Podcasts about aspree

The Western AF meeting, aspirin, cannabis use, LVEF in athletes, and shared decision making before ICD implantation are the topics John Mandrola, MD, discusses in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I. ASA in Primary Prevention Campbell Meta-analysis https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.123.065420 Swedish Observational study https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.117.028321 ASPREE https://www.nejm.org/doi/full/10.1056/NEJMoa1805819 II. Cannabis Cannabis Use Tied to Increased Cardiovascular Risk https://www.medscape.com/viewarticle/cannabis-use-tied-increased-cardiovascular-risk-2024a10003yr It Sure Looks Like Cannabis Is Bad for the Heart, Doesn't It? https://www.medscape.com/viewarticle/1000250 Journal of the AHA Observational Study https://www.ahajournals.org/doi/full/10.1161/JAHA.123.030178 III. Low EF in Athletes Reduced Ejection Fraction in Elite Endurance Athletes: Clinical and Genetic Overlap With Dilated Cardiomyopathy https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.063777 IV. ICDs and Shared Decision-Making Association of a Medicare Mandate for Shared Decision-Making With Cardiac Device Utilization https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2815017 You may also like: The Bob Harrington Show with the Stephen and Suzanne Weiss Dean of Weill Cornell Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

Our latest episode of Cardiology Digest delves into some of the most intriguing and thought-provoking recent studies in the realm of heart health. Here's a sneak peek into what awaits you:   STUDY #1: We have the Amiodarone Enigma: An observational study in the Annals of Internal Medicine has brought up some concerns regarding the use of amiodarone in patients with heart failure, coronary disease, and renal failure. But is everything as it seems? Dive into the nuances of this study with us, as we explore whether the observed excess bleeding is truly due to the drug, or the elevated bleeding risk in these patients. Is it time to change our practice or do we need more compelling evidence? Ray WA et al. Risk for bleeding-related hospitalizations during use of amiodarone with apixaban or rivaroxaban in patients with atrial fibrillation: A retrospective cohort study. Ann Intern Med 2023 Jun; 176:769. (https://doi.org/10.7326/M22-3238)   STUDY #2: We re-evaluate Aspirin for older patients, thanks to the ASPREE study that was recently published in JAMA Network Open. It looks like it's time to reassess our recommendations and consider whether we're truly informed about the pros and cons of aspirin as a risk-reduction strategy.  Cloud GC et al. Low-dose aspirin and the risk of stroke and intracerebral bleeding in healthy older people: Secondary analysis of a randomized clinical trial. JAMA Netw Open 2023 Jul 3; 6:e2325803. (https://doi.org/10.1001/jamanetworkopen.2023.25803)   STUDY #3: Lastly, we find out if there are health benefits to being a “weekend warrior”. Have you ever had patients question the health benefits of their active weekends? This study from JAMA sheds light on the potential importance of exceeding the 150-minute weekly threshold of moderate-to-vigorous physical activity. But just how beneficial is it? Tune in to find out! Khurshid S et al. Accelerometer-derived “weekend warrior” physical activity and incident cardiovascular disease. JAMA 2023 Jul 18; 330:247. (https://doi.org/10.1001/jama.2023.10875)   Join us in this episode as we dissect these studies, offering insights and sparking discussions that could reshape our understanding of cardiology. Don't miss out on this enlightening journey!  For show notes, visit us at https://www.medmastery.com/podcasts/cardiology-podcast.

