LifeLineScreening.co.uk tests - Heart, Aorta, Artery, Stroke/Carotid

Update: 21/3/13 Today had my Abdominal Aorta screened for Abdominal Aorta Aneurism (AAA) with Life Line Screening. Result: 2.2cm (top of aorta) to 1.8cm (bottom of aorta) was normal. The pressure of the scanner on the bottom of my rib cage was intense! I've still got a mild bruise a day later. The Sonographer was not very fluent in English and used technical language for the parts of the body that I didn't understand and had to question him on the meaning of the terms.

But it was worth it to know I've not got any Abdominal Aorta Aneurism ... a potentially fatal condition.

Next up, I'm checking for Bowel Cancer Screening which is offered at 60 years for free on the NHS (I'm 56 so not eligible for 4 years).

5th March 2013: Through the post I was targeted by LifeLineScreening.co.uk to take the Vascular and Heart Rhythm tests for £149. I'm checking with my doctor / online to see if these tests are worthwhile for me and whether they are available on the NHS.

Care Quality Commission on Life Line Screening and CQC report.

UK National Screening Committee has advice on private company screening; 3 page brochure.

For another £60 (£209) I could have opted for these extra tests 1) Complete Lipid Panel test* 2) Type 2 Diabetes test** 3) Coronary Heart Disease Risk Analysis (Framingham chart uses 1) & 2) data but QRISK is replacing it in the UK).  LifeLineScreening Price List  here.

*: available from my NHS Doctor for free

**: Roche Accu-Chek Aviva Nano Glucose meter available from Boots for £15

Vascular and Heart Rhythm

£149	Reg. £280 SAVE £131!

1) Overview of Heart Rhythm Screening (Atrial Fibrillation) 

Wikipedia

This test uses electrocardiogram readings to detect irregular heart rhythm (atrial fibrillation) at the time of screening. Atrial fibrillation increases the risk of stroke 5-fold.

How the screening is performed:

You will be asked to lie on your back on the examination table and electrode stickers will be placed on your collar bones or wrists and ankles. A small device then connects the electrodes to the electrocardiogram machine which then takes your reading.

2) Overview of enlarging of the Aorta Test (Abdominal Aortic Aneurysm) 

Wikipedia
This is an ultrasound test used to measure the size of your aorta, your main blood vessel, in the abdomen. Over time, the aorta can become enlarged and if it swells too much it could rupture.

How the screening is performed:

You will be asked to lie on your back on the examination table and the Sonographer will move a transducer over your abdomen to measure the size of your aorta.

Can my doctor provide screenings?

Scans are normally offered via the NHS only when symptoms become present - although currently the NHS is piloting an Abdominal Aortic Aneurysm screening programme [say LifeLineScreening] [what is AAA?], which is scheduled to be fully rolled out across England in 2013 [to over 65s ONLY]  . 

What about men under 65? The NHS programme is offered to men aged 65 and over because 95 per cent of ruptured AAA occur in this group. There is no evidence to show that inviting men who are younger than 65 for screening as part of a population-based screening programme would deliver major benefits [a matter of economics/health benefits??]. 6,000 die of ruptured AAA in UK, ie 300 with AAA under 65 die each year.

The risk of developing an AAA also increases through close family history. If you have a close relative - brother, sister or parent - who has, or has had, an AAA you can receive an ultrasound scan at an appropriate age under existing NHS procedures and should speak to your GP to discuss a referral. 

3) Overview of the Artery Hardening Test (Peripheral Arterial Disease) 

Wikipedia
This test uses ultrasound and blood pressure measurements to check for peripheral arterial disease (hardening of the arteries) in the lower extremities. Peripheral Arterial Disease increases your risk of heart attack or stroke by 2 to 6 times and affects 1 in 6 people over the age of 55.

How the screening is performed:

Pressure cuffs will be placed around your upper arms and ankles and a small ultrasound device is used to measure the systolic blood pressure in your limbs.

4) Overview of Stroke Risk Screening (Stroke/Carotid Ultrasound) 

Wikipedia | National Institutes of Health | NHS Choices | Stroke Prevention
This screening uses ultrasound to look inside your carotid arteries for buildup of fatty plaque. Excess plaque build in your carotid arteries can restrict the flow of blood to your brain and cause a stroke. 

How the screening is performed: 

You will be asked to lie on your back on the examination table. The Sonographer will then apply some gel to your neck and use a transducer to create images of your carotid arteries in order to assess the rate of blood flow within them.

