Sleep is a fundamental pillar of good health and wellness. I like the description that it is the health tide that rises all ships. Unfortunately for me, it has been in short supply recently. Last weekend’s European Society of Cardiology conference in Madrid was excellent, but the Spanish are not known for eating early, and sitting down for starters at 9:30 when you’ve got to be in a conference room first thing in the morning isn’t ideal. Couple that with being on call all this week, including all weekend (I never sleep well on call due to the fear of being called!), AND my children starting back at school with early morning buses to catch, and I find myself in a major sleep debt. Something for me to prioritise this week!
Doctors I think often feel under pressure to DO something when assessing a patient; to prescribe a pill, an injection, an operation… something. However I teach my doctors in training that oftentimes removing unnecessary medicines, or notoperating are harder decisions, but more valuable. In fact, decision making in general is a skill often lacking in medicine, as it is easier to practice defensive medicine, and pass the buck to someone else. Of course if everyone did that where would we be?
This brings me to the conference, and over the next few weeks I will bring you the some of the trials that will affect the way I practice cardiology, and the take home messages for readers.
Only this morning, I was asked to see an elderly man in his mid-80s, suspected of having had a heart attack. Despite his age he was in pretty good health overall with a good quality of life. In actual fact, the evidence for an acute heart attack was fairly weak, yet he had been already given high doses of aspirin and another similar blood-thinning medication called clopidogrel, plus a beta-blocker. This is standard treatment for a heart attack, but in my view is all too often dished out without careful thought of risks vs benefits. This man was already on another blood thinner too for another issue.
One of the most practice-changing trials presented at the ESC was a randomised double blind placebo controlled trial of aspirin (or placebo) in chronic coronary patients already on another blood thinner. It was stopped early due to clear evidence of harm in the group taking additional aspirin. Now please if anyone is reading this on these medications, don’t just stop them without consulting your doctor, but if it may apply to you, it could well be worth getting advice.
Another session I attended looked at the role of beta blockers after a heart attack. Since I qualified in 2001, I’m sure I have prescribed many thousands of patients beta-blockers in this situation. The trial evidence for this is actually fairly old however, but has just become the norm. If we now look at the totality of evidence, I do not think we can justify beta-blockers routinely after a heart attack. Believe me, that is a major departure from current clinical practice. Yes there will always be some in whom it is indicated, but blindly prescribing because that’s the way it has always been done should stop. We should be in a time of personalised medicine, not one size fits all.
So for my patient this morning, I stopped his beta blocker, stopped all the other blood thinners, and sent him home with reassurance. In this case he was being treated with cutting-edge evidence based medicine, yet instead of a fancy new pill, I actually discontinued 3 of them and am sure he will be better for it.