PRACTICAL POINTS FOR PRACTICE
MEDICAL SUBJECT HEADINGS
HIGHLIGHTS AND EDITORIAL COMMENTS
This document is divided into three parts:
1) “Practical
Points”—one sentence statements of how the articles abstracted during the 6
months may influence primary care practice.
2) Seventy seven medical subject headings (MeSH) from “Absolute
Cardiovascular Risks” to “Ximelagatran”. Each of the medical subject headings is linked
to one or more
“Highlights and Editorial
Comments” of articles abstracted during the first half of 2005.
3) A “Highlights-Editorial
Comments” Section, arranged alphabetically following the list of MESH, provides a means of recalling to memory, in an
evening or two, what the editor considered
new and important for primary care presented in 6 flagship journals over the 6 months.
The numbers in the brackets refer to the full abstract. For example, [6-2] indicates the 2nd abstract
published in the June issue.
The indexes and each monthly issue for the past 5 years can be found on
the website (www.practicalpointers.org). HTML links make possible easy and speedy
access to the full abstract and the journal reference of all articles abstracted
under an individual MeSH.
I hope you find the publication useful and interesting.
Richard T. James Jr.
M.D.
The editor thanks Whitney Lowell for internet applications and Lois M.
James for proofreading.
PRACTICAL POINTS JANUARY-JUNE 2005
HOW THE ARTICLES ABSTRACTED INFLUENCED MY PRACTICE
·
Consider use of herpes zoster vaccine
when it becomes available. [6-1]
·
Consider use of delayed prescriptions
for acute lower respiratory infections [6-2]
·
Encourage patients to consider their abdominal
girth a risk factor [6-3]
·
Be cautious in using aspirin for
primary protection of CHD in elderly women. [6-5]
·
Care in using antipsychotic drugs in
nursing homes [6-6]
·
Consider a thiazide a first-line treatment in hypertensive
diabetics and blacks [6-8] [4-1]
·
Use opioids
more freely for patients with neuropathic pain [6-9] Consider use of gabapentin combined with
morphine for severe neuropathic pain [3-4]
·
Advise patients that high dose
vitamin E is useless in the elderly with memory defects or for reduction of
risk of cardiovascular disease and cancer. And it may be toxic [6-10] [3-10]
·
Advise younger overweight patients
that weight loss will prevent later development of hypertension [6-11]
·
Continue to advise vitamin D (800 IU)
for primary prevention of osteoporosis and fractures [5-3]
·
For first-line therapy, advise
symptomatic treatment for traveler’s diarrhea, not antibiotics. [5-4]
·
For patients with persistent cough,
pertussis is a possibility [5-5]
·
Oral vitamin B12 in high dose is
effective therapy [5-6]
·
Progesterone, not estrogen, is the
risk factor for breast cancer in women receiving HRT [5-7]
·
Inform men about risks of PSA
screening as well as benefits. Consider that “most prostate cancers now removed
need not be removed” [5-9]
·
Treat acute pain of herpes zoster aggressively to lower
severity of post-herpetic neuralgia pain [5-10]
·
Stress the benefits of a modified Mediterranean
diet which contains poly-unsaturated fats as well as mono-unsaturated fats. [4-4]
·
Consider the “Money needed to treat”
as well as the “Number needed to treat needlessly” [4-6]
·
Consult with your cardiologist
consultants about availability and advisability of cardiac resynchronization in
patients with left bundle-branch-block and heart failure. [4-10]
·
Consider myasthenia gravis in a
patient with fluctuating weakness which improves with rest and application of
cold. [4-11]
·
Consider that all adults have at
least one risk factor for cardiovascular disease. All should be considered in
each individual patient. Changing life-styles is basic therapy. Many will benefit
from drug therapy [3-1] [3-2]
·
Know the drugs available for
prophylaxis and treatment of influenza [ 2-1]
·
Never give up encouraging smokers to
quit [ 2-3]
·
For atrial
fibrillation, rate control is preferable to rhythm control [ 2-4]
·
Simple first aid and local wound care
the best approach for bites of the brown recluse spider. [ 2-6]
·
Extent of treatment of hypertension
and dyslipidemia should depend on the patient’s absolute cardiovascular risk. [1-1]