Eating nuts and olive oil can reduce the risk of a heart attack

reposted from: http://www.nhs.uk/news/2013/February/Pages/Mediterranean-diet-cuts-heart-disease-and-stroke-risk.aspx

crabsallover highlights, key points, comments / links.

Mediterranean diet cuts heart and stroke risk

Tue Feb 26, 2013 09:59

"Mediterranean diet 'cuts strokes and heart attacks in at-risk groups'," The Guardian advises. Along with much of the global media, The Guardian reports on a study that found that eating a diet rich in fruit, vegetables, fish, olive oil and nuts cuts the risk of heart disease and stroke by 30%.

The story is based on an impressive trial looking at the effects of a Mediterranean diet on people at risk of heart disease and stroke, compared with a standard low-fat diet.

Researchers found that after nearly five years people who followed a Mediterranean diet supplemented with either extra-virgin olive oil or mixed nuts were around 30% less likely to have had a heart attack or stroke, or to have died from one.

It should be noted that the number of strokes, heart attacks and deaths that occurred in the study was fairly small. Nevertheless, this large and well-conducted study supports previous research on the benefits of a Mediterranean-style diet for the heart and circulation. 

Where did the story come from?

The study was carried out by researchers from academic institutions across Spain, including the Universities of Barcelona, Valencia, Malaga and Navarra. It was funded by the Spanish government and other public sources.

Olive oil and nuts used in the trial were donated by commercial sources of these foods. Many of the researchers disclosed grants and fees for work done with agricultural and food industry firms and groups, as is common for research in this field.

It was published in the peer-reviewed New England Journal of Medicine.

The study did not compare the Mediterranean diet with statins, as The Daily Telegraph and Daily Mail's headlines imply. The claim that this diet is better than a drug appears to be an opinion of one of the researchers, rather than a statement of fact.

The current study cannot be used as a way of assessing the effectiveness of statins, not least because some of the people in the Mediterranean diet intervention group were also taking statins.

What kind of research was this?

This was a randomised controlled trial (RCT) involving people at risk of cardiovascular disease. It compared the effects of two variations of the 'Mediterranean diet' – one with extra-virgin olive oil and one with nuts – with a standard low-fat diet.

As the authors point out, previous research has suggested the Mediterranean diet may protect against heart disease and stroke. Helpfully, in this study the researchers have defined what they consider a Mediterranean diet to be and, as the paper is open access, you can view their Mediterranean dietary recommendations for free online.

A well-conducted RCT is the best way of examining the effects of a particular intervention (in this case a Mediterranean diet) compared with a control condition (in this case a standard low-fat diet) on a health outcome.

Randomisation helps iron out other factors that may affect cardiovascular risk, balancing them out between groups. For example, many observational studies of specific diets have been conducted. However, observational studies cannot necessarily prove that the particular diet was responsible for the outcomes seen. This is because people who choose to eat a healthier diet may also choose other healthier lifestyle options, such as exercising more or drinking less alcohol.

What did the research involve?

The trial began in October 2003. Eligible participants included men aged 55-80 and women aged 60-80. Participants did not have a history of heart attack or stroke, but were considered to be at future risk of having cardiovascular disease.

This was because they either had type 2 diabetes or at least three of the following major risk factors for cardiovascular disease:

• smoking
• high blood pressure
• high cholesterol
• being overweight or obese
• having a family member who developed heart disease at a young age

Participants were randomly assigned to one of three groups:

• one group was advised to follow a Mediterranean diet supplemented with extra-virgin olive oil
• a second group was advised to follow a Mediterranean diet supplemented with mixed nuts (walnuts, almonds and hazelnuts)
• the third control group were advised to follow a low-fat diet

Participants in the two Mediterranean diet groups received extra olive oil or nuts at no cost, while those in the control group received free non-food gifts.

All of the groups received a dietary training session at baseline (study start). The Mediterranean groups received further sessions every three months afterwards. This included an assessment of their adherence to the diet, while the low-fat group received a leaflet each year for the first three years explaining the low fat diet. In October 2006, this protocol was amended and the control group got the same intensity of diet advice and assessment as the other two groups.

Participants also filled in a general medical questionnaire, a food frequency questionnaire and a physical activity questionnaire every year. Their weight, height and waist circumference was measured. The researchers also measured certain biomarkers (chemicals in the blood or urine) in random subgroups of participants in the Mediterranean diet groups at one, three and five years to see if they were sticking to the advice to supplement their diet with extra-virgin olive oil or nuts.

