421 - Aspirin for CVD Prevention, NAFLD Diagnosis, Appreciation
Take 3 – Practical Practice Pointers©
From the US Preventive Services Task Force (USPSTF)
1) Draft Recommendation - Aspirin for Primary Prevention of CVD
We don’t normally address draft recommendations by the USPSTF, only their final versions. However, the changes in aspirin recommendations can be confusing…
Keep one thing in mind as you read this:
- This recommendation is about STARTING aspirin for PRIMARY prevention of cardiovascular disease (CVD). The USPSTF doesn’t make recommendations about continuing aspirin already started, or about aspirin use to treat established CVD and prevent recurrence.
In 2016, the USPSTF recommended starting aspirin for primary prevention of CVD for adults aged 50-59 with a 10-year atherosclerotic CVD risk of 10% or greater (B recommendation) and discuss the risks and benefits with those aged 60-69 with a 10-year CVD risk of 10% or greater (C recommendation). Then, three large trials (covered in Take 3 in October 2018) were published that posed big questions about the effectiveness and safety of aspirin for primary prevention in the elderly.
Now, the USPSTF draft recommendation states:
- Adults ages 40 to 59 years with a 10% or greater 10-year CVD risk:
- The decision to initiate low-dose aspirin use for the primary prevention of CVD in adults ages 40 to 59 years who have a 10% or greater 10-year CVD risk should be an individual one. Evidence indicates that the net benefit of aspirin use in this group is small. Persons who are not at increased risk for bleeding and are willing to take low-dose aspirin daily are more likely to benefit. C recommendation
- Adults age 60 years or older
- The USPSTF recommends against initiating low-dose aspirin use for the primary prevention of CVD in adults age 60 years or older. D recommendation
The assessment of bleeding risk should include: older age, male sex, diabetes, a history of gastrointestinal issues (such as peptic ulcer disease), liver disease, smoking, elevated blood pressure, nonsteroidal anti-inflammatory drugs, steroids, and anticoagulants. There is no simple tool for bleeding risk assessment as the available tools (like HAS-BLED) are intended for patients with atrial fibrillation considering anticoagulation.
The USPSTF, in their practice considerations section, suggests that it would be reasonable to stop aspirin for prevention at age 75, since the risk of bleeding continues to increase with age.
Finally, in the 2016 recommendation, colorectal cancer (CRC) prevention was included as part of the recommendation. However, newer data has thrown aspirin’s benefit for CRC prevention into serious question, so it has been removed in the latest version.
These recommendations are in the same vein as those we discussed in Take 3 in 2019, though the specifics differ a bit. The USPSTF notes that CVD risk assessment is not a perfect science at the individual level, so using a calculator to assess risk should be the starting point for the conversation. These will be difficult conversations to have without being able to rely on simple tools.
Remember that this recommendation covers only starting aspirin for primary prevention. If a patient is already on aspirin for primary prevention, and tolerating it, it may be reasonable to discuss stopping it at age 75 if there are no other reasons to continue.
Dr. Ali Hama Amin, Carilion Clinic Cardiologist, reached out to us and notes: “Aspirin or other antiplatelets should be continued for secondary prevention (patients with established CVD), or for people who are taking aspirin for other reasons.”
- US Preventive Services Task Force. Draft Recommendation: Aspirin Use to Prevent Cardiovascular Disease: Preventive Medication. Accessed October 19, 2021. Link
A Clinical Care Pathway From the AGA, AAFP, ACOFP and Others
2) Nonalcoholic Fatty Liver Disease Part 1 – Diagnosis
Nonalcoholic fatty liver disease (NAFLD) currently affects approximately 37% of US adults. Nonalcoholic steatohepatitis (NASH), a subtype of NAFLD, can lead to hepatic ﬁbrosis, cirrhosis, and hepatocellular cancer (HCC). Both NAFLD and NASH are also associated with an increased risk of CVD, cardiovascular and liver-related mortality, and impaired health-related quality of life. Because NAFLD is largely asymptomatic, and because optimal timing of treatment depends on accurate staging of ﬁbrosis risk, screening at the primary care level is critical, together with consistent, timely, evidence-based, widely accessible, and testable management processes.
To achieve these goals, a multidisciplinary Clinical Care Pathway was recently published to provide explicit guidance on the screening, diagnosis, and treatment of NAFLD. This Pathway is intended to be a clinical roadmap applicable in any setting where care for patients with NAFLD is provided, including primary care, endocrine, obesity medicine, and gastroenterology practices. The pathway is outlined in the figure that follows.
Note that the metabolic risk factors in Step 1 include central obesity (deﬁned by waist circumference with ethnicity- speciﬁc cutoffs); triglycerides > 150; reduced serum HDL (<40 in men, <50 in women or speciﬁc treatment);
BP > 130/85 or treatment; and prediabetes.
In Step 2, those with elevated aminotransferases should be evaluated for presence of other chronic liver and biliary diseases.
Step 4 uses an ultrasonic technique called elastograpy to measure liver stiffness, with the most common presently used test called transient elastography (FibroScan).
NAFLD is yet another epidemic in our midst. In this case, it is silently and negatively impacting the health of millions, and often falls off our “radar screen” in the midst of the many demands of day-to-day clinical practice. Awareness of risk is the first important step, for both we clinicians as well as for those we care for. Next week, we’ll review the latest recommendations for the management of NAFLD from the same Pathway group.
From PeerRxMed ( www.PeerRxMed.org )
3) Motivating Through Appreciation
“Each of us wants to know that what we do matters …. and that we matter.”
Gary Chapman, PhD and Paul White, PhD
authors of The 5 Languages of Appreciation in the Workplace
Do you like to feel appreciated? Well duh! And so does everyone else. Yet, in the midst of our incredibly challenging circumstances, “not feeling appreciated” at work is a common theme I’ve been hearing from colleagues both locally and around the country … or as is more commonly expressed, “I’m just not feeling the love right now.” And if we’re not feeling appreciated, we’re likely not expressing it to others either, and that leaves an incredible vacuum for “negative emotional contagion” to run rampant across our organizations and communities (and families). So, the real question is not if, but rather how do you (and they) like to be appreciated?
Perhaps you didn’t realize that not everyone likes to feel appreciated in the same way, and that your attempts to show appreciation to others may be missing the mark. Drs. Gary Chapman and Paul White have devoted a significant portion of their careers to studying the positive impact we can have on each other when we connect in a way that is resonant. Dr. Chapman originally called this type of connection as speaking our “Love Languages,” and the two together brought a similar understanding to the workplace using “Languages of Appreciation.”
Their research found that we are most deeply fulfilled when we receive appreciation in our primary language and that unless we express our appreciation in another’s’ primary language, we “miss the mark” and fail to meet their deepest needs to feel appreciated. This can leave even our “best of intentions” falling far short of potential positive impact and leaving many feeling unsupported and not valued.
They have identified 5 primary “languages”, including Words of Affirmation, Quality Time, Acts of Service, Tangible Gifts, and Physical Touch, and found that most people have a preferred primary and secondary language. Incorporating awareness of these different “languages” in relationships has been shown to dramatically improve marriages, partnerships and friendships, as well creating stronger connections among coworkers and a more positive workplace environment. That has certainly been my experience over many years. Likewise for sharing my preferences with them.
Having a culture of appreciation at work will not only help us get through these challenging times but will enable us to feel more connected and deepen our relationships. This week, perhaps you can learn more about the preferred language of yourself and others, and then practice learning some new languages to make sure you are “contagious” with appreciation.
References: To learn more about your “language”, see the resources below:
Mark and John
Carilion Clinic Department of Family and Community Medicine
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.