It's In the News, a look at the top stories and headlines from the diabetes community happening now. Top stories this week: Abbott acquires Bigfoot, a new study looks at low-dose aspirin to prevent type 2, researchers look into whether the AI ChatGPT can answer FAQs about diabetes, Beyond Type Run is back for the NYC Marathon, and more! Our previous episode with Bigfoot Biomedical: https://diabetes-connections.com/?s=bigfoot Join us for Moms' Night Out! (use promo code School30 to save) Please visit our Sponsors & Partners - they help make the show possible! Take Control with Afrezza  Omnipod - Simplify Life Learn about Dexcom  Learn about Edgepark Check out VIVI Cap to protect your insulin from extreme temperatures Learn more about AG1 from Athletic Greens  Drive research that matters through the T1D Exchange The best way to keep up with Stacey and the show is by signing up for our weekly newsletter: Sign up for our newsletter here Here's where to find us: Facebook (Group) Facebook (Page) Instagram Twitter Check out Stacey's books! Learn more about everything at our home page www.diabetes-connections.com  Reach out with questions or comments: info@diabetes-connections.com Hello and welcome to Diabetes Connections In the News! I'm Stacey Simms and these are the top diabetes stories and headlines happening now XX In the news is brought to you by Edgepark simplify your diabetes journey with Edgepark XX Our top story this week – Abbott scoops up Bigfoot Biomedical. The deal is expected to close later this year – no financial terms yet disclosed. Abbott and Bigfoot have worked together since 2017 on a connected insulin pen system. Bigfoot Unity exclusively works with Abbott's FreeStyle Libre® Long time listeners will recall that Bigfoot was founded in 2015 around serving people with type 1 diabetes with a closed loop pump system that Byran Mazlish had developed for his wife and son. Mazlish was very secretive at first about the algorithm – this was before people were sure the FDA wouldn't crack down on them – so a journalist nicknamed him Bigfoot. Along the way, the company pivoted to CGM connected SmartPens. I believe Bigfoot was my third interview, back in 2015 – I'll ink up all of the interviews I've done with them in the show notes. https://diabetes-connections.com/?s=bigfoot https://www.prnewswire.com/news-releases/abbott-to-acquire-bigfoot-biomedical-furthering-efforts-to-develop-personalized-connected-solutions-for-people-with-diabetes-301918254.html XX Low-dose aspirin reduces the risk for type 2 diabetes among older adults and slows the increase in fasting glucose levels over time, new research finds. The data come from a secondary analysis of ASPREE, a double-blind, placebo-controlled trial of healthy adults aged 65 years or older, showing that 100 mg of aspirin taken daily for about 5 years did not provide a cardiovascular benefit but did significantly raise the risk for bleeding. It's a big study, more than 16-thousand people. This new analysis shows that individuals taking aspirin had a 15% lower risk for developing type 2 diabetes and that the medication slowed the rate of increase in fasting plasma glucose, compared with placebo, during follow-up. However, lead author Sophia Zoungas, MBBS, PhD, head of the School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia, says, "Major prescribing guidelines now recommend older adults take daily aspirin only when there is a medical reason to do so, such as after a heart attack… Although these new findings are of interest, they do not change the clinical advice about aspirin use in older people at this time." https://www.medscape.com/viewarticle/996058 XX A class-action lawsuit filed against Medtronic (NYSE: MDT)+ alleges that the company's insulin delivery devices shared patient data with third parties. The lawsuit — filed by the plaintiff “A.H.” in U.S. District Court in Central California — levels allegations against Medtronic and its MiniMed and InPen devices. It addresses MiniMed's transmission and disclosure of personally identifiable information and protected health information to Google and other third parties. Per the lawsuit, the data was transmitted via tracking and authentication technology, including Google Analytics, Crashlytics, Firebase Authentication and related tools. A.H. says these technologies, installed on the website and/or mobile applications, include the InPen iOS and Android applications. “Information about a person's health is among the most confidential and sensitive information in society, and its mishandling can have serious consequences, including embarrassment, discrimination, and denial of insurance coverage,” the lawsuit reads. A Medtronic spokesperson issued the following statement via email: We have strong processes, technologies, and people in place to safeguard and protect our information and systems, the information of our business partners, and most importantly, the privacy and safety of the patients and healthcare providers that use our products.” https://www.massdevice.com/lawsuit-patient-data-sharing-medtronic-diabetes/ XX Interesting new way to look at type 2 – not weight loss or medication, but about reducing how much blood glucose goes up and stays up after eating and drinking. University of Virginia Daniel Cox says this is called Glucose Everyday Matters, or GEM – aims to prevent blood sugar spikes via educated food and drink selection. This is coupled with physical activity to hasten recovery when blood-sugar spikes do occur. So someone might indulge in a piece of fruit or a small, sweet treat, knowing how it will affect them, and then go for an evening stroll to help even out their blood sugar. Sounds really simple, but in its first study, it helps almost 70-percent of people put their type 2 into remission without weight loss or medication. The National Institutes of Health has provided $3.5 million for a large-scale clinical trial Cox himself went from an A1C of 10.3 at the time of diagnoses to reading consistently under 6.0 for the past 13 years on no medication using his approach. https://newsroom.uvahealth.com/2023/08/31/radical-new-approach-to-managing-type-2-diabetes-receives-3-5-million/ XX Final preparations are in place to initiate the first clinical site for DIAGNODE-3 in the United States, and additional sites are expected to be initiated over the coming months. Approximately 10-12 clinical sites across the US are planned to be initiated, expanding the DIAGNODE-3 trial in the US and eight European countries to approximately 60 clincal sites in total. DIAGNODE-3 is designed to confirm the efficacy and safety of the antigen-specific immunotherapy Diamyd® in patients aged 12 to 29 years recently diagnosed with type 1 diabetes and carrying the genetic HLA DR3-DQ2 marker. Approximately 40% of all screened patients carry the genetic HLA DR3-DQ2 haplotype. This proportion aligns well with expectations based on previous Diamyd® clinical trials and published epidemiological research. Supported by published retrospective analyses and prospective clinical trials, the presence of the genetic HLA DR3-DQ2 haplotype determines the likelihood of responding to Diamyd® therapy, and serves as one of the main inclusion criteria in the DIAGNODE-3 trial. "Patient recruitment is a complex and central element in