Over the period of the study, they looked at the main (primary) outcome of interest, which was the number of participants who had suffered either a heart attack or stroke or who had died from any cardiovascular cause. Other (secondary) outcomes the researchers examined were the number of people who had suffered these individual events and those who had died from any cause. They obtained this information from:

• repeated contact with participants
• contact with family doctors
• yearly review of medical records
• the national death index

The researchers initially estimated they would need a sample of 9,000 participants to detect any significant differences in outcomes between the groups. However, this figure was recalculated in April 2008 to 7,400 participants.

What were the basic results?

A total of 7,447 people were enrolled in the trial. The researchers report that the people in the two Mediterranean diet groups said they adhered to their diets, which was confirmed by biomarkers in the blood or urine.

After an average follow-up of 4.8 years, they found that in total 288 people either had a heart attack, stroke or died from a cardiovascular event. Of these:

• 96 (3.8%) events occurred in the Mediterranean diet group with extra olive oil
• 83 (3.4%) occurred in the Mediterranean diet group with extra nuts
• 109 (4.4%) occurred in the control group on a standard low-fat diet

After adjusting for baseline risk factors (such as diabetes), the researchers calculated that, compared with those who followed the standard low-fat diet, those assigned to a Mediterranean diet with extra-virgin olive oil had a 30% reduced risk of suffering a heart attack, stroke or dying from a cardiovascular event (hazard ratio 0.70, 95% confidence interval (CI), 0.54 to 0.92).

Similarly, those assigned a Mediterranean diet with nuts had a 28% reduced risk of suffering a heart attack, stroke or dying from a cardiovascular event (hazard ratio 0.72, 95% CI 0.54 to 0.96).

No diet-related adverse effects were reported.

How did the researchers interpret the results?

The researchers say that among people at high cardiovascular risk, a Mediterranean diet supplemented with olive oil or nuts reduced the number of cardiovascular events over the study period.

They suggest there is a "synergy" in the diet's nutrient-rich foods that fosters favourable changes to some risk factors, including blood fats, insulin sensitivity and inflammation. However, they say that in this trial olive oil and nuts were probably responsible for most of the benefits.

Conclusion

The results of this randomised controlled trial appear to confirm previous studies that there are benefits to following a Mediterranean diet. The trial has many strengths, including its large size, long period of follow-up, thorough assessment of medical outcomes (including reviewing medical records and having contact with the family doctor), and careful attempts to assess whether the diets were being followed.

As this is a randomised controlled trial, it should also balance out other health and lifestyle differences between the groups that may influence cardiovascular risk. This avoids the limitations of many previous diet observational studies, where participants choose which diet to follow.

However, there are still several limitations to bear in mind:

• The protocol for the control groups was changed halfway through the trial. This group did not receive the same intensity of dietary advice as the other two groups, a factor which could have affected their compliance with the diet.
• Despite careful attempts at screening and measuring biomarkers, it is still difficult to know how far participants stuck to their assigned diets.
• The control group had a higher dropout rate (11.3%) compared with the Mediterranean diet groups (4.9%).
• The participants were at high risk of cardiovascular disease at study start, but had not yet suffered any cardiovascular events. It is not certain if the results are generalisable to other groups, including those with no risk factors for cardiovascular disease and those who have already suffered from a heart attack or stroke.

The 30% reduction in risk may sound impressive but, as the authors point out, these results mean that following a Mediterranean diet would mean that about three major cardiovascular events would be avoided per 1,000 person-years. This means that if 1,000 people at high risk of cardiovascular disease ate a Mediterranean diet for one year, there would be three fewer 'events' (such as stroke) than there would be if they ate a standard low-fat diet.

Despite these limitations, this large and well-conducted study adds to the body of previous research on the benefits of a Mediterranean style diet for the heart and circulation.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Mediterranean diet 'cuts strokes and heart attacks in at-risk groups'. The Guardian, February 25 2013

Mediterranean diet 'as good as statins'. The Daily Telegraph, February 25 2013

Eating nuts and olive oil can reduce the risk of a heart attack as much as statins. Daily Mail, February 26 2013

Links To Science

Estruch R, Ros E, Salas-Salvadó J, et al. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet. The New England Journal of Medicine. Published online February 25 2013

Aspirin Foundation: Benefits and risks of preventative aspirin - Prof Jane Armitage - Clinical Trials Service Unit, Oxford University, UK

Aspirin Foundation: Benefits and risks of preventative aspirin - Prof Jane Armitage - Clinical Trials Service Unit, Oxford University, UK

reposted from:

crabsallover highlights, key points, comments / links.

