Aspirin for primary CVD prevention: the continuing debate

In 2002, the U.S. Preventive Services Task Force (USPSTF) strongly recommended that primary care clinicians discuss preventive aspirin use with adults at increased risk of cardiovascular events. Four years later, the National Commission on Prevention Priorities (NCPP) ranked counseling for aspirin use the number one priority on its list of the most effective clinical preventive services. According to the NCPP, if the percentage of eligible patients using aspirin (then estimated to be about 50 percent) increased to 90 percent, 45,000 additional lives could be extended each year.

At that time, the benefits of aspirin use in men and women were assumed to be the same. However, an updated USPSTF recommendation statement published in the June 15th issue of AFP indicates that aspirin use actually prevents heart attacks in men, but ischemic strokes in women. In addition, physicians and patients must weigh the benefits of reduced cardiovascular risk with the risk of gastrointestinal bleeding events, and use shared decision making when these risks are closely balanced.

To further complicate matters, a 2009 meta-analysis published in the journal The Lancet questioned the value of aspirin for primary prevention, concluding that for patients who without a history of cardiovascular disease, "aspirin is of uncertain net value." In response, family physicians and USPSTF members Ned Calonge and Michael LeFevre wrote an editorial that concluded, "There is not a simple message for aspirin prophylaxis as a primary preventive strategy, and we need to consider gender, age, and the associated balance of potential risks and benefits to provide the best advice and preventive care for our patients."

We pick up the continuing debate with two thought-provoking editorials in the June 15th issue. Alison L. Bailey and colleagues caution that routine aspirin use is not justified for primary prevention in adults at low risk of CVD. On the other hand, W. Fred Miser asserts that the main issue regarding aspirin for primary prevention continues to be underuse in appropriate-risk patients. Finally, a Putting Prevention Into Practice case study applies information from the USPSTF recommendation to a sample patient scenario.

FP Blog Roundup: Remembering Barbara Starfield

The recent passing of legendary primary care researcher Barbara Starfield, MD, MPH was the subject of many Family Medicine blog posts this week. At Medicine and Social Justice, Josh Freeman, MD called Dr. Starfield "the pre-eminent scholar on health workforce policy." At Family Medicine Rocks, Mike Sevilla, MD posted a video of her receiving the Family Medicine Education Consortium's Lifetime Achievement Award and commented on the surprising silence from family medicine organizations about Dr. Starfield, who, though a pediatrician by training, "gave this specialty [of family medicine] a voice." Finally, at The Singing Pen of Doctor Jen, Jennifer Middleton, MD, MPH pondered, "With all of the national chatter about [unsustainable] heath care costs, why hasn't the media broadcasted the message of primary care's cost-saving and health-prolonging benefits?"

Through her research, Dr. Starfield did more than perhaps any other individual to establish the essential role of family medicine in improving population health outcomes in the U.S. and abroad. In a 2009 interview for AAFP News Now, she observed:

The thing that is wrong with our current health care system is that it is not designed to produce the best effectiveness, efficiency and equity in health services because it is too focused on things that are unnecessary and of high cost rather than arranging services so that the most needed services are provided when needed and with high quality. [This] is the case because the country has not put sufficient emphasis during the past 50 years on a good infrastructure of primary care. Primary care everywhere in the world is most of the care, for most of the people, most of the time. We have done a reasonably good job at making subspecialty care available, but a lot of subspecialty care is not necessary if you have good primary care. So we end up with a very expensive system that does things unnecessarily. If we followed what the evidence shows, we could do a whole lot better with a much better infrastructure of what we call primary health care.

Earlier that year, in a provocative editorial published in Family Practice Managment, Dr. Starfield had argued that the timeless principles of family medicine - first-contact care; comprehensive care; person-focused care over time; and care coordination - should be driving practice reforms such as the Patient-Centered Medical Home, rather than the other way around. To honor Dr. Starfield's career, Health Affairs is offering free access until June 28th to four landmark articles that she previously wrote in their journal.

Evaluation and management of heat-related illness

Last July, a record-breaking heat wave affected most of the Northern Hemisphere and led to many cases of heat-related illness in the U.S. and abroad. As the summer of 2011 approaches, Drs. Jonathan Becker and Lynsey Stewart from the University of Louisville, Kentucky present an updated review of the evaluation and management of heat cramps, heat exhaustion, and heat stroke in the June 1st issue of AFP. In addition to using the suggested evaluation algorithm, family physicians should also be aware of the many conditions and substances that may increase the risk of heat-related illness. As the authors note, heat stroke is a true medical emergency that requires immediate assessment and lowering of core body temperature, preferably through cold water immersion.