·
In considering application of results
of trials beware of surrogate endpoints, composite outcome measures,
underreporting of adverse effects, and reports by pharmaceutical companies. [1-2]
·
Uncertainty is inherent in primary
care practice. Evidence helps quantify the uncertainty, but cannot remove
it. [1-4]
·
Know the benefits of a new class of
drugs to treat breast cancer (aromatase inhibitors) [1-5]
·
Fast foods are an ominous public
health issue [1-8]
·
For patients with persistent
dyspepsia consider testing of H pylori and treating if positive. [1-9]
·
The U. S Preventive Services Task
Force recommends one-time screening for abdominal aortic aneurysm in persons
who smoke. [1-11]
MEDICAL SUBJECT HEADINGS (MeSH) JANUARY-
JUNE 2005
ALLHAT STUDIES (SEE HYPERTENSION [6-8])
AROMATASE INHIBITOR (SEE BREAST
CANCER [1-5])
CONGESTIVE HEART
FAILURE (SEE HEART
FAILURE)
CORONARY
HEART DISEASE (SEE ALSO ISCHEMIC HEART DISEASE [5-2])
C-REACTIVE PROTEIN (SEE STATIN
DRUGS [1-13])
ESTROGEN (SEE HORMONE REPLACEMENT THERAPY)
FOLIC ACID (See HOMOCYSTEINE [3-9])
FRACTURE (SEE VITAMIN D [5-3])
GASTRO
ESOPHAGEAL REFLUX DISEASE
NUMBERS
NEEDED TO TREAT (NEEDLESSLY)
PAIN (SEE OPIOID AGONISTS [6-9])
PERTUSSIS (SEE WHOOPING COUGH
[5-5])
POLYPILL (SEE CORONARY HEART DISEASE)
POSTHERPETIC NEURALGIA
AND PAIN (SEE HERPES
ZOSTER)
POWER AND AUTHORITY IN MEDICINE
SENSITIVITY,
SPECIFICITY, AND PREDICTIVE VALUES: A REVIEW
HIGHLIGHTS AND EDITORIAL COMMENTS
JANUARY- JUNE 2005
Treat the Patient, Not the BP, Not
the cholesterol
Absolute risk of a cardiovascular
disease is the probability that an individual
patient will have an event over a defined period. It is determined by a
synergistic effect of all CVD risk
factors present in the individual. It may be true that, in a large group of
individuals with a systolic BP of 160, the CVD risk is twice as high as in a large group with a
systolic of 110 (relative risk). In
an individual, however, absolute risk depends on much more than a single risk
factor. Indeed, absolute differences in risk can vary more than 20-fold in
patients with the same BP.
“Cardiovascular
treatment benefit is directly proportional to the pre-treatment absolute risk.”
A
new approach to preventive therapy is to modestly reduce all modifiable risk
factors rather than concentrating on reaching “target levels’ of one or two.
This is a sea change in our approach to
lowering risk.
Please read the full
abstract.
Proposing an ABCDE Memory Device to Simplify Adherence to
Guidelines
1-6 A SIMPLIFIED APPROACH TO THE MANAGEMENT OF
NON-ST-SEGMENT ELEVATION ACUTE CORONARY SYNDROMES
The
study assembled a comprehensive plan through an “ABCDE” approach. The intention
was to provide a
memory device to overview therapies and
lifestyle changes that are clinically useful for patients with NSTE-ACS.
Elements
of the plan:
A Antiplatelets; Anticoagulation; ACE
inhibitors; Angiotensin II blockers.
B Beta-blockers; Blood pressure control
C Cholesterol management; Cigarette cessation
D Diet; Diabetes management
E Exercise.
This practical
approach allows physicians to more effectively create disease management
protocols, define roles and responsibilities for different medical personnel,
and ensure implementation of evidence-based short-
and long-term medical and risk-reducing
strategies.
This
plan is almost identical to a check list presented in the Archives Int Med July
2004 for secondary prevention of cardiovascular disease. (See Practical
Pointers July 2004 [7-8] )
I
believe check lists can be a valuable addition to primary care. In the hurried
pace of practice, we all omit (simply forget to consider) aspects of treatment
and lifestyle which should be addressed at almost every patient visit. A
mneumonic check list is a practical approach.
Some
clinicians may make their own. I tried to create a mneumonic check list for
diabetes:
D Diet;
Depression
I Insulin
A Aspirin; ACE
inhibitors
B BMI; BP
E Exercise
T Tests (blood glucose; HbA1c; lipids;
microalbuminuria; liver function; ejection fraction)
E Eye (retinopathy); Extremities (foot
health; foot pulses; peripheral neuropathy)
S Sulfonylureas, Statins, and other oral
drugs; Smoking
Plus
(Add others which might be indicated.)
