Aspirin at bedtime 'cuts' morning heart attack risk

Aspirin at bedtime 'cuts' morning heart attack risk - Health News - NHS Choices

“Take aspirin before bed to cut morning heart risk,” is the advice in The Daily Telegraph today. It’s prompted by a presentation that explained research that found a night-time aspirin helped thin the blood in the morning.

The researchers randomised 290 people who were already taking low-dose aspirin to make the blood less "sticky" for the prevention of cardiovascular disease (CVD) either to take aspirin in the morning or at bedtime. ... more

for each 1 unit BMI rise, risk of heart failure increases by 17%

Just a few extra pounds increases heart failure risk - Health News - NHS Choices

• for each one unit rise in body mass index (BMI) the risk of experiencing heart failure increased by 17%.
• being fatter increased the risk of developing other cardiovascular diseases such as type 2 diabetes.
• The Daily Telegraph’s headline stated how “piling on as little as 4lbs can raise risk of heart attack by 17%” when in fact the 17% figure related to heart failure. These are not the same thing.
• Heart failure is a serious chronic (long term) condition whereby a damaged heart cannot pump enough blood around the body. A heart attack on the other hand is an acute medical emergency that happens when the supply of the blood to the heart is suddenly blocked. 
• a one-unit increase in BMI corresponds to roughly 220,000 additional heart failure cases in Europe (113,000 additional cases in the US).
• So even a modest gain in weight (for a man who is 5'10", one BMI unit is equivalent to a seven pound or 3.2kg weight gain) can lead to extensive health costs at a population level.

Conclusion

This large study uses an interesting genetic approach (Mendelian randomisation) to suggest obesity increases the risk of heart failure and adverse changes in liver enzymes.

The combination of a very large sample, prospectively collected information, and a wide range of cardiometabolic measures lend credibility to the findings. The method the researchers used is also thought to reduce the chances of factors other than BMI influencing results, and the chance that the ‘outcome’ could be causing the ‘exposure’ (reverse causality).

The main limitation of this kind of research is that assumptions need to be made. The potentially weakest assumption is the reliability of the association between the FTO genetic variant and BMI. Although the researchers report that this link has been widely found in many other studies, they also note that the strength of the link is relatively weak – the variant is only thought to explain about 0.3% of the variation of BMI in the population.

Estimates of the effect of BMI would be more accurate if this link was stronger.

The researchers suggest that studies in the future might use more than one genetic variation to increase the strength of the link, leading to more precise estimates. 

They also note that an effect of the variant on characteristics other than BMI cannot be ruled out.

Body mass index also has its limitations as a measure of fatness – you can be very muscular and have a high BMI. However, it is a widely used measure of obesity, and across the large number of people involved in the study, measuring BMI should give a reasonable measure of relative fatness.

Overall, this study provides additional evidence to suggest obesity (raised BMI) has a causal influence on a number of different cardiovascular diseases, including heart failure.

And this serves to re-emphasise the message that maintaining a healthy weight is beneficial to many aspects of health.

If you are concerned about your weight, try the free NHS Choices 12-week weight-loss guide – for an evidence-based method of working to achieve safe and sustainable weight loss.  

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

Links to the headlines

Few extra pounds ‘could be deadly’. Daily Express, June 26 2013

Piling on as little as 4lbs can raise risk of heart attack by 17%. The Daily Telegraph, June 26 2013

Being just four pounds overweight can increase your risk of heart disease by 20%. Mail Online, June 26 2013

Links to the science

European Network for Genetic and Genomic Epidemiology (ENGAGE) consortium. The Role of Adiposity in Cardiometabolic Traits: A Mendelian Randomization Analysis. PLoS Medicine. Published online June 25 2013

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.

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

Binge drinking 'doubles heart risk'

reposted from: NHS Choices
crabsallover highlights

‘Binge drinking doubles heart risk,’ BBC News reported today. This study was in almost 10,000 men aged 50 to 59 without heart disease from France and Northern Ireland. Most French men drank regularly (90%) compared to half of Irish men. However, Irish men were more likely to binge drink than French men (9.4% compared to 0.5%).

The combined outcome of heart attack or death from heart attack over 10 years was observed in 5.3% of men from Belfast and 2.6% of men from France. 

