efforts are wasted to finish off humble generic drugs with proven worthiness. Doing research in established concepts is the most silly thing to do. Its duplication of knowledge.

Counterpoint

It’s scientific blasphemy to criticise  studies without analysing it in a professional manner.It appears all too brutal to take a biased view and questioning the motive of researchers. Yes agreed , I may be prejudiced , . . but , why a doctor of this caliber make a statement of this sort ?

Its a fact  , there are so many true scientist doing their job right, my query is simple why we are not getting clear answer in many common issues In spite of great research ?

Is it the limitation of science or vagaries of research ? I think it’s more of a  Intellectual insufficiency  aided by  malfunctioning regulators !

 

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We essentially live in our blood vessels and age in our arteries.CAD is the principal  cardio vascular disease, which  God has created in Homo-sapiens to ensure they  do not stay more than “allotted life span” in this planet. Of course , the current generation cardiologists equipped with scientific weapons , have since decided to take the fight directly in the Almighty’s domain .Contrary to the popular medical doctrine, treating an established CAD seems to be easier task than preventing a new onset CAD.

While , arteriosclerosis is a normal aging process, atherosclerosis could be an  aging as well as a distinctive pathological process. However , athero-thrombosis  is a definite pathology of vessel wall .We know at any time atherosclerosis  can transform into  athero-thrombosis  and result in  clinical event depending upon the  triggers and other associated conditions, which we refer to as major or minor  risk factors.

In scientific terms ,

  • Primary prevention  of CAD is preventing first episode of  Coronary  event*(Typically , CSA, STEMI/UA,NSTEMI/SCD,)
  • Secondary prevention  is  prevention  of  second  or subsequent episodes following the first clinical event.(*What if , if  the first event is silent and never known ? )

For all practical  purposes CAD and  coronary atherosclerosis is synonymous. Can we  prevent atherosclerosis in human biological system ?  What are we  supposed to refer to  such a preventive measure , if any ?

We are biased towards obstructive CAD as we often  think it is the  the only form of CAD .Then , how do we diagnose , treat and prevent a minimal non flow limiting plaque , coronary endothelial dysfunction , or  acute coronary erosion that can occur in very early stages of atherosclerosis, in other wise healthy persons.(Routine IVUS ,OCT ? Futile isn’t )

  • Preventing  sub-clinical  CAD  from manifesting  as clinical CAD , is technically   primary prevention”  but still  patho-biologically  secondary prevention.
  • Preventing a CAD in a patient  with peripheral vascular  disease  or preventing CAD in a patient with TIA or stroke is secondary prevention for cerebrovascular disease but  falls within the definition  of primary prevention of  CAD.
  • Then  comes the new semantics :Primordial prevention .This could be same as primary (or another  version of primary prevention ).Primordial prevention is preventing development  the risk factor  itself (Like DM,HT, Dyslipidemia )

So ,whenever , we talk about primary prevention of CAD by Aspirin or Statins ,realize the complexities involved .Before i finish, let me make you  dizzy further with this quixotic one . In a multivessel CAD, as the  atherosclerotic  plaques are scattered across the coronary arteries in various stages of  maturity  , long term Aspirin  following  anterior STEMI has to secondary prevent an event  in LAD territory  . . . but   primary prevent a plaque disruption in RCA territory !

Reference

1.USPSTF Guidelines : Aspirin for the Prevention of Cardiovascular Disease: Preventive Medication

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CokeMini_Happiness_03

  It costs just one Dollor !

Harvard school of Public health has  recently  published some  hard data about  the adverse effects of bad diet habits especially the impact of  soft drinks on long term cardio vascular health.

soft drinks and impact on healthAnother prestigious journal confirms it . . .

risk of soft drinks and coronary artery diseaseThe ultimate journal for the cardiologists Circulation reaffirms it .

soft drinks carbonated and coronary artery diseaseWe  have overwhelming evidence , prolonged use of soft drinks
increase CAD (Like tobacco ). Still , we haven’t added the customary caution on the bottles of these soft drinks ?

Why  ?

My guess would be, there are powerful forces in  modern society that would love to keep  the  threat of diseases high in the  human domain  so that all  stake holders  make a profit .

The poor , World health instigation(WHO)  and various public health forums  simply watch it .If they protest , they are at risk of sucked into the loop of deceit !

Failure to reverse public health hazards  may be a  lesser crime  in modern days  . . . But , here comes  a series of  advertisements in Indian media , that is a strong indicator that human  intellect and the sixth sense  is going nuts !

It suggests , Do you want  ever lasting happiness . . . Drink  it  . . . earnestly believe  in it  . . . and drink again  !

Coca-Cola-12

I was also told  a shocking fact that , The beverage war in India has  started and the soft drink giants have heavily Invested to take it into the rural markets .Their aim is to  provide  “health  for all Indians”  by 2020 !

Concluding question

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