“Ask Your Doctor if X is Right for You”
4-12 DIRECT-TO-CONSUMER ADVERTISING
A Haphazard Approach to Health
Promotion
DTCA drives sales of newer, more
expensive products for symptomatic relief of chronic conditions. The market
potential is huge. Erectile dysfunction, arthritis, and allergies are the most
common conditions advertised.
“Relying
on emotional appeals, most advertisements provide a minimal amount of health
information, describe benefits in vague, qualitative terms, and rarely offer
evidence of support claims.”
The
great majority of physicians believe that DTCA does not provide balanced
information. The FDA
rarely writes regulatory letters. “Millions of patients are
exposed to misleading advertisements.” Nearly 80% of physicians think that DTCA
encourages patients to seek treatments they do not need. Less than 10% of
physicians consider DTCA a positive trend in health care.
Is ED a manufactured “disease”? Is drug treatment mainly recreational?
I confess that
advertisements on TV touting a drug in market terms and then asking the
listener to “Ask your doctor if the drug is right for you” irritates me. It
would require considerable time and patience to educate individual patients
about the benefit/harm-cost ratio of a given drug. It may be easier to submit
as gracefully as possible.
I believe claims by drug
companies that DTCA is for instruction and benefit of the consumer are
specious. The purpose is to market the drug and increase profits.. After all, we live in a capitalistic society.
One or Two Drinks per Day may Reduce
Risk of Cognitive Decline
1-12 EFFECTS OF MODERATE
ALCOHOL CONSUMPTION ON COGNITIVE FUNCTION IN WOMEN.
This
study asks—What is the effect of moderate consumption of alcohol on cognition? A benefit is
plausible considering the strong link between moderate alcohol and decreased
risk of cardiovascular disease. Cognitive impairment and cardiovascular disease
share common risk factors.
Compared
with abstainers, moderate drinkers (less than 15 g alcohol per day; one drink)
had better mean cognitive scores. (Relative risk of impairment = 0.81 based on
a global cognitive score.) Also,
compared with abstainers, moderate drinkers (15 to 30 g per day) had a reduced
relative risk of cognitive impairment (although slightly less favorable, with
wider confidence intervals).
In
older women consumption of one alcoholic drink per day did not impair cognitive
function, and may actually decrease risk of cognitive decline.
Benefits of moderate alcohol consumption have
been reported with remarkable consistency over the past 10 years. Indeed, some
epidemiologists consider abstinence to be a risk factor for cardiovascular
disease.
As always, we should be cautious about generalizing the conclusions of
observational studies.
“Almost No Pattern of Drinking (Even
Low-To-Moderate) is Entirely Risk Free.”
Over the past 30
years, advances in our understanding of drinking problems have been
substantial.
This review
considers 3 subtopics: 1) the
epidemiology of alcohol’s role in health and illness, 2) treatment of alcohol
use disorders as part of public health, and 3) prevention and policy research.
Alcohol is
causally linked to more than 60 different medical conditions—most, but not all,
detrimental.
For most diseases there is a dose-response relationship. Not
only the volume of consumption, but patterns of drinking (especially binge
drinking) determine the burden of disease. Almost no pattern of drinking (even
low-to-moderate) is entirely risk free.
Breast cancer (BC):
Meta-analyses have shown
a linear increase in risk of BC associated with increasing average consumption
of alcohol.
Coronary heart disease
(CHD):
Comprehensive
meta-analyses reiterate the protective effect of low-to-moderate alcohol
intake—a J-shaped
curve.
Injury
(violence)
Several
pharmacological effects are likely to increase probability of aggressive
behavior.
Alcohol accounts
for about as much of the burden of disease globally as tobacco. Its burden is surpassed only by unsafe sex,
high blood pressure, and malnutrition.
Among heavy
drinkers who have no evidence of severe alcohol dependence, an intervention in
primary care aimed at reduction of drinking to moderate levels may benefit.
Evidence suggests that clinically significant effects on drinking behavior can
follow a brief intervention—but not in alcohol-dependent persons.
Overall, a discouraging
report. Primary care
clinicians may have some place in prevention of alcohol dependence by early
assessment and intervention.
Many
experts have urged screening, especially for patients who are hospitalized for
any reason.