Aspirin effect on cancer, strokes and heart attacks (with /without diabetes) v GI bleeding.


Prof Armitage talks to ecancer at the Aspirin Foundation 'Aspirin for the older person' meeting at the Royal Society of Medicine, London, 3rd November 2011. Prof Armitage discusses the risks of taking regular aspirin, such as gastrointestinal bleeding, versus the benefits it can bring to vascular disease and cancer. She discusses trials underway, such as aspirin vs placebo for various diseases, due to report 2017.

Peter Rothwell: A Stratospheric Rise to a Giant of Neurology

reposted from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60662-4/fulltext

crabsallover highlights, key points, comments / links.

The Lancet, Volume 377, Issue 9778, Page 1645, 14 May 2011

<Previous Article|Next Article>

doi:10.1016/S0140-6736(11)60662-4Cite or Link Using DOI

Peter Rothwell: a dedicated flouter of fashion

David Holmes 

Peter Rothwell, 1980—90: a lack of direction and an undistinguished career as a medical student. Peter Rothwell, 1991—2011: award-winning Director of the Stroke Prevention Research Unit at the University of Oxford, UK, and author of over 300 publications that have transformed the landscape of stroke prevention. He is a man who takes some figuring out. Reflecting on Rothwell's stratospheric rise to a giant of neurology, Charles Warlow, Rothwell's mentor and Professor of Medical Neurology at Edinburgh University, says simply, “he's a phenomenon”.

The past two decades have seen Rothwell show which patients benefit from carotid endarterectomy to prevent stroke, that there is a high risk of major stroke after transient ischaemic attack (TIA) and minor stroke, and that there are enormous benefits from urgent treatment to reduce this risk. This work called for greater urgency in investigating and treating minor stroke and TIA, which had previously been thought of as fairly benign conditions, so Rothwell developed a risk scoring system to enable clinicians to predict the likelihood of stroke in the first few days after TIA.

More recently, Rothwell has found that variability in blood pressure is at least as important as mean blood pressure for predicting the risk of stroke and that some of the most effective antihypertensive drugs reduce variability, as opposed to simply reducing mean blood pressure. Along the way, he has proved that the statistical basis of the “usual blood pressure hypothesis” approach to diagnosis and treatment of hypertension is invalid, and has still found time to show that aspirin can reduce mortality due to several major cancers.

Rothwell's record is extraordinary by any measure, but juxtaposed with his early years as a medical student it almost defies belief. Born to a 16-year-old single mother in a poor area of Liverpool and adopted and brought up by a family in Manchester, Rothwell got good grades at school. But, as the first person from his family to go to university, he had little sense of what kind of career he wanted. “I didn't have sufficient knowledge or originality to think of anything else to do, so I did medicine”, he says. Rothwell ended up at Edinburgh University, where he cheerfully admits to not being “particularly academic”. Far more interested in indulging his passion for mountaineering than attending medical lectures, “he was completely obscure as a student”, says Warlow. “And he became even more obscure when he went off to do his senior house officer [SHO] jobs in Middlesbrough.”

It was during his time working at the intensive therapy unit in Middlesbrough that Rothwell gathered data, largely unsupervised, on the endocrine response to critical illness, which he then wrote up for his MD. “That was extraordinary”, says Warlow. “I mean, no SHO collects data for an MD. Somehow or other, Pete just did it. And it's been just like that ever since. He just gets on and does it, and he does it at the most extraordinary speed.” A move back to Edinburgh as a clinical research fellow, and into Warlow's tutelage followed. “He got me interested in stroke and was an inspirational supervisor”, he says of Warlow. “And stroke has been my main focus since then”. His time with Warlow also laid the foundations for Rothwell's appreciation of the importance of asking the simple questions about how to best do medicine in the real world, and gave him the confidence to challenge the consensus. Louise Silver, Research Co-ordinator at the Stroke Prevention Research Unit, Oxford, which Rothwell established in 2000, explains that these are virtues that he is passing on to his own fellows. “His focus on clinical research, and how this can directly impact patient care, certainly gives myself and others a feeling that all our hard work has and will make a difference”, she says.