any trial and it is encouraging to see a significant and continuous uptick in the screening rate and that the observed frequency of the genetically defined responder group enrolled into DIAGNODE-3 confirms our previous observations", says Ulf Hannelius, President & CEO of Diamyd Medical. "This shows the operational and clinical feasibility of our precision medicine approach to Type 1 Diabetes and we look forward to expanding the trial to the United States". https://finance.yahoo.com/news/registrational-phase-iii-trial-type-142600082.html XX A low-carbohydrate diet during pregnancy may have some benefits in gestational diabetes, but overall, low-carbohydrate diets are not associated with any significant differences in outcomes. That was the conclusion of a presentation at the ADA Scientific Sessions. That was back in June but I just learned about it, so I'm passing along to you in case you missed it as well. During a debate at the American Diabetes Association Scientific Sessions, Amy M. Valent, DO, MCR, associate professor in the division of maternal-fetal medicine in the department of obstetrics and gynecology at Oregon Health & Science University, said identifying Teri L. Hernandez, PhD, RN, associate dean of research and scholarship in the College of Nursing and professor in the department of medicine and the division of endocrinology, metabolism and diabetes at the University of Colorado Anschutz Medical Campus, agreed that the first line of therapy with gestational diabetes is nutrition. However, Hernandez said, low-carbohydrate diets are not the only approach in gestational diabetes treatment with nutrition. Currently, dietary advice for treating gestational diabetes is inconsistent, and current professional guidelines have limitations and biases, according to Valent. Different diet strategies include low-carbohydrate, low glycemic index and total energy restriction eating plans, according to Valent. Valent said ACOG guidelines recommended a low-carbohydrate diet for gestational diabetes until the most recently revised edition in January. Valent reviewed several major landmark studies demonstrating that gestational diabetes treatment can decrease pregnancy complications such as preeclampsia and large for gestational age infants. “These studies were in the era where treatment of diabetes in pregnancy involved recommending a low-carbohydrate diet,” Valent said. “The concern with lowering carbohydrates is the risk of consuming lower nutrient-dense foods and resulting in the body to produce ketones, which may be associated with negative effects on the developing baby.” “Pregnancy is dynamic. Nobody's the same today as they were yesterday. They're going to be different 1, 2 or 3 weeks from now, and the nutritional demands and the fetal growth and development stage are going to be different,” Valent said. “So, nutritional demands are going to vary.” Hernandez also added that women and girls tend to be priced out of good nutritional patterns, which is an issue not only in the pregnancy field, but also in the global community. According to Hernandez, it is important to create ways moving forward to identify what nutritional patterns are best that are also affordable for families, especially in lower-income settings. https://www.healio.com/news/womens-health-ob-gyn/20230905/experts-debate-benefits-of-lowcarb-diets-for-gestational-diabetes XX XX Commercial – Edgepark XX Can ChatGPT help answer questions about diabetes? In a recent study published in the journal PLoS ONE, researchers tested chatGPT, a language model geared for discussion, to investigate whether it could answer frequently asked diabetes questions. In the present study, researchers evaluated ChatGPT's expertise in diabetes, especially the capacity to answer commonly requested questions related to diabetes in a similar manner as humans. The 'Frequently Asked Questions' section of the Diabetes Association of Denmark's website, viewed on 10 January 2023, included eight questions. The researchers designed the remaining questions to correlate to particular lines on the 'Knowledge Center for Diabetes website and a report on physical activity and diabetes mellitus type 1. Across the 10 questions, the proportion of correct responses ranged from 38% to 74%. Participants correctly identified ChatGPT-generated replies 60% of the time, which was over the non-inferiority threshold. Males and females had 64% and 58% chances of accurately recognizing the artificial intelligence-generated response, respectively. Individuals who had past contact with diabetes patients had a 61% chance of precisely answering the questions, compared to 57% for those who had no prior contact with diabetes patients. In contrast to the initial premise, participants could discern between ChatGPT-generated and human-written replies better than tossing a fair coin. While ChatGPT demonstrated some potential for accurately answering frequently asked questions, issues around misinformation and the lack of nuanced, personalized advice were evident. As large language models increasingly intersect with healthcare, rigorous studies are essential to evaluate their safety, efficacy, and ethical considerations in patient care, emphasizing the need for robust regulatory frameworks and continuous oversight. https://www.news-medical.net/news/20230905/Can-ChatGPT-be-a-diabetes-consultant-Study-probes-the-potential-and-pitfalls.aspx XX SAN MATEO, Calif., Aug. 24, 2023 /PRNewswire/ -- On November 5, diabetes nonprofit Beyond Type 1 will join more than 550 official charity partners and philanthropists raising awareness and funds while participating in the world's largest marathon, the TCS New York City Marathon. This year, the organization is expanding its 50-person team, Beyond Type Run, to include people living with type 1 or type 2 diabetes, as well as caregivers to those living with diabetes. "Since 2017, we've featured more than 200 runners on our teams who've exemplified what it means to survive and thrive with diabetes," said Beyond Type 1 CEO Deborah Dugan. Beyond Type 1 announces the 2023 NYC Marathon team to raise awareness and funds for people living with diabetes As a part of the Beyond Type Run team, runners will be advocating to raise awareness and funds for Beyond Type 1's portfolio of educational resources, awareness campaigns and peer-to-peer support programs for people impacted by diabetes. This advocacy is elevated through the NYRR Official Charity Partner Program, which offers opportunities for nonprofit organizations to raise funds to support their missions and services. Dexcom and Tandem Diabetes Care are presenting sponsors of Beyond Type Run for a fourth consecutive year. The TCS New York City Marathon Official Charity Partner Program has raised more than $440 million for more than 1,000 nonprofit organizations since its establishment in 2006. https://www.prnewswire.com/news-releases/team-of-50-individuals-impacted-by-diabetes-prepare-for-the-2023-tcs-new-york-city-marathon-301909163.html XX MNO update On the podcast next week.. tandem diabetes celebrity panel from friends for life – Hollywood, the NFL and NASCAR. Last week's episode was Benny off to college That's In the News for this week.. if you like it, please share it! Thanks for joining me! See you back here soon. ----  