AUDIT and CAGE questionnaires available on Google. Screening
in itself may broach the subject and lead patients to self-examination.
The
relation between breast cancer and alcohol has not been well publicized. I
believe it prudent to inform women at high risk (family history; breast cancer
genes) about the risk.
No
level of alcohol consumption is known to be safe in pregnancy.
Associated With A Slight Reduction
In Days Of Heavy Drinking
4-13 EFFICACY AND TOLERABILITY OF LONG-ACTING
INJECTABLE NALTREXONE FOR ALCOHOL DEPENDENCE
The opioid antagonist naltrexone has been shown to be effective
for treatment of alcohol dependence (AD).
The FDA approved naltrexone in 1994 to treat AD after it was shown to reduce
drinking frequency and likelihood of relapse to heavy drinking.
However, adherence to daily oral
therapy is problematic, as it is with other medications.
Recently a new
formulation of naltrexone has been made available. When given by injection, it
releases the drug over a period of one month without daily peaks in
concentration.
A randomized,
double-blind, placebo-controlled multicenter trial followed over 400 patients
(mean age = 45). All were considered to be AD and almost all were still
actively drinking (median heavy drinking days per month = 20). All were seeking
treatment for their AD.
Randomized to: 1) monthly injections of 380 mg long-acting
naltrexone, or 2) placebo injections.
All also received low-intensity psychosocial intervention.
Follow-up = 6
months.
Conclusion: Long-acting naltrexone, given by injection
once a month, was associated with a slight reduction in days of heavy drinking.
Authors
(with concurrence from journal editors) persist in reporting efficacy as
percentages. (“Naltrexone resulted in a 25% reduction in the event rate of
heavy drinking days”).
Results of the trial were not impressive. Dropout rate was high. Women
did not benefit. Adverse effects were frequent. “Spin” was evident.
The
most evident benefit shown by the study was in the “placebo” group (motivated
patients who received counseling). At 6
months there was a median reduction in days of heavy drinking per month from
about 19 to about 6. Naltrexone was
associated with a further reduction from
Should
primary care clinicians administer long-acting naltrexone by injection? I believe only in exceptional circumstances.
If a patient with AD approaches the primary care clinician for help, the desire
to quit must be understood to be strongly motivated. The clinician must be able
to provide adequate counseling. Follow-up must be rigid. The clinician and
patient must enter a contract to guide compliance. The small added benefit from
naltrexone must be made clear.
We await better treatments, perhaps with the addition of two or more
pharmacological agents (eg, acamprosate).
The
study was sponsored by Alkermes and Pharmacological Product Development Inc.
who collected and monitored the data. Data were managed and analyzed by Alkermes
clinical and statistical staff.
The USPSTF Now Recommends One-Time
Screening in Select Subsets of Men
1-11 SCREENING FOR ABDOMINAL ANEURYSM
The
U.S. Preventive Services Task Force (USPSTF)
now recommends one-time ultrasonographic screening for abdominal aortic
aneurysm (AAA) for men ages 65 to 75
who presently smoke or who have smoked in the past.
The
task force makes no recommendation for or against screening men who have never
smoked. It recommends against routine
screening for women.
One-time
screening is sufficient.
Is there any medical treatment? Will
beta-blockers decrease the rate of expansion by reducing the
stress caused by the steep increase in wall
expansion during systole? Many patients
in this age group with AAAs would be candidates for beta-blocker therapy
because of an increase in risk factors for CVD, including sub-optimal BP
control.
As always, primary care
clinicians must judge benefits vs harms of individual patients. The
availability of expert, safe surgery is a major factor influencing the
recommendation.
Advice for screening carries
ethical considerations. Although opportunistic preventive medicine is
considered a part of good medical practice, is it always ethically justifiable?
Consider a male smoker age 70 who consults for arthritis. Should the primary
care clinician at the time of the consultation advise the patient to undergo
screening for AAA? Should the primary care clinician advise a prostate specific
antigen?
Physicians who offer a
screening test carry a considerable responsibility. They must offer enough information about
risks and benefits in order to enable the patient to give informed consent.
Every test carries a chance of a false-positive result leading to interventions
that do not benefit the patient, and may cause harm.
I believe many primary care
clinicians would limit screening for AAA to patients who consult for a specific
indication—assessment of their general health status.
Antibiotics Provided Little Advantage Compared With
No-Antibiotics.
