Heart attack paper continued

30) Why pharma is against aspirin: long-term daily aspirin 325 mg dose (not the baby aspirin) [1] reduces the risk of most cancers (if not all) over 35%, and also the risk of the cancer becoming metastatic. One mechanism is that it promotes the death of abnormal cells through the body’s necrosis factor. Also the 325 mg slows the progression of atherosclerosis which causes CVD and thus its assorted signs including hypertension. Aspirin prevent heart attacks and pulmonary embolisms by preventing blood clots, thus it competes with their anticoagulants. So doctor’s recommend the baby aspirin for which tolerance quickly develops. Aspirin competes with drugs for migraine head ache, and drugs for moderate pain. And until the 1980s it was the most widely used drug to treat arthritis.[2] It also lowers the risk of Alzheimer’s disease. Regular usage of the other drugs in the NSAID family, including acetaminophen, through inhibition of COX-2, they increase the risk of heart attacks, but not aspirin which affect a different pathway--see.[3] To limit aspirin’s market presence doctors are repeatedly warned about the risk of an ulcer and that children shouldn’t take it because of Reye syndrome [4](which happens to be the extremely rare)—more pharma’s tobacco ethics and tobacco science. Moreover it costs a penny a day. Aspirin is natural; the salicylic acid form is widely produced by plants. Mammals, like with vitamins, has evolved mechanisms for usage. Pharma is in the business of marketing drugs for illnesses, thus pharma is against aspirin. I have been taking a 325 mg or two daily since 1992.

“An angiogram typically takes from 45 minutes to one hour [longer if an angioplasty is performed or problems are encountered]. The femoral artery in the groin - near where your leg bends from the hip - is one of the blood vessels doctors most commonly use to insert a catheter (a flexible tube that is smaller than the vessels) and thread it through the arteries to the heart to perform the angiogram” at. “A sheath is a vascular tube placed into the access artery, such as the femoral artery in the groin that allows catheter exchanges easily during these complex procedures. A balloon catheter is a long, thin plastic tube with a tiny balloon at its tip. A stent is a small, wire mesh tube. Balloons and stents come in varying sizes to match the size of the diseased artery” at. “Instead of the femoral artery, your doctor may choose to insert the catheter in the brachial artery in the inside of the elbow or the radial artery in the wrist. From this “access” point in your leg or arm, the catheter is threaded through the arteries to your heart. Because there are no nerves in your arteries, you will not feel the catheter passing through the blood vessels. The x-ray camera helps the physician guide the catheter to your heart. When the catheter is properly positioned, the cardiologist injects a contrast dye (radiographic contrast agent) through the catheter into the heart and its arteries. When the x-ray beam passes through the dye, the arteries appear in black silhouette on a white background. If you have blockages, they appear as white areas. The x-ray camera records a “movie” of your heart’s pumping chamber and arteries. The movie is recorded as a medical digital image. By enabling the cardiologist to see blood flow and the size, shape and length of any blockages, the angiogram provides vital information for planning the best approach to treating each one. If the angiogram shows serious blockages, the interventional cardiologist may immediately perform a coronary interventional procedure, such as balloon angioplasty and stenting, to open the blockage and restore blood flow to your heart. Or your doctor may refer you for coronary bypass surgery. During your angiogram, your interventional cardiologist may perform other tests to determine the severity of your heart condition, including the degree to which your heart arteries are narrowed by plaque buildup and whether oxygenated blood is flowing to your heart. These tests include optical coherence tomography (OCT) and intravascular ultrasound (IVUS). These tests can be performed while you are having your angiogram and can provide your interventional cardiologist with information to help guide treatment decisions. After the wound is dressed, and if the catheter was inserted in your leg, you will be asked to lie still and avoid bending your leg or lifting your head. You may need to be still for two to six hours after the catheter is removed.”

SecondsCount is a project of The Society for Cardiovascular Angiography and Interventions (SCAI). Not surprisingly restenosis, kidney damage, arterial spasms, etc. are not mentioned on their website. Nor is the quality studies that prove that the only significant benefit is the relief of angina pain, and only for some, and this might be just for a few months given that there is significant restenosis in two-thirds of patients within 3 months. Also missing is the need of a second instrument—such as the Judkin’s catheter, which is need to push the original catheter into the coronary artery. “The push-pull technique for cauterizing the left coronary artery with the judkin’s left catheter…” Figure 8-6 in Braundwald, supra. Business trumps science.

Percutaneous Coronary Angioplasty Compared with Exercise Training in Patients with Stable Coronary Artery Disease: A Randomized Trial, Circulation--Hambrecht R. et al.

Background— Regular exercise in patients with stable coronary artery disease has been shown to improve myocardial perfusion and to retard disease progression. We therefore conducted a randomized study to compare the effects of exercise training versus standard percutaneous coronary intervention (PCI) with stenting on clinical symptoms, angina-free exercise capacity, myocardial perfusion, cost-effectiveness, and frequency of a combined clinical end point (death of cardiac cause, stroke, CABG ~~[bypass surgery]~~, angioplasty, acute myocardial infarction, and worsening angina with objective evidence resulting in hospitalization).