Este pódcast está destinado exclusivamente a profesionales de la salud. Se dice que la cantidad de conocimiento médico se duplica cada 73 días, lo que hace que sea mucho más difícil para los médicos identificar hallazgos innovadores y nuevas guías para ayudar a los pacientes. En esta ocasión nuestros anfitriones, Aldo Rodrigo Jiménez (Twitter: @aldorodrigo) y Alejandro Meraz (Twitter: @nephroguy) presentan 6 estudios para su práctica clínica. Notas: https://espanol.medscape.com/verarticulo/5911216 Time stamps 73 días ... 00:38 Recomendaciones de la semana ... 02:07 Puntaje de PEN-FAST para confirmar la alergia a penicilina ... 5:30 Análisis secundario de ASPREE (anemia y ácido acetilsalicílico) ... 10:11 Dosis alta de semaglutida vía oral ... 14:54 Control de la hipertensión arterial intrahospitalaria ... 18:48  Kiwi para el estreñimiento ... 23:06 Estudios de imagen en exacerbaciones de EPOC para descartar trombosis venosa profunda/tromboembolia pulmonar ... 26:22  

O retorno do bolus com Joanne e Marcela falando sobre AAS na profilaxia primária para doença cardiovascular (DCV)! Elas abordam 3 tópicos: - História de AAS na prevenção de DCV - Recomendação atual e os principais estudos que motivaram a mudança de recomendação (ASPREE, ARRIVE E ASCEND) - O que fazer com quem já usa? Tá imperdível! Referências: 1. Aimo A, De Caterina R. Aspirin for primary prevention of cardiovascular disease: Advice for a decisional strategy based on risk stratification. Anatol J Cardiol. 2020;23(2):70-78. 2. Berger JS. Aspirin for Primary Prevention—Time to Rethink Our Approach. JAMA Netw Open.2022;5(4):e2210144. 3. Bowman L, et al. Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus. N Engl J Med 2018; 379:1529-1539 4. Chiang KF, Shah SJ, Stafford RS. A Practical Approach to Low-Dose Aspirin for Primary Prevention. JAMA. 2019;322(4):301-302 5. Gaziano JM, et al. Aspirin to Reduce Risk of Initial Vascular Events - ARRIVE. Lancet 2018; 392: 1036–46 6. McNeil JJ, et al. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med 2018; 379:1519-1528 7. Précoma DB, Oliveira GMM, Simão AF, Dutra OP, Coelho OR, Izar MCO, Póvoa RMS, et al. Atualização da Diretriz de Prevenção Cardiovascular da Sociedade Brasileira de Cardiologia – 2019. Arq. Bras. Cardiol. 2019;113(4):787-891 8. Raber I, et al. The rise and fall of aspirin in the primary prevention of cardiovascular disease. Lancet 2019; 393: 2155–67 9. US Preventive Services Task Force. Aspirin Use to Prevent Cardiovascular Disease: US Preventive Services Task Force Recommendation Statement. JAMA.2022;327(16):1577–1584.