In an age when so many researchers fall over themselves to jump on the latest bandwagon, Rothwell is something of an iconoclast. “Medical research is so fashion conscious”, he says. “Everyone suddenly becomes geneticists, then 10 years later they're stem cell researchers.” By contrast, Rothwell's willingness to eschew fads has helped him reap a bumper crop of what he calls, for want of a better term, low-hanging fruit. “There's so much simple clinical research that should have been done 50 years ago but wasn't”, he explains. “The work we've done on working out the prognosis of TIAs and minor stroke should have been done years ago but wasn't.” The same can be said of his work on blood pressure variability and risk of stroke or the non-vascular effects of aspirin. “It's all simple stuff”, he insists.

For someone whose work has garnered such acclaim, Rothwell's modesty is striking. But beneath the softly spoken self-effacement, you get a sense of the kind of strength of character that has helped propel him so far, so fast. Moving to Oxford having been an undergraduate elsewhere certainly requires mental fortitude, and despite “still feeling like a new boy”, he has flourished. “He's quite tough you know, Pete”, Warlow attests. Still only 47, Rothwell is showing no signs of slowing down, and wants to carry on the Oxford Vascular Study, which he established in 2002, for another 20 years “to really understand what's happening to vascular disease over time”. He also expects variability in blood pressure to come further to the fore, especially in relation to dementia. And he hints that aspirin (he takes it) might still have a few new tricks up its sleeve. Considering what he has achieved in the past 20 years, the possibilities for the next 20 seem endless.

Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials

reposted from: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60503-1/fulltext

From The Lancet, Vol. 373 No. 9678 pp 1849-1860, May 30, 2009
crabsallover says 'this trial was cited by Moayyedi & Jankowski', my other comments in blue

Antithrombotic Trialists' (ATT) Collaboration ‡

Summary

Background

Low-dose aspirin is of definite and substantial net benefit for many people who already have occlusive vascular disease. We have assessed the benefits and risks in primary prevention.

Methods

We undertook meta-analyses of serious vascular events (myocardial infarction, stroke, or vascular death) and major bleeds in six primary prevention trials (95 000 individuals at low average risk, 660 000 person-years, 3554 serious vascular events) and 16 secondary prevention trials (17 000 individuals at high average risk, 43 000 person-years, 3306 serious vascular events) that compared long-term aspirin versus control. We report intention-to-treat analyses of first events during the scheduled treatment period.

Findings

In the primary prevention trials, aspirin allocation yielded a 12% proportional reduction in serious vascular events (0·51% aspirin vs 0·57% control per year, p=0·0001), due mainly to a reduction of about a fifth in non-fatal myocardial infarction (0·18% vs 0·23% per year, p<0·0001). The net effect on stroke was not significant (0·20% vs 0·21% per year, p=0·4: haemorrhagic stroke 0·04% vs 0·03%, p=0·05; other stroke 0·16% vs 0·18% per year, p=0·08). Vascular mortality did not differ significantly (0·19% vs0·19% per year, p=0·7). Aspirin allocation increased major gastrointestinal and extracranial bleeds (0·10% vs 0·07% per year, p<0·0001), and the main risk factors for coronary disease were also risk factors for bleeding. In the secondary prevention trials, aspirin allocation yielded a greater absolute reduction in serious vascular events (6·7% vs 8·2% per year, p<0.0001), with a non-significant increase in haemorrhagic stroke but reductions of about a fifth in total stroke (2·08% vs 2·54% per year, p=0·002) and in coronary events (4·3% vs 5·3% per year, p<0·0001). In both primary and secondary prevention trials, the proportional reductions in the aggregate of all serious vascular events seemed similar for men and women.

Interpretation

In primary prevention without previous disease, aspirin is of uncertain net value as the reduction in occlusive events needs to be weighed against any increase in major bleeds. Further trials are in progress.

Full free report....

note the 0.03% increased extracranial bleeds with aspirin

Risk Factors for strokes

reposted from: NHS Choices.

The conclusion that "targeted interventions that reduce blood pressure and smoking, and promote physical activity and a healthy diet, could substantially reduce the global burden of stroke", seems sensible says NHS Choices.

Health Profile of England 2007 - part 5

reposted from:

Wonder Pill - slash heart attack or strokes - June 2003

A wonder pill that could slash the rate of deaths from heart attack or stroke by over 80 per cent is being proposed by UK researchers.

The "Polypill" would contain a cocktail of six existing drugs and should be given to everybody over the age of 55, the researchers argue. It could potentially save 200,000 lives every year in the UK alone, they say.