Risk was doubled for binge drinkers compared to those men who drank alcohol at least one day a week but did not binge drink. Compared to regular drinkers, non-drinkers also had a doubled risk of heart attack or death from heart attack, and former drinkers had an apparent tripled risk.

The study has a few limitations, but the adverse health effects of binge drinking are well established and these results are probably reliable. Men are advised to drink no more than 21 units a week (no more than four units a day), and women should drink no more than 14 units a week (no more than three units a day). Binge drinking (more than eight units a session for men and more than six for women) should be avoided.

Where did the story come from?

The study was carried out by researchers from Toulouse University School of Medicine, other institutions in France, and Queen’s University, Belfast. Funding was provided by grants from the Institut National de la Santé et de la Recherche Médicale (INSERM) and the Merck, Sharp & Dohme-Chibret Laboratory. The study was published in the peer-reviewed British Medical Journal.

Both BBC News and The Telegraph focused on the hazards of binge drinking. However, the research findings were not as straightforward as this because never drinkers and former drinkers were also at an increased risk of heart attack compared to regular drinkers.

What kind of research was this?

This cohort study investigated how different patterns of alcohol intake affect the risk of heart disease. It examined separate study populations in Northern Ireland and in France, due to the typically different lifestyles of these countries.

A cohort study is usually the best study design to investigate the association between an exposure that occurs in daily life (in this case alcohol) and an outcome (in this case heart disease).

Limitations may arise, however, in accurately quantifying how much a person drinks. A person’s consumption at the start of the study may not reflect their previous or future consumption. Participants also needed to be checked that they did not have heart disease at the time of assessment, something that may not be certain in all cases.

Potential confounders – factors that can affect results – also need to be taken into account. Therefore, attributing alcohol consumption as the cause of heart disease may be difficult.

What did the research involve?

This study enrolled 9,778 men between 1991 and 1994, with an average age between 50 and 59. Of these, 2,745 were recruited in Belfast, Northern Ireland (from industry, the civil service and general practice). The others were recruited from three areas in France (Lille [2633], Strasbourg [2612], and Toulouse [2610], through free medical health screening and occupational medicine settings).

At the beginning of the study, all men completed health and lifestyle questionnaires, which included their alcohol consumption. The London School of Hygiene & Tropical Medicine Cardiovascular Questionnaire for Chest Pain on Effort and Possible Infarction (the Rose questionnaire) was used, which is a validated tool to evaluate chest pain.

The particpants also had their BMI, blood pressure and blood cholesterol measured and an electrocardiogram (ECG) recording. Heart disease was established based on either a prior diagnosis by a physician, ECG evidence of past heart attack, or a positive Rose chest pain questionnaire.

Weekly alcohol consumption, assessed once by questionnaire, took into account frequency of consumption, times of day alcohol was drunk, and types of beverage and their alcohol content (e.g. 10% wine, 12% wine, 4% beer, or 5% beer). One drink of alcohol was standardised as 10-12g of ethanol. The participants were then categorised into the following groups:

• never drinkers
• former drinkers
• regular drinkers (men who drank alcohol on at least one day a week, and, if drinking on only one occasion, consumed less than 50g of alcohol)
• binge drinkers (alcohol >50g on at least one day a week)

Follow-up was by annual letter or telephone call, and participants were asked to complete a clinical event questionnaire, including hospitalisations, medical consultations, and so on. Possible coronary events were confirmed by further follow-up of medical records. Death certificates were examined where necessary. The relation between characteristics at the start of the study and major coronary events (heart attack or death due to heart disease), was then analysed.

What were the basic results?

About 50% of men in Belfast and 90% of French men reported drinking regularly, with an average daily consumption of 40.2g in Belfast and 36.4g in France. In Belfast, 12% of men drank daily compared to 75% of French men who drank daily. Only 0.5% of French men (33 out of 7373) were classified as binge drinkers, compared with 9.4% of men in Belfast (227 out of 2405). Non-drinkers (including never and former drinkers) comprised 39.5% of men in Belfast and 9.4% of men in France.

Over an average 10 years of follow-up, 5.3% of the men in Belfast suffered either heart attack or related death, compared to 2.6% of the men in France (combined - 3.3% [322] of the total 9,778 sample). A further 3.7% of the total sample (361 men) developed angina (chest pain related to heart disease).