For more information, contact us at 859-721-1414 or myhealth@prevmedheartrisk.com. Also, check out the following resources:  ·PrevMed's website·PrevMed's YouTube channel·PrevMed's Facebook page

The ASPREE study was a trial of aspirin in 20,000 healthy adults, age 70 and older. It was published in September 2018 in the New England Journal of Medicine.  Surprisingly, aspirin did not show a preventive benefit. Even more surprisingly, it showed an increased risk. And even more surprisingly, it was in cancer. Even the authors suggested that we look at these results with caution since there are meta-analyses which showed just the opposite.  There's one more surprise. The mortality rate was less than half of that predicted in the study. This is being seen in several studies, such as the ASCEND trials. Are we getting healthier in our old age? Is this washing out benefits of less powerful interventions such as aspirin and low-dose Omega 3s?References:https://www.nejm.org/doi/full/10.1056/NEJMoa1800722?query=recirc_curatedRelated_articlehttps://www.nejm.org/doi/full/10.1056/NEJMoa1805819?query=recirc_mostViewed_railB_articleFor more information, contact us at 859-721-1414 or myhealth@prevmedheartrisk.com. Also, check out the following resources: PrevMed's blogPrevMed's websitePrevMed's YouTube channelPrevMed's Facebook page

Vol 214, Issue 2: 1 February 2021. Dr Alice Owen is a Senior Research Fellow at Monash University, working on the ASPREE study. Associate Professor Ingrid Hopper is a clinical pharmacologist and general physician at Monash University. They talk about the prevalence of complementary medicine use in older Australians. With MJA news and online editor, Cate Swannell.

Dr Caitlin Yolland, a Postdoctoral Researcher at Swinburne University, canvasses research on how oxidative stress relates to symptoms of schizophrenia; Professor John McNeil AO, Head of the Department of Epidemiology and Preventive Medicine and Head of the School of Public Health and Preventive Medicine at Monash University, discusses the ASPREE study and the effect of low doses of aspirin on otherwise healthy elderly people; and the team discuss High Intensity Interval Training (HIIT) exercise, and the world's first Positive Body Image Chatbot. With presenters Dr Mal Practice, Dr G-Spot, and Nurse Epipen.Website: https://www.rrr.org.au/explore/programs/radiotherapyFacebook: https://www.facebook.com/RadiotherapyOnTripleR/Twitter: https://twitter.com/_radiotherapy_?lang=enInstagram: https://instagram.com/radiotherapy_tripler?igshid=3944brpx7l0g

Dr Heather Bell and Dr Kurt DeVine deviate from addiction to address the COVID19 pandemic. Jerica Berge, U of MN Research, discussed the ASPREE study looking at ASA use in elderly. Next we had Dr Roeder, M Health Fairview, discussing Post intensive care syndrome (PICS). To learn more about the doctors as well as keep up with current happenings follow us on twitter: @echocsct and Facebook: @theaddictionconnectionhk

Dr Heather Bell and Dr Kurt DeVine deviate from addiction to address the COVID19 pandemic. Jerica Berge, U of MN Research, discussed the ASPREE study looking at ASA use in elderly. Next we had Dr Roeder, M Health Fairview, discussing Post intensive care syndrome (PICS). To learn more about the doctors as well as keep up with current happenings follow us on twitter: @echocsct and Facebook: @theaddictionconnectionhk

作为预防心血管疾病的常用药，阿司匹林也有过失败的临床试验。比如2018年发布在《新英格兰医学杂志》上的ASPREE试验就显示：服用阿司匹林，与健康老年人的死亡风险上升有关，而主要原因可能是因癌死亡率的上升。近期在《美国国家癌症研究所杂志》（JNCI）上，ASPREE试验的研究者们发表了对试验数据的进一步分析：服用阿司匹林可能促进了癌症的进展和转移，从而使更多的老年人确诊存在远处转移的IV期癌症！

作为预防心血管疾病的常用药，阿司匹林也有过失败的临床试验。比如2018年发布在《新英格兰医学杂志》上的ASPREE试验就显示：服用阿司匹林，与健康老年人的死亡风险上升有关，而主要原因可能是因癌死亡率的上升。近期在《美国国家癌症研究所杂志》（JNCI）上，ASPREE试验的研究者们发表了对试验数据的进一步分析：服用阿司匹林可能促进了癌症的进展和转移，从而使更多的老年人确诊存在远处转移的IV期癌症！

In this episode, we discuss the latest and the greatest updates regarding aspirin use in primary prevention and provide you with a summary of results from recently published primary literature.