6-2 INFORMATION LEAFLET AND ANTIBIOTIC
PRESCRIBING STRATEGIES FOR ACUTE LOWER RESPIRATORY INFECTION
Pharyngitis and acute bronchitis are the main causes of
excess antibiotic prescribing.
This pragmatic
study assessed the effectiveness of 3 different antibiotic strategies for acute
bronchitis.
Randomized,
controlled trial followed over 800 patients presenting to primary care with
acute uncomplicated
LRI.
Patients with findings suggestive of pneumonia were excluded—new focal
chest signs (focal crepitations or bronchial breathing); and systemic features (high fever,
vomiting, severe diarrhea). Also excluded patients with
asthma, other chronic or acute lung diseases, cardiovascular disease, or with
previous pneumonia.
Randomized
to: 1) no antibiotic prescribed [control
group], 2) delayed prescription [to be
picked up later], or 3) immediately prescribed antibiotic. The antibiotic of
choice was amoxicillin 250 mg 3 times daily for 10 days, or, if allergic,
erythromycin 250 mg 4 times a day for 10 days.
Compared with no
antibiotics [control group], the other strategies did not significantly alter
cough
duration: Delayed prescription shortened
duration by 0.75 days; immediate
prescription by 0.11 days. Treatment
group had no effect on duration of other symptoms.
“Compared with
immediate antibiotics, a strategy of either no offer of antibiotics or a
delayed prescription was associated with little difference in duration or
severity of symptoms.”
Overall, antibiotics probably do provide modest symptomatic relief. If a
benefit is present, it represents a shortening of only one day in a relatively
long history. “It is difficult to
justify widespread antibiotic prescribing for uncomplicated lower respiratory
infection on this basis, given the dangers of antibiotic resistance.”
I
was somewhat surprised at the duration of cough symptoms in this group of
patients—a mean total of 3 weeks. However, I believe most patients would
experience a gradual improvement over this period. We are admonished to
consider pertussis in patient with LRI when the cough lasts 3 weeks or more. I
presume in pertussis the cough continues unabated.
I
believe advising patients that antibiotics may be associated with serious
adverse effects (eg, colitis) will do more to tilt them toward accepting only
symptomatic therapy than would advising them of the danger of antibiotic
resistance in the community.
I
have had success in prescribing delayed prescriptions of patients with
uncomplicated lower respiratory infections. The great majority never fills the
prescription. This may be an acceptable means of satisfying a demanding
patient.
In
the
The
decision by primary care clinicians to prescribe or not prescribe, I believe,
will often depend on how “sick” the patient appears.
Potentially A Less Intimidating
Alternative to Warfarin. Concerns about
Hepatotoxicity
2-7 XIMELAGATRAN—Promises and Concerns
Melagatran is a highly-specific direct thrombin inhibitor,
an analogue of hirudin, the thrombin inhibitor found in the medicinal leech. It is a small dipeptide which binds
reversibly to the active site of thrombin. It inhibits clot-bound thrombin as
well as free thrombin. Ximelagatran is a prodrug form of melagatran. It is
rapidly absorbed from the GI tract. When given orally it is rapidly converted
to melagatran. Its antithrombin activity is immediate. Peak blood levels are
attained in 3 hours. It is cleared entirely by renal excretion in 12 hours.
Since
the effect is predictable at a fixed dose, monitoring is not necessary.
This
is not yet a practical point for primary care since the drug is not yet
approved by the FDA. Many attributes of
the drug make it a very attractive anticoagulant: immediate action when given orally; a fixed dose
without need for monitoring; rapid renal clearance; no food or drug interactions; active against clot-bound as well as free
thrombin; reversible binding to
thrombin.
If
the risk of hepatotoxicity can be controlled by monitoring, I believe it will
be a major therapeutic advance.
Warfarin Provided No Benefit Over Aspirin. Was
Associated With More Adverse Effects.
3-7 COMPARISON OF WARFARIN AND ASPIRIN FOR
SYMPTOMATIC INTRACRANIAL STENOSIS.
Randomized, double-blind multicenter
(59 sites) trial entered over 550 patients (mean age 63). All
had experienced a TIA or a non-disabling
stroke caused by angiographically verified 50% to 99% stenosis of a major
intracranial artery (internal carotid, middle cerebral, vertebral, or basilar).
Randomized to: 1) warfarin—target INR of 2.0 to 3.0, or 2)
aspirin 650 mg twice daily.
