Is the new advice on aspirin a course change in medicine or just science? | Health | Magazine

For more than 30 years, many people have relied on this pain reliever to protect them from a first heart attack or stroke.

When it comes to preventive health, few principles are as ingrained as taking a daily aspirin. For more than 30 years, many people have relied on this pain reliever to protect them from a first heart attack or stroke.

That’s why many were surprised last month that A group of influential experts, the US Preventive Services Task Force, appears to be reversing decades of medical practice, announcing that daily low-dose aspirin should no longer be automatically recommended in middle age to prevent heart attacks

“For some people it was almost like taking a vitamin,” said Eric Topol, a cardiologist and professor of molecular medicine at Scripps Research in La Jolla, California.

At a time when many people are already confused by the pandemic’s changing advice – on face masks, viral transmission, and booster shots – the new aspirin recommendations left some shaking their heads.

“Wait long enough, and tobacco and heavy cream will be good for your health,” wrote Richard Koss, a New York economist, in a comment after reading about the new guidelines. “The vast majority of people are fed up with this kind of thing and, with good reason, don’t pay attention to it.”

However, experts say that patients should be reassured that even the most reliable medical guidelines are reviewed and updated as scientific knowledge evolves.

“It seems to happen overnight, but that’s the way science works,” said Sophie M. Balzora, a gastroenterologist at New York University Langone Health. “If we had the same guidelines all the time, then the question would be: Is science really advancing? Are we really learning more?

A history of turnaround in medicine

Changes in medical advice are quite common and tend to fall into three categories: emergent guidance, replacement advice, and rollbacks.

The emerging orientation occurs in times of crisis, such as pandemics, and is bound to change rapidly. In recent months, provisions on how best to treat COVID-19 patients, masks to prevent transmission, and the limits of vaccine protection have changed as knowledge about the coronavirus and its diseases has evolved. variants.

Sometimes it is difficult to tell the difference between a replacement advice, which is issued when research improves on previous advice, and a complete reversal, which occurs because common medical practice ahead of science and never worked or even worked. caused damage. Here are some examples of true course changes in medicine in recent years.

Hormones of menopause to protect the heart: In 2002, decades of advice on the benefits of menopausal hormones for the heart seemed to change overnight when a major study called the Women’s Health Initiative stopped after researchers found more heart attacks in women. taking hormones. In retrospect, the clinicians had misinterpreted the data from the observational study. The current advice is: hormones can alleviate the symptoms of menopause, but should not be used to prevent chronic diseases.

Vioxx as a low-risk treatment for arthritis: In 1999, the U.S. Food and Drug Administration (FDA) approved Vioxx as an innovative pain reliever because it reduced the risk of gastrointestinal problems, but in 2004, Merck withdrew the drug because studies showed that it increased significantly the risk of heart attack.

Arthroscopic surgery on aging knees: For years, the partial removal of torn meniscus tissue was the most common orthopedic procedure in the United States, with about 700,000 surgeries a year. In 2013, a researcher from Finland compared the operation to a “sham” procedure and revealed that there was no benefit. Now, instead, most doctors recommend physical therapy.

Mega doses of vitamins to reduce the risk of cancer and heart disease: For years, doctors thought that various vitamins could reduce the risk of cancer and heart disease, but several studies have shown just the opposite. A study on beta-carotene and vitamin A revealed that supplements actually increased the risk of developing lung cancer in male smokers. A study on vitamin E and selenium, which in theory protect against prostate cancer, revealed that they increased the risk of developing the disease.

Stents for stable heart disease: Doctors used to insert stents – small metal mesh tubes that prop up open arteries – in millions of otherwise stable heart disease patients. One study revealed that the surgical procedure was no better than drug treatment in preventing heart attacks.

Vinay Prasad, associate professor at the University of California, San Francisco, and Adam S. Cifu, professor of medicine in the Department of Medicine at the University of Chicago, coined the term “medical reversal” and concluded that about 40 percent of the Common medical practices they reviewed were found to be unhelpful or harmful. In their book, “Ending Medical Reversal: Improving Outcomes, Saving Lives,” they noted that most of these failed treatments were initially adopted because they were based on logical reasoning. .

“What is usually behind the reversal is that all these actions have a good history, they have a good pathophysiological reasoning,” said Cifu. “They should work, but they only do it if they have been shown to work in people, and people are very complicated.”

The reason the aspirin advice changed

Although taking a daily aspirin can reduce the risk of having a heart attack or stroke, it can also increase the risk of internal bleeding. Although the absolute risk of bleeding is more or less low, it increases with age.

For people who have had a heart attack, stroke, or other major cardiovascular problem, the arguments that using aspirin protects them from a second episode remain strong. The new guidelines from the Preventive Services Task Force do not change this advice.

What has changed is the guidance on using aspirin to prevent a first heart attack or stroke.

Three major aspirin studies influenced the task force’s advice this year.

– A 2018 study involving more than 19,000 healthy people 65 years of age and older showed that regular use of low-dose aspirin significantly increased the risk of bleeding and did not reduce the risk of heart problems compared to a placebo.

– A 2018 study of the use of aspirin in 15,480 people with diabetes revealed a benefit for the heart, but also a significant risk of bleeding.

– A study conducted in seven countries on the use of aspirin in 12,546 moderate-risk people between the ages of 50 and 60 was inconclusive, actually perhaps because other prevention strategies concealed the effect of aspirin.

Consequently, last month, the task force stated that people 60 and older should not start taking aspirin to prevent a first heart attack or stroke. For people ages 40 to 59, the task force suggested talking to a doctor about the risks and benefits.

“There is new evidence, and now we need to look at how to collect it and relate it to today’s population. How do we relate them to the American population in 2021? ”Asked Chien-Wen Tseng, task force member and director of research at the John A. Burns School of Medicine at the University of Hawaii.

Tseng said he hoped the new aspirin regulations would induce more people to talk to their doctors about their heart health.

“One of the key messages we need to get across is that aspirin is not like a vitamin,” concluded Tseng. “There are potential benefits and risks. Everyone should talk to their doctor instead of just opening a bottle and taking an aspirin automatically because they have reached a certain age. “ (I)

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