Dr. Mike Miedema, a preventive cardiologist with the Minneapolis Heart Institute, discusses cardiovascular disease (CVD) prevention, including current uses of aspirin and diabetic agents for primary CVD prevention.  Dr. Miedema also discusses current changes in recent cholesterol guidelines. Objectives: Upon completion of this CME event, program participants will be able to: Describe current optimal use of aspirin for primary cardiovascular disease prevention. Express their understanding of novel diabetic agents used for CVD prevention. Explain changes in the recent cholesterol guidelines. CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within 2 weeks.  You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit:  CME Evaluation: A 2018 Cardiovascular Prevention Update - CME Enduring Activity (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.”   FACULTY DISCLOSURE ANNOUNCEMENT  It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.     Show Notes:   We were fortunate to be joined by Dr. Michael Miedema on December 14, 2018 to discuss cardiology updates and how they are about to impact our practice, if not already. He is a board certified cardiologist, and senior consulting cardiologist and principal investigator with MHI. He trained in medical school at U of M, then went on to an internal medicine residency at Abbott Northwestern, with his cardiology fellowship to follow at the University of Minnesota.  He went on then to another fellowship in cardiovascular prevention at Harvard, in addition to earning his Masters in Public Health. He happens to also be on the committee for the ACC/AHA 2019 Guidelines for the primary prevention of cardiovascular disease. And despite the fact that he grew up in rural Minnesota, this midwesterner speaks as fast as any east-coaster I’ve ever met! So whether you’re in your car,  operating your snowblower or starting that crossfit New Year's resolution , enjoy the knowledge that’s about to be dropped by our very esteemed colleague, Dr. Mike Miedema.   Aspirin: should people take aspirin for primary prevention of heart attack and stroke? We used to say, probably yes!  In the ASCEND trial (New England Journal) in the fall of 2018, Low dose aspirin was looked at and in 7.5 years there was approximately a 12% reduction in major CV events, however serious bleeding was increased by 29%. Not a simple nose bleed, but hospitalization type bleeding.    Another trial, ASPREE in the NEJM also in the fall of 2018, looked at older patients without CV disease, above age 70, taking low dose aspirin for 5 years. It showed no benefit again in overall CV risk, but bleeding risk was increased signficantly, by 38%. In fact all cause mortality showed an increase in cancer in this group, which is interesting. At the very least, the study showed no improvement in cancer risk.   Another trial published in Lancet, the ARRIVE study, consisted of 12000 patients. They were kept on ASA low dose for 5 years, and once again no improvement in the aspirin group was shown. However, the calculated risk was about twice what their actual risk was. The bleeding risk once again was higher.  Rates of MI actually demonstrated no change in the aspirin group.    The Physicians Health Study looked at a primary outcome of MI. It showed that ASA prevented the outcome of MI. Later the investigators tried to expand the outcomes of the study to include CV deaths in general. Unfortunately this now diluted the effect of aspirin and in other words, aspirin’s effect on preventing all cause CV death, like aortic dissection, etc., which makes aspirin look less effective. In addition, there is the issue of these trials looking at “intention to treat” which relates to an inherent bias toward the intervention arm, which didn’t account for the people who had to pull out the trial.  The double edged sword is that many people do in fact pull out of the trials and are still included in the trial results, which skews the results as well.    To conclude, aspirin is likely not helpful if you’re over age 70.  Essentially, if you’re at low CV risk or increased bleeding risk, you probably also shouldn’t take it. Between the ages of 40 and 70, patients may benefit from aspirin therapy, although not without risk of bleeding.      Cholesterol: One month ago, ACC/AHA updated the cholesterol guidelines from the 2013 version. In 2013, statins were recommended for primary and secondary prevention.  Secondary prevention includes lifestyle modifications.  There has been a movement to stratify people into not high risk and higher risk.    With regard to secondary prevention, the Improve-It trial was reanalyzed. The initial trial looked at ezetimibe with and without a statin.  Over 7 years and 18000 patients, there was  a 2% reduction in risk for CV disease. Cholesterol went down by 20%. Risk scores were calculated when the study was reanalyzed. Only half the trial had zero to 1 of the usual risk factors, and there was no benefit in this group. And in this group over the 7 years, there was no benefit from ezetimibe. In 25% of the trial, there was a benefit, but these people had 3 or more risk factors. Consequently, this group saw the most improvement and benefit. Essentially, if you’re not at high risk, a statin is sufficient. Ezetimibe can be considered in this group if the statin does not get you below an LDL of 70.  Otherwise, if you decide not to add ezetimibe, a maximally tolerated statin is appropriate. Older than age 75?  A statin can be offered but not mandatory. The very high risk group, however, meaning a major CV event (ACS, MI, Stroke or symptomatic PAD) history, along with at least one other risk factor, the LDL goal must be less than 70.  Statin therapy, along with ezetamibe is warranted, and if this doesn’t work, a PCSK9 inhibitor is indicated as well. These are expensive meds, though. Ezetimibe is not very expensive and tolerated well, so if that LDL can’t get below 70, it should really be added in this group.   Regarding primary prevention, familial hypercholesterolemia should be screeened for.  An LDL > 190 should be on a statin. No other risk factors are needed. People with type2 DM should be on a statin as well. Greater than age 75? Risks must be weighed, but statin is optional. Age 0-20, lifestyle, FH screening. 20-39, if LDL > 160 and/or a calculated greater lifetime risk, a statin can be offered. Plaque is much more regressable in earlier rather than later stages. A trial is currently under way looking at this concept, attempting to treat people in their 30s. This is the Cure Athero trial which is ongoing.  