Methods and Results— A total of 101 male patients aged ≤70 years were recruited after routine coronary angiography and randomized to 12 months of exercise training (20 minutes of bicycle ergometry per day)[5] or to PCI. Cost efficiency was calculated as the average expense (in US dollars) needed to improve the Canadian Cardiovascular Society class by 1 class. Exercise training was associated with a higher event-free survival (88% versus 70% in the PCI group, P=0.023) and increased maximal oxygen uptake (+16%, from 22.7±0.7 to 26.2±0.8 mL O₂/kg,P<0.001 versus baseline, P<0.001 versus PCI group after 12 months). To gain 1 Canadian Cardiovascular Society class, $6956 was spent in the PCI group versus $3429 in the training group (P<0.001). [This cost for exercise could be greatly reduced if after instructions by a physical therapist, the patient joined a local gym and used their exercise bike, or bought one. I have done both, and my costs yearly membership is $300 at LA Fitness, and a quality exercise bike stand ran me under $275]

Conclusions— Compared with PCI, a 12-month program of regular physical exercise in selected patients with stable coronary artery disease resulted in superior event-free survival and exercise capacity at lower costs, notably owing to reduced re-hospitalizations and repeat revascularizations.

In a large meta-analysis that included 8440 patients in 32 trials, exercise training as part of coronary rehabilitation programs [for those who had a PCI] was associated with a 31% reduction in the mortality rate in patients with stable CAD/myocardial infarction.12 [The study above is compared exercise alone to PCI.]

Study showed that of the real-world population of patients, the procedure was a failure for 52.5%; 43% within 3 months. they had major restenosis at 1 year of the patients at one year, and 61.9% at 3 months. [6] I wouildn’t submit to a procedure which in the real-world population is a failure for over two-thirds of patents? Add to this the assorted other damage not measured in this trial, such as to kidney from contrasting dye, cholesterol embolism causing minnie strokes and MIs, and the damage to the endothelia cell through abrasion and punctures caused by the instrument navigating through the arties. And there is good reason to believe that only slightly better numbers are obtained for the use of a stent. And it gets worse because having these procedures in quality studies does not reduce the risk of MI or death. Thus undergoing the angiogram, an expensive procedure (we are all paying for it through taxes and insurance premiums) that often leads to the incursion of a stent and balloon angioplasty will not benefit me. See “Hopes Hypothesis” at #28 which lays to rest the faulty logic that the one-third of patients benefited. I would say no to an angiogram.

Restenosis After Successful Percutaneous Transluminal Coronary Angioplasty: Serial Angiographic Follow-Up of 229 Patients

Abstract

To further understand the temporal mode and mechanisms of coronary restenosis, 229 patients were studied by prospective angiographic follow-up on day 1 and at 1, 3 and 6 months and 1 year after successful percutaneous transluminal [through the skin, standard procedure] coronary angioplasty. Quantitative measurement of coronary stenosis was achieved by cine-video-densitometric analysis. Actuarial restenosis rate was 12.7% at 1 month, 43.0% at 3 months, 49.4% at 6 months and 52.5% at 1 year.

In 219 patients followed up for ≥3 months, mean stenosis diameter was 1.91 ± 0.53 mm immediately after coronary angioplasty, 1.72 ± 0.52 mm on day 1, 1.86 ± 0.58 mm at 1 month and 1.43 ± 0.67 mm at 3 months. In 149 patients followed up for ≥6 months, mean stenosis diameter was 1.66 ± 0.58 mm at 3 months and 1.66 ± 0.62 mm at 6 months. In 73 patients followed up for 1 year, mean stenosis diameter was 1.65 ± 0.56 mm at 6 months and 1.66 ± 0.57 mm at 1 year. Thus, stenosis diameter decreased markedly between 1 month and 3 months after coronary angioplasty and reached a plateau thereafter. In conclusion, restenosis is most prevalent between 1 and 3 months and rarely occurs beyond 3 months after coronary angioplasty.

[1] With the baby aspirin, tolerance develops so that at 1 year it doesn’t prevent heart attacks. Thus pharma tells doctors it is okay to give the 125 mg aspirin. And it is too weak to prevent cancer or Alzheimer’s disease. More dirty pharma. Others include reducing the pill from 500 mg to 325, and promoting the coated which dissolves to slow to treat pain. The risk of ulcers with daily use goes up about 2%, the same as for most other drugs used long-term. But pharma is against aspirin, so the risk is exaggerated.

[2] “For almost 100 years the salicylates [aspirin family of drugs] have retained their preeminent position” Goodman and Gilman Pharmacology, 11^th Ed, 2006, p. 692. “It is the standard against which all rheumatoid arthritis medication should be measured” supra 690. 3.5 gram is the recommended dose--Merck Manual 1987, p. 960, and same in earlier editions.

[3] For example Vioxx was voluntarily withdrawn in 2004 after causing an estimated 125,000 heart attacks--mechanism. The American Heart Association and others warn of the increased risk with long-term usage of NSAIDs but for aspirin.

[4] The 2010 Wikipedia article on aspirin stated that the incidence of Rye syndrome once diagnosis based on symptom occurred over 500 times, but when diagnosed by a blood test dropped to 2 cases yearly. That section was changed so as to continue the scare tactics.

[5] Those in the exercise group “participated in one 60-minute group training session of aerobic exercise per week” full supra. This group session would cause a greater compliance of the daily 20 minute exercise part of the program.

[6] 52.5% restenosis + 18.9% failure = 71.4% at one year; 43% restenosis + 18.9% failure at 3 months