"There's probably no other preventative measure which would have greater impact on public health in the Western world," says Nicholas Wald, research leader and an expert in preventative medicine at the Wolfson Institute of Preventive Medicine, London.

"In people who start taking it at 55, about a third would expect to benefit," he says. "Each of these individuals would gain about 12 years extra life - that is enormous." In some cases the increase in longevity might be as much as 20 years, says the proposal.

"This is extremely important," says Richard Smith, editor of the British Medical Journal, which released three papers by Wald's group on Thursday. "Heart attack and stroke kill half of the British population." Smith suggested that the BMJ issue in which the proposals appear might be the most important for 50 years.

Key risk factors

The proposal is underpinned by a massive analysis of earlier trials of drugs that can lower different aspects of the risk of cardiovascular disease. Over 750 trials involving 400,000 people were assessed. However, the "Polypill" has yet to be tested in any clinical trials.

The pill would combine different drugs to try to lower the four key risk factors for heart disease: cholesterol, high blood pressure, high homocysteine blood levels and blood platelet function.

A statin would reduce high levels of the "bad" LDL cholesterol, slashing the risk of heart disease, while three blood pressure lowering drugs would reduce stroke risk, says Wald.

Folic acid in the pill would cut high homocysteine levels, which can encourage the build up of fatty plaques in arteries. And finally aspirin would be added to regulate the function of blood platelets. Overall, the wonder pill would cut the risk of heart disease by 88 per cent and stroke by 80 per cent, the scientists estimate.

The pill could also be produced cheaply, says Wald, as the patents on many of the components have expired or will do soon.

Little to lose

Eventually the drug could be given to everyone over 55, without requiring a medical examination, says Wald. He believes that age is a more powerful predictor of cardiovascular disease than the risk factors usually considered. "In Western society, the risk factors are high in us all, so everyone is at risk," he says. "There is much to gain and little to lose by the widespread use of these drugs."

Rory Collins, a British Heart Foundation professor of medicine and epidemiology at Oxford University told New Scientist he supports the Polypill concept, noting the idea has been mooted before.

"I think, in principle, it would produce substantial reductions in risk," says Collins, leader of the UK Heart Protection Study. "The idea is a perfectly sensible one in that the effect of these treatments do appear to be largely independent of one another."

Wald and colleagues are planning a small trial examining combinations of blood pressure lowering drugs for use in the Polypill. But he says clinical trials of the pill itself may be "tricky" as pharmaceutical companies are unlikely to be keen on funding the development costs of a pill containing off-patent drugs.

Journal reference: British Medical Journal (vol 326, p 1419, 1423, 1427)

Mark Porter discusses heart attacks

From this discussion:

• i will carry aspirin with me to take in the event of a (suspected) heart attack
• consider the evidence for taking half an aspirin a day
• consider the evidence (again) for taking statins - which reduce risk of heart attack or stroke by a THIRD EVEN IF cholesterol levels are average
  

pdf file transcript (page same as link in title). CASE NOTES 5. - Heart Attacks

RADIO 4 TUESDAY 04/05/2004 2100-2130 PRESENTER: MARK PORTER, CONTRIBUTORS:
TOM QUINN, RORY COLLINS, British Heart Foundation Professor of Medicine and Epidemilogy at Oxford. TOM MARSHALL visiting fellow at Harvard Medical School


Extracts:

Aspirin

PORTER
I want to go back to aspirin. Tom, there has been some coverage in the press suggesting that we should all be carrying an aspirin around with us, just in case we get chest pain, what do you think of that?

QUINN
I think it's important, I carry aspirin for that reason, just in case someone falls over when I'm on the train or something. Aspirin alone is as effective as one of the clot buster drugs, alone at saving lives, solving heart attacks, it's very important. Given in combination with one of these clot buster drugs it's even more powerful. And as an emergency first aid measure for suspected heart attack it's a pretty good thing.

PORTER
What about low dose aspirin - a daily half or quarter of an aspirin?

QUINN
Yes I think the current guidance on this is that if you've got a cardiac diagnosis you should have been prescribed low dose aspiring almost ad infinitum but if you haven't had a diagnosis then it's probably best to discuss with your GP or practice nurse before starting to take that treatment because even low dose aspirin isn't totally without risk.