Annual incidence of hard coronary events was 5.63 per 1,000 ‘person years’ (the total sum of the number of years that each member of a study population has been under observation) in Belfast and 2.78 per 1,000 person years in France.

After adjusting for recognised cardiovascular risk factors and country of study, binge drinkers had almost double the risk of major coronary events compared to regular drinkers (hazard ratio 1.97, 95% confidence interval [CI] 1.21 to 3.22). Never drinkers and former drinkers also had greater risk compared to regular drinkers (hazard ratios 2.03, 95% CI 1.41 to 2.94, and 1.57, 95% CI 1.11 to 2.21, respectively).

How did the researchers interpret the results?

The researchers conclude that regular and moderate alcohol intake throughout the week is associated with a low risk of heart disease, whereas a binge-drinking pattern confers a higher risk.

Conclusion

This research assessed 9,778 men in Northern Ireland and France over an average period of 10 years. It has several strengths including its large size, consideration of various possible confounders, and confirmation of heart disease and heart disease events during follow-up using medical records and death certificates. However, there are still some points that need to be taken into account:

• Alcohol consumption was only assessed once, and it is not known whether this measurement represents the participant’s previous or future consumption. Also quantifying the exact alcohol content of beverages can be difficult, and people may be reluctant to report their true levels of alcohol consumption. Therefore, there may be some inaccuracy when categorising people according to their alcohol consumption.
• Though the researchers took great care to exclude anyone with heart disease when they were enrolled, it is still difficult to ensure that all participants were completely free of heart disease. A person was considered to have no heart disease if they had a never been diagnosed by a doctor, had no ECG evidence of heart disease, and gave a negative response to questions on chest pain and discomfort. However, there are various symptoms of heart disease, and sometimes a heart attack can occur suddenly in a person with no prior evidence of the condition.
• Though the news focused on the doubled risk of heart attack in binge drinkers, it should be noted that this was compared to regular drinkers (men who drank alcohol on at least one day a week, and, if drinking on only one occasion, consumed less than 50g of alcohol). Compared to regular drinkers, non-drinkers also had a doubled risk of heart attack and former drinkers had an apparent tripled risk. This complex ‘U-shaped’ relationship between alcohol and cardiovascular risk has also been observed in other studies.
• Many factors affect the risk of heart disease, and separating the effects of these factors is difficult. Although the researchers attempted to take into account factors that could affect results (potential confounders), some were not included, such as diet. They acknowledge that ‘it is difficult to conclude whether the pattern of alcohol intake has a major role in the incidence of ischaemic heart disease independent of other behaviours, such as diet’.
• The study was carried out in men, and so the results may not be directly applicable to women. The average age of the men was also 50-59, so in younger men there may not be the same association between binge drinking and heart disease.

Men are advised to drink no more than 21 units of alcohol a week (no more than four units a day), and women should drink no more than 14 units of alcohol a week (no more than three units a day). One unit is considered to be 8g by weight of alcohol. Binge drinking (more than eight units a session for men and more than six for women) should be avoided.

Links to the headlines

Binge drinking doubles risk of heart attack. The Daily Telegraph, November 24 2010

Binge drinking 'doubles heart risk'. BBC News, November 24 2010

Links to the science

Ruidavets JB, Ducimetière P, Evans A, et al Patterns of alcohol consumption and ischaemic heart disease in culturally divergent countries: the Prospective Epidemiological Study of Myocardial Infarction (PRIME). BMJ 2010; 341: c6077

Daily aspirin in middle-age call

More about Aspirin and heart attacks at crabsallover personal blog. Emma Wilkinson Health reporter, BBC News

Aspirin makes it harder for blood clots to form

Men and women over a certain age should take aspirin daily to prevent heart attacks, experts say in Heart journal.

Nottingham and Sheffield universities' analysis of almost 12,000 patients

found men from the age of 48 and women from 57 would benefit from the drug.

Heart attacks occur when a blood vessel is blocked by a clot, but aspirin makes it harder for blood clots to form.

The British Heart Foundation said more research was needed before "blanket prescribing" could be recommended.

We would encourage everyone to examine their own individual risk and take steps to reduce it by adjusting their lifestyle Dr Mike Knapton British Heart Foundation

Under existing recommendations, a GP will prescribe the drug if a person has already suffered a heart attack or a stroke.

It is also prescribed if factors such as high blood pressure put a patient at high risk of having such an "event" in the next few years.