For age 40-75 with ldl between 70-190, if risk is less than 5%, no intervention besides lifestyle is indicated. With a calculated risk of >20% they should be on a statin.  If somewhere between low and high risk, there are other risk enhancers that should be looked at, i.e. family hx, inflammatory diseases, ethinicity, etc. If the calculated risk is 7.5 to 20%, a statin should be offered, but if there is uncertainty about whether to treat, a calcium score should be obtained. In fact, this is one of the major guideline changes, in that calcium scoring should be looked at. If the score is 0, then no therapy should be used. Scores between 1-99, statin should be offered, but 100 or greater, statin is indicated.  This concept was from a paper published in JACC in 2015.  Again, Ca++ scoring is best used in the group with intermediate risk between 7.5 and 20%.  Following the cholesterol is also advised. In fact, fasting lipid panels are not required. The panel can now be done non-fasting. Trial data has also shown that statins are very safe. Over 20 years, cancer, dementia and other theorized health risks were debunked.  Coenzyme Q10 use, and monitoring CPK, ALT/AST on asymptomatic patients are not indicated.  To summarize, people with known CV disease should be on a high intensity statin with goal LDL < 70, ezetimibe and PCSK9 added if at high risk. Also, if FH, consider adding ezetimibe and PCSK9, goal < 100. DM? Moderate intensity statin, higher if at high risk. Primary prevention? Moderate intensity statin, high intensity if high risk. If risk is uncertain, do a Calcium score.  Another trial is ongoing looking at fish oil (EPA and DHA).  EPA (vasepia) the purified variety ("fish oil on steroids"), is implemented in the mildly elevated TG population. Over 5 years, this medication along with statin therapy showed a reduced risk 25% reduction and 5% absolute risk reduction. Strangely, if your TG are in the 1000s, you are not at higher CV risk, but when they are mildly elevated, there is more atherogenicity. Essentially, if you have mildly elevated TG, you may benefit from this treatment. Expense and dosing is an issue, but this must be a considered therapy.    Diabetes: Cardiologists are becoming more engaged in DM care once again. The vast majority of DM is type 2. 1/3 of adults in this country are pre-diabetic. The risk of MI and stroke is significantly greater in diabetics and lifestyle really matters most with diabetics as well.  A recent paper in JACC demonstrated the significant benefit in lifestyle improvement.  The UKPDS trial looked at lifestyle vs. insulin vs. metformin.  Metformin showed substantial benefit in diabetes related events and diabetes related death. If metformin is started before insulin, a significantly lower Hgb A1C and lower BMI is seen. Type 2 DM is a disease of insulin sensitivity, not deficiency. Insulin is a storage hormone and does lead to weight gain. Metformin is recommended therefore as first line for type 2 DM, based on studies in the 90s and early 2000s. They showed improvement in Hgb A1C, but CV risks really weren’t shown to improve.  Based on 3 large trials in 2010 (ADvance trial, a VA trial and the Accord trial) no significant reduction in CV events was shown. In fact a slight increase in all cause mortality was shown. This was in people with more intense glucose control. Weight gain was a significant issue in aggresive Hgb a1c treatment group.   There a two relatively new medications: sglt2 inhibitors and the glp1 agonists. The sglt2s basically block the  pulling of glucose from the urine back into the blood stream. This lowers the HgbA1C. It also has a natriuretic/diuretic effect as well. There is very little risk of hypoglycemia with this drug as well. It is also a natriuretic. In 2015, a trial looking at this class of med revealed a 14% reduction in MACE.  CV death showed a 38% reduction. Most of the benefit was in patients with risk of heart failure.  Another trial also showed a 33% reduction in heart failure hospitalizations.  The largest trial though of 17000 patients was a primary and secondary prevention trial. Similar benefts were noted, but also a renal benefit. Ultimately, our type 2 DM patients should have these medications considered for both primary and secondary prevention. GLP1 receptor agonists or glutides, are also an option. This medication class causes less glucose production by the liver, more uptake by the muscles and delayed gastric emptying. Weight loss may occur with this med. CV effects include decreased inflammation and decreased risk for clotting in the smaller vessels. Overall reduction in Hgb a1c, weight loss, improved LDL, decrease in BP and decreased inflammation. 13 to 14 % reduction in MACE was noted with this, especially in stroke and atherosclerosis. Not so much with CHF due to an anti-atherosclerotic mechanism.  Glutides are given once weekly. Yeast infections are more common with the SGLT2s due to increased glucose in the urine.  ACC constructed a pathway for use of these various medications:  Essentially, For your DM pts with CHF, an SGLT2 should be given, and a GLP1 for DM pts with previous CV events. Cost is also an issue with these meds; however they can be used together.   CV genetics considerations and screenings is an up and coming topic.  The Framingham study said CV disease is due to multiple-factorial processes and risk factors. Therefore it is hypothesized that mutliple genes may lead to higher risk.  If your lifestyle is good, even if you have increased genetic risk, you can substantially lower your risk. In about 2% of the population, an FH gene can be found.  If you have this gene, your risk is higher than others at a similar cholesterol level, and for a longer period of your life of course. Therefore it is important for these patients to address this with medication and lifestyle.  Adding the genetic risk score to your overall basic CV risk factors will help to predict your actual CV risk.  This risk calculation and stratification is still being studied and looked at.   ACC/AHA Risk calculator link: cvriskcalculator.com   In summary:    ASA for primary prevention probably shouldn’t be used. Select high risk patients are okay, but avoid in the elderly.  Cholesterol:  Statin plus ezetemibe and pcsk9 for higher risk, and Ca score for  those uncertain about their risk.  DM: use the new meds with type 2 DM at high CV risk.  Genetics: not quite ready for prime time, but we need to look into this more and get ready for patients desiring this in the future.  Again, a big thanks to Dr. Miedema for joining us and for providing this cardiology update. Ridgeview appreciates his expertise, his ongoing dedication to his patients and to the cardiology specialty.

