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From the New York Times 7/20/04, via AOL:

Kirk Condyles for The New York Times
Dr. Mark A. Goodman of Garden City, N.Y., has tested all his patients and found many are aspirin resistant.

For Some, Aspirin May Not Help Hearts
By ANDREW POLLACK

Published: July 20, 2004

More than 20 million Americans take aspirin regularly to help prevent heart attacks and strokes. But new evidence suggests that for many of them, the pills do little if any good. Recent studies have found that anywhere from 5 percent to more than 40 percent of aspirin users are "nonresponsive" or "resistant" to the medicine. That means that aspirin does not inhibit their blood from clotting, as it is supposed to.

"They are taking it for stroke and heart attack prevention, and it's not going to work," said Dr. Daniel I. Simon, the associate director of interventional cardiology at Brigham and Women's Hospital in Boston and an associate professor at Harvard.

A vast majority of doctors do not test patients for aspirin resistance. Several doctors said even resistant patients would probably still be better off taking aspirin than dropping it. Also, people who use aspirin to fight pain or inflammation are not affected by the new findings.

Scientists are racing to clarify further the significance of aspirin resistance and how to counteract it. What they learn could influence how one of the oldest and most widely consumed medicines is used, perhaps leading to more customized therapies.

"You're talking about a huge number of people" who might not be benefiting, said Dr. Michael J. Domanski, head of the clinical trials unit of the National Heart, Lung and Blood Institute.

Although some experts have known about aspirin resistance for years, it is a topic of growing interest as studies have confirmed that aspirin takers who are resistant have a higher rate of heart attacks and strokes than nonresistant aspirin users.

"Aspirin resistance is associated with a worse outcome,"' Dr. Deepak L. Bhatt, director of the interventional cardiology fellowship program at the Cleveland Clinic, said. "The literature is pretty consistent about that."

New tests make it far easier than in the past to measure response to aspirin. Companies selling such tests are calling attention to aspirin resistance to help in their marketing.

Some experts caution that not enough is understood about the meaning of resistance to justify routine tests. Moreover, the experts say, it is unclear what to do for aspirin-resistant patients. Should aspirin be dropped? Should the doses be increased? Should patients be switched to other anticlotting drugs?

"For none of these tests is there evidence that altering treatment is beneficial to the patient," said Dr. Alan D. Michelson, director of the center for platelet function studies at the University of Massachusetts. "I don't think doctors should do these tests, and I don't think they should change treatments based on these tests."

A small but growing number of doctors are starting to test patients. They argue that even without conclusive evidence it is reasonable to alter therapy rather than have a patient continue to take a drug that a test shows is ineffective.

Dr. Mark A. Goodman, president of Cardiovascular Medical Associates in Garden City, N.Y., said he tested all his patients and found that 20 to 25 percent were aspirin resistant. For those people, Dr. Goodman said, he first tries a higher dose, because that is the least expensive alternative.

If that does not work - and it usually does not - he prescribes another anticlotting drug, Plavix, that can cost $3 or more a day, compared with pennies a day for aspirin.

Aspirin resistance could be one reason many people continue to have heart attacks and strokes even though they take aspirin. But, experts said, it is quite likely that some people have heart attacks or strokes even if aspirin is providing the desired anticlotting effect.

It is widely believed that the main way aspirin provides cardiovascular protection is by blocking the ability of platelets in the blood to stick together, a vital step in forming clots that can lead to a heart attack or stroke. Aspirin blocks an enzyme, cyclo-oxygenase, that is involved in producing thromboxane, a substance that induces platelets to clump.

The standard test of how readily platelets clump is called aggregometry. It is usually performed in a specialized laboratory and can take two to three hours.

 

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Flying and Air Travel After OHS

Flying and Air Travel After OHS

From CNN.com:

Experts: Flying not risk for some heart patients
Study finds risk low for those with stable heart disease
Monday, July 19, 2004 Posted: 5:52 PM EDT (2152 GMT)

PHILADELPHIA, Pennsylvania (AP) -- Flying is not as risky for heart patients as doctors once thought, researchers say.

"The important take-home message is that for people with stable coronary disease, all the data points to air travel being safe," said Dr. Stephen Possick, a cardiologist at Yale University and an author of the paper published Tuesday in the Annals of Internal Medicine.

Commercial aircraft are not pressurized to a ground equivalent and the oxygen level is lower at high altitudes. Those factors have long prompted fears that flying could interfere with circulation and endanger passengers with heart or blood vessel problems.

The researchers reviewed dozens of recent studies of people with different kinds of cardiovascular disease, patients with pacemakers and those who had recently undergone heart procedures such as stent implants and angioplasty.

For those whose heart disease was under control and who had no post-surgery troubles or major bouts with chest pain or other troubling symptoms, the risk is low that air travel will create problems, Possick said.

The researchers concluded that people should not travel if they have had a heart attack, an angioplasty or a heart stent implant in the preceding two weeks, or if they have had a coronary artery bypass within the previous three weeks.

People also should not fly if they have an unstable angina, which is chest pain caused by lack of blood flow to the heart; an abnormal heartbeat that is not well controlled by medication; or heart failure that does not respond well to medication.

The report said it is also a good idea for many heart patients to wear below-the-knee compression stockings and get up and walk around during long plane rides to prevent deep vein thrombosis, or blood clots that typically form in the legs and can be painful and even fatal. The authors said there is no hard evidence that taking aspirin during a flight does anything to prevent such clots, so recommendation was made either way.

Dr. Gerald Fletcher, a spokesman for the American Heart Association, said the guidelines provide a good rule of thumb.

"Flying is a part of life, and in general it's not problematic," he said. "Heart disease is so common, and there's no need to frighten people into thinking they can't travel."

While none of the findings are new -- the Aerospace Medical Association published similar guidelines in 2002 -- Possick said the review puts together recent research in a way that family doctors can use and share with their patients.