But the researchers said, in reality, many people are not treated.

Some have speculated it may be easier to treat everyone over a specific age threshold such as 50 years.

Risks

An analysis of almost 12,000 patients aged between 30 and 75 showed that by the age of 47 in men and 58 in women, the 10-year coronary heart disease risk is 10% - a risk worth treating, the researchers said.

At that point, unless someone is at risk of dangerous side effects because they have a condition such as a stomach ulcer, the benefits outweigh the disadvantages, they concluded.

But this did not apply to people with diabetes or those at high risk of bleeding, the researchers said.

Although diabetics are likely to benefit from aspirin treatment because of their high heart disease risk, the evidence is not yet quite clear, they added.

And in anyone over the age of 75 years, the decision whether or not to take aspirin must be made on an individual basis, because they are more likely to suffer bleeding complications.

Study leader Dr Iskandar Idris, an honorary senior lecturer at Sheffield University, said routinely prescribing aspirin in these age groups was a feasible option.

But he added: "The final decision about use of aspirin must eventually be made after discussion with a healthcare provider."

Dr Mike Knapton, director of prevention and care at the British Heart Foundation, said: "Currently the recommendations in the UK are that aspirin is prescribed after a full risk assessment under medical supervision to those who have established cardiovascular disease.

"Further robust research is needed before aspirin should be considered as a blanket primary prevention measure in the UK.

"We would encourage everyone to examine their own individual risk and take steps to reduce it by adjusting their lifestyle."

Brits 'dying not to do exercise'

reposted from: http://news.bbc.co.uk/1/hi/health/6994632.stm

Brits 'dying not to do exercise'

Lack of exercise increases the risk of heart disease and cancer

Most UK adults are so unwilling to exercise that not even the threat of an early death is enough to get them off the sofa,

a survey suggests.

Only 38% of people questioned by YouGov said they would do more exercise if their life depended on it.

And British Heart Foundation figures show only a third of people manage to do enough exercise to achieve the minimum recommended amount.

Experts warned inactivity is dangerous even in those who are a healthy weight.

Among the 2,100 people surveyed, brisk walking was found to be the favourite way of getting exercise - before dancing, swimming or going to the gym.

Physical activity and obesity are two different risk factors so even if you're lean, if you're inactive you increase your risk of cancer and cardiovascular disease Dr David Haslam, National Obesity Forum

However, only 4% said they found exercise fun.

A greater inspiration was exercising to change body shape, particularly among women and young adults.

Almost a third of 18 to 24-year-olds reported they would do more exercise if they saw an unflattering photo of themselves or were told they looked fat.

Other less predictable forms of motivation to work out included fancying someone at the gym.

But

only 13% of men and 7% of women said keeping a healthy heart was their main motivator.

Excuses for not exercising were found to be always close at hand - from not having enough time to the one in seven who blame bad weather for not doing enough physical activity.

Deadly serious

The British Heart Foundation, which

is launching a campaign to encourage people to up their heart rate for 30 minutes a day,

says that

someone dies every 15 minutes as a direct result of physical inactivity.

Dr Mike Knapton, director of prevention and care at the BHF, said it was a "deadly serious" problem.

"With our busy lifestyles and labour-saving devices we've stopped getting the exercise our bodies desperately need.

"For many people, exercise has become an ugly word, something to avoid at all costs - but you'd be amazed how easy it is to up the tempo of your heartbeat.

"Just 30 minutes a day will do you and your heart the world of good."

The government recommends a minimum of 30 minutes of moderate-intensity physical activity five times a week.

Dr David Haslam, clinical director of the National Obesity Forum, said it made for depressing reading but confirmed what had been shown in clinical trials, where even those who had a heart attack did not change their lifestyles.

"Children instinctively exercise when left to their own devices, but they don't because they're stopped from doing that by the school curriculum and parents scared of child abductors and murderers lurking on every corner.

"So, if it doesn't become a habit, you're not going to work hard to go against the tide and introduce it as an adult."

He added that exercise could be incorporated into everyday life.

"Physical activity and obesity are two different risk factors, so even if you're lean, if you're inactive you increase your risk of cancer and cardiovascular disease,"

he said.

The evidence I've considered for Statin treatment - to reduce cholesterol & risk of Cardiovascular disease

this blog copied in full from my crabsallover blog February 2007.