Warfarin provided no benefit over
aspirin. It was associated with significantly higher rates of adverse events.
“Aspirin should be used in preference to warfarin for patients with
intracranial arterial stenosis.”
This is a good example of a pragmatic (real world of practice) trial.
Difficulty in control of warfarin dosage may have been the cause of its lack of
benefit.
“Our Most Important Finding Was The High Level Of
Antipsychotic Prescribing In NHs.”
6-6 THE
QUALITY OF ANTIPSYCHOTIC DRUG PRESCRIBING IN NURSING HOMES
Antipsychotic drug prescribing in
nursing homes (NHs) has been rising.
Federal statutes are in effect to
protect NH residents from receiving inappropriate antipsychotics. They may be
appropriately prescribed for delirium and dementia only if psychotic features
or dangerous behaviors are present. Guidelines also stipulate maximum daily
doses.
For residents with dementia,
behavioral assessments must also show evidence of verbal or physical aggression
or delusions or hallucinations.
Impaired memory, wandering,
restlessness, unsociability, uncooperativeness, and indifference to
surroundings are NOT indications.
Use of antipsychotic drugs in NHs was
widespread. Most atypicals were prescribed outside the prescribing guidelines
with doses, and for indications without strong clinical evidence of benefit.
About 1 in 4 received doses exceeding recommended. About 2/3 of use was
appropriate—dementia with aggressive behavior; dementia with delusions;
psychotic disorder. About 1/3 received the drugs inappropriately—impaired
memory; depression without psychotic
features; indifference to surroundings;
insomnia; anxiety; wandering; restlessness; uncooperativeness; unsociability.
The study failed to detect positive
relationships between behavioral symptoms and antipsychotic therapy.
“This study raises questions about
the current uses of antipsychotics in NHs.”
These are powerful drugs. Elderly patients are subject to more adverse
effects. They require a lower dose because of impaired renal function and
concomitant illness. The PDR reiterates that schizophrenia is the only
indication. There is no mention of use in nursing homes. Few studies have
concerned patients over age 65.
I believe the most appropriate question to ask when contemplating use of
antipsychotics in NHs is...
Am I prescribing this drug to benefit
the patient, or the nursing staff and the family? This can be a most difficult
decision to make. If they are prescribed, individual-
patient’s response must be carefully monitored.
The NNT to Prevent One Stroke is Very High
Use of aspirin in primary prevention in women is
controversial. The current recommendations for use of aspirin in primary prevention in women are based on
limited data.
The Women’s Health Study was a large,
randomized, double-blind placebo-controlled trial of low-dose aspirin in the
primary prevention of cardiovascular disease among over 39 000 apparently
healthy women followed for a mean of 10 years for major cardiovascular events.
For the entire group of women over
age 45, aspirin reduced risk of ischemic stroke. It did not protect against
myocardial infarction and death from cardiovascular causes until after age 65.
Women taking aspirin experienced
significantly more GI hemorrhages (RR = 1.40)
By my calculation, between 500 and 900 individuals would need to be
treated for 10 years to prevent one ischemic stroke. Is this clinically
significant?—especially when the increased risk of hemorrhage is
considered. RTJ)
Thus far, studies indicate that, in men, the prophylactic benefit against
first occurrence of myocardial infarction is much greater than in women. But in
men, aspirin does not provide primary protection against stroke.
“No Indication Of A Net Benefit.”
Current
“Prophylactic use of a potentially
toxic agent can be problematic, particularly in people in whom comorbidity and
polypharmacy are common.” In a prospective observational study in two large
This epidemiological modeling study
was conducted in a hypothetical population (10 000 men and 10 000 women)
selected from a reference population from a state in
Proportional benefit gained from aspirin
in prevention of MI and ischemic stroke vs
excess hemorrhage from age 70-74 to age 100 or to death:
Benefit in preventing Men (n = 10
000) Women (n = 10 000)
Myocardial infarction - 389 - 321
Ischemic stroke - 19 - 35
Harm
Excess GI hemorrhage +
499 + 572
Excess hemorrhagic stroke + 76 + 54
When comparing net harms vs net benefits of aspirin, the effects
on length and quality of life were equivocal.
“Despite sound evidence for efficacy,
the temptation to blindly implement low-dose aspirin treatment for the primary prevention of cardiovascular
disease in elderly people must be resisted.”
Benefits may be offset by harms.
I believe low