Statins & Cholesterol levels

PORTER
Statins - a family of cholesterol lowering drugs that can protect against heart disease. At the moment they are only prescribed on the NHS to people at the highest risk, but there is now good evidence that far more us could benefit them - and there are moves to make them available over-the-counter in the near future. The global prescription market for statins is already worth billions of pounds a year - could the over-the-counter market soon follow suit? Dr I started by asking Tom how the statins work?

PORTER
Because it's possible isn't it to have a higher than ideal cholesterol level, even if you don't eat a particularly poor diet.

MARSHALL
There's a lot of variation between individuals, so that what we find is that different individuals have different cholesterol levels. We know that whatever your cholesterol level is if you eat a diet that's more high in saturated fat your cholesterol will be higher and if you eat a diet that's less high in saturated fats - bit more polyunsaturates - you'd have a lower cholesterol. So there's variation between individuals but there's also variation caused by what people eat. Approximately what they do is whatever your chances are of getting heart disease they knock about a third off that. So if you take a statin it will reduce your risk of heart disease by about a third and probably similar for stroke.

PORTER
Pretty significant given that heart disease and stroke of course are the biggest killers of Americans and British people. But it actually doesn't make an awful lot of difference what your cholesterol level is to start with does it.

MARSHALL
Well that's the curious thing about it because originally we thought that what we were treating was high cholesterol levels and if you brought them down to a more normal sort of level that was really what the advantage was coming from. But what we're finding more and more, for example from the heart protection study, it was a very large study in the UK a couple of years back, is that it doesn't really make a lot of difference what your cholesterol level is, it still reduces your risk. So if you're at high risk, even if your cholesterol level's pretty well average you're better off having a lower cholesterol level. And so the general rule about cholesterol is lower the better.

PORTER
So potentially nearly everyone could benefit from taking a statin?

MARSHALL
Well that's an interesting question. In principle, it would be very hard to prove that you were really benefiting people who very rarely get heart disease anyway but in principle that's probably correct, that virtually everybody can reduce their risk of heart disease, their chances of getting heart disease by about a third by taking a statin. But the key question is a third of what? Because if I've got a very high chance of getting heart disease then reducing my chances by a third seems like a pretty good idea but if I'm the sort of person who is very unlikely to get heart disease it means an awful lot of people like me are going to take the tablet and very few of us are actually going to really prevent anything.

PORTER
Well at the moment statin use is effectively rationed by the NHS to those who need it most - put simply, at around, I suppose, a £1 per day a person, the NHS couldn't afford to supply these drugs to everyone who, the latest evidence shows, may benefit from them. Rory, it's going to a difficult problem to solve.

COLLINS
Well you call it a problem, I call it a solution. The fact is that the statins and cholesterol lowering therapy are much more effective than we had realised - they're more effective for a much wider range of individuals at high risk, they're effective for people at high risk not just of heart attacks or strokes, they're protective for people throughout the cholesterol levels that we see in Western populations. So we can produce benefits for a very much wider range of people who are otherwise going to have a heart attack, stroke and die - or be disabled by those conditions. So I see it as solution. And you say it's an expensive treatment but you know so too is being hospitalised with a heart attack, so too is being disabled with a stroke. And in fact when we do analyses of the benefits in terms of cost terms - leaving aside the human benefits - actually these treatments turn out to be cost effective for a much wider range of individuals than have previously been thought to be the case. And of course now that sinvastatin is no longer protected by patent and is available as a generic drug, as the cost of the drug falls the cost effectiveness of the treatment increases and it will become cost effective, cost saving, for a very much wider range of patients.

PORTER
So what are the downsides Tom?

MARSHALL
Statins do have side effects. There are some that are considered relatively minor and seem to be reversible when you stop them like sometimes people have suffered a little bit of hair loss and things like that. But the most important kind of side effect is a type of muscle damage which can be sort of mild, in the sense that people get some muscle pain and some blood tests show that there's some evidence of muscle damage and they can stop the treatment or in its more severe form can actually be quite a serious problem where there's breakdown of the muscles and this is referred to as rhabdomyolysis.

PORTER
Are there doubts about the current statins that we're using, because this is quite an unusual side effect isn't it?

MARSHALL
It's a very - yeah it's a very unusual thing and when it happens in its full blown form it's pretty serious - people can die from it. In its very serious form it's quite infrequent - it's in the region of 1 in 10,000 or even less frequent than that, so it's really quite infrequent.

PORTER
Rory, what impact do you think deregulation of statins is going to have?