This week SIGN (Scottish Intercollegiate Guidelines Network) published Guideline No 97 - Risk estimation and prevention of Cardiovascular Disease (CVD):-

• Full Guideline (this review references this booklet)
  
• Patient Guideline
  
• Quick Reference Guide
• Costs and Resources to implement in Scotland
  

Cardiovascular Disease (CVD) is any disease which affects the heart and blood vessels (examples include coronary heart disease, peripheral heart disease, stroke and heart failure).

Coronary Heart Disease (CHD) is a disease of the heart and coronary arteries caused by a build of fatty materials in the blood vessels which supply the heart with oxygen. This can cause a heart attack, or chest pain or angina.

My risk of CVD in the next 10 years is 1 in 12.5 (8%) according to my 'ASSIGN' score (table 1). So for every 1000 persons with my CVD risk, 80 will have a CVD event in the next 10 years.

Other Factors - not accounted for by 'ASSIGN' score

• At 102cm I have borderline abdominal obesity (defined as greater or equal to 102cm waist measurement in men). (4.7 pg 15)
• waist hip ratio is 102cm/98cm = 1.04 (<0.95>
• I'm overweight BMI >25 (12st 6 pounds, height 5'7.5", BMI 27.5).

I've reviewed Statins in several other blogs. Statins inhibit cholesterol synthesis in the liver, activate hepatocyte LDL receptors and increase uptake of LDL from the circulation (9.3 pg 28)

In October 2006 my blood tests were:

• 5.1 mmol/l total cholesterol (NHS normal: <=5.0)
• 3.0 mmol/l LDL 'bad' cholesterol
• 1.02 mmol/l HDL 'good' cholesterol (normal >1.03) (4.7 pg 15)
• total cholesterol/HDL cholesterol ratio = 5.0
• Blood pressure = 130 systolic/70 diastolic (normal <130/85)
• On 30th April 2007 my figure (ex Poole Hospital 110/70)
  
• 5.9 mmol /l glucose
  

Grades of evidence The SIGN study grades evidence ranging from High quality meta-analyses (1++) to Expert Opinion (4). It grades recommendations from A to D based on this evidence. (page 2, Full Guideline) The report defines people in a 'High Risk' category if they have a >=20% risk of CVD over the next 10 years. For those with 1% annual risk of CVD ( viz. 10% over 10 years) benefits have been shown using statins (3-Hydroxy-3-Methylglutaryl-CoA (HMG-CoA) Reductase inhibitors). Annual CVD is 1% in USA and Europe. So most middle aged men and women could benefit from a statin and CVD reduction. (Full Guideline (FG) 2.4 pg 11) 8.2 Aspirin Antiplatelet therapy with Aspirin reduces Myocardial Infarction (heart attack) risk but increases stroke and major gastrointestinal bleeding risk. P S Sanmuganathan et al in Heart85:265-271 2001; concluded "Aspirin treatment for primary prevention is safe and worthwhile at coronary event risk greater than 1.5%/year; safe but of limited value at coronary risk 1%/year; and unsafe at coronary event risk 0.5%/year.^" With my 8% over 10 year CVD risk, Aspirin is of limited value or unsafe. 9 Lipid Lowering Low density Lipoprotein (LDL) makes up 60-70% of serum cholesterol. The Friedwald equation LDL = TC-HDL-(TG/2.2) (9.2 pg 32) Statins reduce Total Cholesterol TC by approx. 20% or 1mmol and LDL Cholesterol by 30% (9.3, pg 28) with a 30% reduction in CHD mortality (9.3 pg 29). With each doubling of the dose of a statin LDL levels fall by 6%. A reduction of 1.6 mmol/l halves the risk of CHD events after 2 years and this reduction can be achieved with standard doses of statins. (9.4 pg 30, table 8) My 8% (1 in 12.5) risk of CVD (table 1, total cholesterol 5.1 mmol/l) could be reduced to a 6% risk (1 in 17) (table 2, total cholesterol 3.88 mmol/l) - a 25% risk reduction. 80 people per thousand, like me, will have CardioVascular Disease over 10 years. By taking Statins that risk is reduced to 60 people with CVD. Mild muscle pains or other adverse effects (eg fever, malaise) may require reduction in statin levels or change of statin type whilst severe side effects will require statin therapy to be discontinued. (para 9.6, pg 36). Current NHS target for individuals at high cardiovascular risk is a TC level of less than 5 mmol. Reducing this target to 4.5 or 4.0 mmol/l would have major resource implications for NHS (9.7 pg 32). Zocor (simvastatin, 10mg per day) is available from Boots over the counter for £8 per month. HDL Cholesterol my level of 1.02 mmol/l HDL Cholesterol is low and may require treatment with Fibrates (raises levels 10-15%,) (9.10.2 pg 39) or Nicotinic Acid (raises levels 15-35%) (9.10.3 pg 40) 9.8 Safety of Statins Statins are safe. No increase in cancer levels has been found. Raised levels of liver enzymes (aspartate and alanine aminotransferase) occur in 1% cases which is completely reversible when treatment is withdrawn. Minor muscle discomfort is common though the incidence varies. Rare more serious Myopathy with raised creatine kinase occurs in 0.1% cases. In 0.01% cases Rhabdomyalysis (renal failure) occurs. Withdrawal of treatment leads to recovery in a majority of cases but death can occur if patient is receiving several drug treatments or experiencing multiple symptoms. Statins may possibly interact with other medications eg fibrates (niacin, nicotinic acid). Inhibitors of cytochrome P450 and grapefruit juice may increase Myopathy risk. Atorvastatin, fluvastatin, pravastatin, rosuvastatin and simvastatin are licensed for use in UK. Annex 2 pg 62 Joint British Societies (JBS2 - reference 28) proposed total cholesterol target of <4mmol/l size="4">Annex 3 pg 65 Creatine Kinase (CK) baseline pretreatment level might be useful to monitor possible muscular symptoms. Annex 4 pg 66 Liver transaminase levels advisable prior to statin treatment, 3 months after treatment and when dose level is increased. This indicates potential for jaundice, malaise, fatigue, lethargy etc. Annex 5 pg 67 Assessment of renal function is advisable before starting statin therapy. Test for serum creatinine and proteinuria. Conclusions for my health