This week we talk about the results of the 3 ASPREE aspirin trials, whether omega-3 oil prevents CV events, and a new biologic agent for migraine. Pubmed abstract links: ASPREE: https://www.ncbi.nlm.nih.gov/pubmed/30221596 ; omega-3: https://www.ncbi.nlm.nih.gov/pubmed/30146932 ; and migraine: https://www.ncbi.nlm.nih.gov/pubmed/30360965

Aspirin’ to figure out if ASA can help prevent a heart attack? Interpreting all the new trials doesn’t have to cause chest pain! Join Dr. Ambarish Pandey from UT Southwestern as he helps The Curbsiders ASCEND the mountains of the latest studies to ARRIVE at some well-informed conclusions on the role of aspirin in primary prevention for cardiac events. The team also discusses secondary prevention, aspirin and dual (or triple) antiplatelet therapy, and whether it’s okay to stop giving aspirin to older adults without known CAD (Spoiler alert: it’s okay). ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes (goes live 0900 EST). Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Justin Berk MD, Matthew Watto MD CME questions by: Justin Berk MD Hosts: Matthew Watto MD, Paul Williams MD, Stuart Brigham MD Edited by: Matthew Watto MD and Chris Chiu MD Guest: Dr. Ambarish Pandey MD Time Stamps 00:00 Disclaimer, intro and guest bio 04:15 Guest one liner, book recommendation, career and research advice 11:07 Case of aspirin for primary prevention, aspirin’s public persona, and nocebo effects of statins 21:40 ARRIVE and ASCEND trials 28:14 Aspree trial 32:38 Coronary artery calcium; aspirin use for secondary prevention 37:42 Dual antiplatelet therapy and the DAPT score 41:25 Should we continue aspirin when a patient also needs a DOAC? 46:14 Should we continue DAPT in a patient who needs a DOAC (or warfarin)? 49:40 Deprescribing aspirin for primary prevention in older adults? 50:51 Closing remarks 52:33 Outro

• Dr. Kristi Milley and Sophie Chima talk to Professor Mark Nelson about the results of his recently published ASPREE trials, (ASPirin in Reducing Events in the Elderly). The guidelines around daily aspirin for prevention of colorectal cancer have recently been updated in Australia, however aspirin still does not feature in UK guidelines. Recent studies have implied aspirin may aid prevention or delaying of the onset of cardiovascular disease, dementia, depression and some types of cancer. Professor Nelson describes in detail the results of the ASPREE trials, which found no benefit in healthy adults, aged 70 and above. The podcast explores the complexity of international trials, the use composite outcomes and how these results will shape future work. Show notes are located here http://pc4tg.com.au/research-round-up-october-2018-professor-mark-nelson/

Using aspirin across the board is not justified based on results of the ASPREE trial as well as on the equivocal results from other recent primary prevention trials (http://bit.ly/2Ophib1). Also today, swings in four metabolic measures predicted death in healthy people (http://bit.ly/2y4StXQ), anticoagulation plus single antiplatelet fails noninferiority measure 1 year after stenting (http://bit.ly/2Iuohdm), and Behavioral checklist identifies children at risk of depressive and/or anxiety disorders (http://bit.ly/2xRdHJr).

Prof John McNeil, chair of the 2012 Aspirin Foundation meeting, talks to ecancer about the ASPRee study, which aims to provide evidence that aspirin prolongs disability free survival. The ultimate end point of the study is to make aspirin a standard of care in elderly patients.