COLLINS
I think number one, the fact it's going over-the-counter emphasises our very good evidence about the safety of this treatment. I think the other thing is that it will bring to the attention, not just of the people that the over-the-counter is targeted at, but also the higher risk patients, the possibility that there are ways of lowering their risk and it may, I hope, encourage them to go and talk to their family doctors to get on to prescribed statin for people with vasc disease or diabetes or hypertension.

PORTER Tom, Katherine - do either of you take a statin?

HENDERSON
I don't but I measure my cholesterol and I know that I don't need to.

PORTER
What about you Tom?

QUINN
I did, my cholesterol was a little bit high, as was my blood pressure, but the statins didn't agree with me so I've now bought a bicycle and try and cycle more and eat less but I don't take a statin.

Take One Aspirin a day to prevent heart attack or stroke?

Evidence about daily use of Aspirin to prevent heart attacks or stroke. But how does it work?

Low dose Aspirin is an antiplatelet agent (clot buster).

Aspirin has a risk of internal bleeding (Am J Medicine): - Conclusions of this report was

Low-dose aspirin increases the risk of major bleeding by ~70%, but the absolute increase is modest: 769 patients (95% CI, 500-1250) need to be treated with aspirin to cause one additional major bleeding episode annually.

For Many Women, Daily Aspirin Can Protect the Heart
11.05.06, 12:00 AM ET SUNDAY, Nov. 5 (HealthDay News) -- The message is clear, but not enough women heed it: Taking an aspirin a day can help prevent heart attacks and stroke in some women, and even prevent further problems if you already have cardiovascular disease.

But it's not a one-size-fits-all prescription. Whether you should -- or shouldn't -- take a daily aspirin depends on a number of factors, including your age and your risk factors for heart disease and stroke, such as high cholesterol levels or diabetes.

One thing's clear: Fewer than half of American women who could definitely benefit -- those who already have cardiovascular disease -- actually take a daily pill, according to recent research. Doctors say the finding underscores the need for women to talk with their health-care provider about what's best for them.

"Aspirin works for women who already have cardiovascular disease, for those with multiple risk factors [for suffering a heart attack or stroke] and for healthy women over the age of 65," said Dr. Nieca Goldberg, chief of women's cardiac care at Lenox Hill Hospital in New York City, and author of The Women's Healthy Heart Program.

Goldberg was summarizing the findings of several recent studies and the latest guidelines issued by the American Heart Association. According to those guidelines, there's good reason to prescribe a daily aspirin for high-risk women. But the decision about aspirin for women at intermediate and lower risk is more difficult, the heart association said.

Doctors should take a more conservative approach with low- and intermediate-risk women, the AHA suggests, and should bear in mind that aspirin therapy has the potential for gastrointestinal bleeding and other side effects. Those side effects may outweigh the benefits in women at low and moderate risk.

Women between the ages of 45 and 65 who haven't had heart disease but do have risk factors -- including diabetes, high blood pressure and high cholesterol -- might benefit from aspirin therapy to prevent cardiovascular disease. But, they should discuss the matter with their doctor to determine their degree of risk, Goldberg said.

Once even healthy women reach the age of Medicare eligibility, it's probably wise to take a daily aspirin, doctors say. "At age 65 and over, for healthy women, it looks like aspirin prevents cardiovascular events," said Dr. Raluca Arimie, a cardiologist at the Santa Monica-UCLA Medical Center, in California.

But for healthy women between the ages of 45 and 65, doctors "haven't found any benefit to the heart, but they found a slight benefit for stroke prevention," said Arimie, who's also an assistant professor of medicine at the University of California, Los Angeles David Geffen School of Medicine.

Goldberg and Arimie agreed that it's crucial to know and understand your individual risk for heart disease and to make any decision on aspirin therapy in concert with your physician.

"Every woman should have a conversation with their own doctor," Arimie said. And, she added, don't necessarily expect to get the same advice doctors might give a man of the same age, or a woman of the same age with a different health status.

It's also important to know that doses in aspirin therapy can vary, Arimie said, with an 81 milligram tablet the typical starting dose for healthy people. "Sometimes it goes to 325 milligrams in those who have already had a heart attack," she said.

"I don't think everybody should be on aspirin," Arimie added. "But it should be decided case by case. If a healthy woman [under age 65] wants to take it to reduce stroke risk, she must be aware of the [GI] bleeding risk."

More information

To learn more about aspirin and heart health, visit the American Heart Association.