• current risk of CVD is 8% - table 1
  
• Aspirin is of limited value or unsafe
• Statins are safe and should be taken daily after
• a baseline checkup (total cholesterol, LDL, HDL, Triglycerides, blood pressure, Creatine Kinase, liver transaminase, serum creatinine and proteinuria)
  
• Statin treatment targets
  
• 30% reduction in LDL cholesterol (from 3 to 1.9 mmol/l)
  
• 24% reduction in total cholesterol (from 5.1 to 3.88 mmol/l)
  
• reduce risk of CVD by 25% - from 1 in 12 (8%) to 1 in 17 (6%) over 10 years - table 2.
  
• Fibrates or Nicotinic acid treatment targets (after initial statin treatment)
  
• Reduce CVD risk to 5% (1 in 20) by increasing HDL cholesterol to medium levels (1.34 mmol/l) - table 3
  
• Reduce CVD risk to 4% (1 in 25) by increasing HDL cholesterol to high levels (1.73 mmol/l) - table 4
  
• Reduce CVD risk to 3% (1 in 33) by reducing systolic blood pressure from 130 to 108 mmHg by improving diet and increasing exercise - table 5
  

Table 1: Baseline 8% risk Table 2: 6% risk after Statin treatment Table 3: 5% risk after treatment to give medium HDL cholesterol levels Table 4: 4% risk after treatment to give high HDL cholesterol levels

Table 5: 3% risk after treatment to give low blood pressure

Polypill with Statins + 5, Brilliance or Ridiculous? - July 2003

• 05 July 2003
• From New Scientist Print Edition.

IT IS, depending on who you talk to, either the most important idea in medicine for over half a century or a crazy, dangerous fantasy.

"No other preventive measure would have a greater impact on public health in the western world," say Nicholas Wald and Malcolm Law of the Wolfson Institute of Preventive Medicine in London, who proposed the "polypill" in last week's British Medical Journal. "I thought it was a joke," says Steve Nissen, a cardiologist at Ohio State University. "It is stupid and ridiculous."

The idea is to combine five cheap off-patent drugs and the vitamin folic acid in a single pill offered to everybody over the age of 55. The polypill, claims Wald, would slash the risk of heart attacks by 88 per cent and strokes by 80 per cent (see "How the polypill would work"), extending people's lives without these diseases by up to 11 years. If his calculations are right, in the US alone, it could save nearly 800,000 lives a year. Given to everyone in developed countries, where heart disease is the biggest killer, it would save many millions.

