Guest: Dr. Lori Mosca
Presenter: Neal Howard
Guest Bio: Lori Mosca, M.D., M.P.H., Ph.D., is a leading authority on the prevention of cardiovascular disease and stroke. She currently serves as Professor of Medicine Emerita and Director of the American Heart Association Go Red for Women Strategically Focused Research Network Center at Columbia University Medical Center. Dr. Mosca received her medical degree from SUNY Upstate Medical University in Syracuse, and her Masters in Public Health and Ph.D. in Epidemiology from Columbia University. She completed a residency in Internal Medicine at Upstate Medical University and a fellowship in Preventive Cardiology at Columbia University. Dr. Mosca has been listed among America’s and New York’s Top Doctors numerous times and in 2015 was named the American Heart Association (AHA) Physician of the Year.
Segment overview: Dr. Lori Mosca, a noted cardiologist, researcher and preventive cardiology leader discusses alternative solutions to daily aspirin therapy which can cause gastrointestinal issues such as ulcers and bleeding.
Health Professional Radio – Gastrointestinal Trauma and Daily Aspirin Therapy
Neal Howard: Hello and welcome to Health Professional Radio, I’m your host Neal Howard. Thank you so much for joining us today. Every year more than half a million Americans experience that first heart attack enjoin nearly 26 million at risk of getting another heart attack and those who are in accordance with gold standard clinical guidelines maybe prescribed daily aspirin therapy to help prevent recurrent heart attacks but this presents another treatment challenge. Our guest in studio today is Dr. Lori Mosco, 2015 American Heart Association Physician of the Year and the leading researcher in preventive cardiology. She’s in studio today with us to talk about some of these issues with daily aspirin therapy and how some of it can cause some gastrointestinal issues that maybe you can avoid. How are you doing Dr. Mosca?
Dr. Lori Mosca: Very well, thank you so much for having me.
N: I’m glad to have you back in studio with us. When we were here before we were talking about some of the preventive measures that one can take in order to prevent that first or even recurring heart attacks. We didn’t talk about daily aspirin therapy, we see these commercials on television touting aspirin, some of them I guess children’s aspirin for some issues. Some would think that taking an aspirin everyday just because would kind of do something to the stomach. Is there information that you have that’s contrary to that popular belief?
M: Well I think you’ve already brought up some really good points about aspirin. First of all, it is the gold standard therapy for the secondary prevention of heart disease and you eluded to some other situations where there may be a much more room for discussion between health care provider and the patient but when it comes to secondary prevention there really is no debate that unless there’s a contraindication that aspirin is a very evidence based approach to prevent recurrent disease. Now what you brought up Neal is the reality of the situation which is that many patients who are taking aspirin therapy to prevent recurrent disease have gastrointestinal side effects. In fact when you look at clinical trials of aspirin therapy, one in twenty patients had GI side effects and this is a real concern because it often leads to discontinuation.
N: So someone’s on daily aspirin therapy and it seems you say it’s evidence based. How exactly does the aspirin work to prevent that heart attack and then once someone’s rolling with that and everything’s okay, suddenly having to come off of it where does that lead the patient?
M: Well it’s so funny, aspirin really is a chemo preventive agent was discovered in 400 B.C. by Hippocrates who prescribed it really as an anti-inflammatory to relieve pain and fever and we know that recurrent heart disease is often caused by a thrombotic event and also an inflammatory milieus so the anti-platelet effects and the anti-inflammatory effects may be very important in how aspirin prevents recurrent disease. But the flip side of it is that aspirin is also can be very upsetting to the stomach and the most common side effect associates with why patients discontinue their aspirin therapy is the GI side effects and it’s very concerning because we know that discontinuation of aspirin in this setting is associated with a threefold increase in major coronary event and happens very quickly within eleven days and that’s likely due again to this sort of the clotting milieu and the inflammatory milieu.
N: What about some of the other anti-inflammatory agents that are out there? I mean once aspirin proves to be a little bit disruptive, aren’t there avenues that you can go that maybe mimic aspirin?
M: Well there are other agents that may have some of the therapeutic benefits of aspirin but they don’t substitute for aspirin, I mean aspirin is really the gold therapy for preventing heart disease. There are of course we have statin therapy, we have a whole litany of agents but there’s really nothing that substitutes for aspirin therapy. So we need to keep that in mind and of course the concern that I eluded to about our highest risk patients that are most likely to develop an event in the future if they stopped aspirin therapy they can triple their risk of having another major coronary event and if unfortunately if they’ve already had problems with GI bleeding that risk can be increased 7 fold. So we’ve got to address the reality of trying to achieve the benefits of aspirin therapy and try to minimize the side effects of therapy and we have ways to do that but surprisingly Neal physicians are not aware of this especially among my colleagues in cardiology.