Wald and his colleagues, who are patenting the idea, now hope to find a backer to finance the polypill's development. They want to carry out small trials involving a few hundred volunteers to identify the specific drugs to include in the polypill, and then larger trials involving thousands of volunteers and various different combinations of placebo and drugs to prove it really does deliver the benefits they claim.

"The necessary trials should be started immediately," BMJ editor Richard Smith told a press conference last week. But such trials will be very expensive, and big pharma companies may not be keen to back a cheap pill that could slash demand for their more expensive patented drugs. Nor will getting approval from regulators be easy.

The polypill idea is radical for several reasons. Giving drugs to healthy people to prevent disease, rather than just to those at high risk, has been proposed before, but has never been tried on a large scale. In 2001, for instance, after a massive 7-year trial showed that a statin called simvastatin (a potential polypill ingredient) reduces the chances of a heart attack or stroke by a third, without serious side effects, the researchers suggested it should be prescribed far more widely (New Scientist, 24 November 2001, p 7).

Wald points out that most people who suffer a heart attack or stroke are not known to be at risk - so if you want to make a big difference, you have got to give the polypill to everyone over 55. Efforts to prevent heart disease by changing lifestyle factors such as smoking, diet and exercise make much less difference, he says, and anyway the polypill should be seen as an addition to these efforts, not a replacement.

Critics say the polypill could have serious side effects: aspirin can cause internal bleeding, while blood pressure drugs can cause dizziness and fainting. But Wald claims the benefits will far outweigh the risks: a third of people taking it would live longer as a result, he calculates, whereas only 8 to 15 per cent would suffer any side effects.

While aspirin can cause bleeding and strokes, he admits, it prevents more strokes than it causes. And the strategy of combining three blood pressure drugs at half the usual dose will minimise any side effects. Even people with average blood pressure will benefit, Wald says. "All the evidence suggests the lower, the better."

Another contentious issue is combining so many drugs in one pill and giving the same pill to everyone. "People are different," says Nissen. "It is just not safe." Nissen sat on the US FDA advisory panel that assessed Pravigard, the first combination pill containing a statin and aspirin, which was approved last week for people suffering from heart disease. But the application was initially rejected, until Bristol-Myers Squib came back with more combinations of different doses - six in all. If the same principle were applied to the polypill, there would be over a hundred different combinations. Wald accepts the polypill may have to be adjusted to suit some individuals. But to keep costs down "you start with one-size-fits-all, then you start tailoring", he says.

There are also more mundane problems. Pravigard still comes as two pills, because of problems with the stability of a combined pill. Putting six drugs in one tablet will be even more of a challenge.

But convincing critics like Nissen may prove even harder. "Getting the idea accepted will require a shift in attitudes," says Wald. "I recognise the obstacles. But I don't think they are insurmountable."

From issue 2402 of New Scientist magazine, 05 July 2003, page 4

How the polypill would work

The four main risk factors for cardiovascular disease are high levels of low-density lipoprotein (LDL) cholesterol and homocysteine in the blood, high blood pressure, and the tendency of blood to clot or platelet aggregation. (The link with homocysteine remains controversial.) The idea of the polypill is to combine six different drugs that lower these risks in a single pill.

The reduced risk of a heart attack or stroke due to treating each risk factor individually can be calculated from the results of clinical trials. The polypill's proponents believe these trials also show that the benefits of treating each risk factor are independent of each other. In other words, if you lower cholesterol and blood pressure, the reduction in risk is greater than if you just lower one or the other.

To work out the overall effectiveness of the polypill, they multiplied the relative risks. To understand what this means, imagine 100 people at risk of heart attacks are given a statin that reduces the risk by 60 per cent over five years. Only 40 out of the 100 will then suffer heart attacks in the next 5 years. If all 100 are also given a blood-pressure drug that lowers the risk of heart attacks by 50 per cent, only the 40 still vulnerable to heart attacks stand to benefit - but only half of them (20) will suffer heart attacks. Together the two drugs will have reduced the risk by 80 per cent (60 + 20).

A key point, say the polypill's proponents, is that if someone does not benefit from one component, they could still be helped by another. If the statin does not save them, the blood pressure drugs might.