N: It would seem that your colleagues would be at the forefront of knowing about some of these developments. Is it always a matter of complete discontinuing of therapy or do you say take half doses and if that doesn’t work over a period of time? Or can you discontinue and then maybe go back with a different dosage or is it always ‘Hey once it’s done, it’s done’ and maybe talk about baby aspirin?
M: Okay well let’s talk about that because actually this is a really good point and again cardiologists who are most likely to prescribe aspirin therapy for the benefits because we live sort of in a siloed world in medicine and in academia often aren’t aware of what’s going on with the GI symptoms and innovations. We need to understand that discontinuing therapy increases risk yet we have ways to approach that, you brought up some of them and let me clarify some of these myths because I was a believer in these myths as well that if we took really low dose aspirin we wouldn’t be at risk of bleeding, not true. There’s an increased risk of bleeding across all doses of aspirin therapy, number one. I used to believe like many of my colleagues and you eluded to watching commercials about this buffered aspirin, enteric coated aspirin, do these protect us? Answer? No. There’s an increased risk of bleeding regardless of the type of coati ng that we have and that’s why cardiologists and primary care physicians, nurse practitioners, individuals that are prescribing, recommending aspirin therapy for the secondary prevention of heart disease need to be aware of new innovations that we have available. Now the proton pump inhibitors many of us are aware of, we use them short term for gastric distress but we haven’t really thought about these long term in conjunction with aspirin therapy and one of the reasons I’m really excited now is because of the launch and availability now of a new medication that’s available for our patients that was just approved by the FDA called the Yosprala which combines aspirin therapy with a proton pump inhibitor so that you can sort of maximize the benefits of aspirin and minimize the GI side effects and thus increase adherence to the aspirin therapy.
N: Being aware about the lack of knowledge of some of these developments among your colleagues, in your opinion what do you think is I guess the number 1 contributing factor to preventing your colleagues from having this widespread or much more knowledge about some of these things?
M: Well I guess I do think the paradigm is changing now where there’s a lot more cross talk and I think that’s a really great development in medicine in general. I said that we live in a siloed world but I think these barriers are now beginning to be broken down and I think that’s a really good thing because we can’t have blinders and only look at the prevention of heart disease. We have to understand that our patients care about their symptoms, they worry about side effects, we know that fear of side effects is a big deterrent to patients taking our recommendations seriously and that’s a particular challenge with aspirin because in the past aspirin has really been available only over the counter. I worry sometimes that patients don’t take it seriously enough and now with a new prescription form of aspirin in conjunction with a PPI I think this provides a really new opportunity for us to revisit how important it is to take aspirin, how important it is as health care providers that we monitor the side effects and monitor adherence critically important and something that we’ve not always been taught to do or not integrated into our practice.
N: I’d like to ask you a question about in your opinion, the importance of not only being able to talk to the patient getting honest answers about some of these side effects because if you’re the cardiologist and they’re having a stomach problem they maybe a little reluctant to talk to you saying “Well this guy knows my heart but he doesn’t know my stomach or my intestines.” How important is it to understand the symptoms as well as how to treat them and address them or is it simply a matter of recognizing them and then referring them to a gastroenterologist?
M: Well I think both are important and I don’t actually think it’s necessary in a preventive setting to refer to a gastroenterologist. Certainly if somebody had a bleed or is having anemia or symptoms that would be a situation where we would refer our patients. But I think as we get more comfortable with this new paradigm where if we look at it as a way to really maximize the benefit of something we’re doing to prevent the heart. And we don’t really need to learn that much more, I mean I think it’s pretty easy for most of us to understand the pharmacology around using an agent like Yosprala where basically what you’re doing is you are releasing the omeprazole, the component that’s protecting the stomach lining that’s an immediate release component, gets the gastric pH to where we want it then boom the aspirin comes in a delayed release – we have less symptoms, greater adherence, it’s a win-win.
N: Lori it’s been a pleasure having you in studio with us today. I’m glad that you stepped in and gave us more of your time.
M: Sure my pleasure, thank you.
N: Thank you. You’ve been listening to Health Professional Radio, I’m your host Neal Howard in studio with Dr. Lori Mosca. Transcripts and audio of this program are available at healthprofessionalradio.com.au and also at hpr.fm and you can subscribe to this podcast on iTunes.