To: Dr. James M. Wright, MD PhD CRCP(C) Editor-in-Chief, Therapeutics Letter, Therapeutics Initiative: Evidence-Based Drug Therapy*, University of British Columbia, Vancouver, BC Canada
From: Carolyn Thomas, Heart Sisters
Dear Dr. Wright,
I’m a heart attack survivor and patient advocate who blogs about women and heart disease at Heart Sisters.
Recently, a well-known family physician who writes a syndicated medical column did a presentation on heart health to about 200 members of our local cardiac rehab alumni group. He told us about a new protocol to be followed at the first symptoms of a heart attack – one that’s apparently superior to the current “Call 911 and chew one full-strength aspirin” patient recommendation.
Instead, he favours something new that he called “Axe the Aspirin”. He waved a little plastic baggie with two pills in it as he spoke, adding that he carries this in his wallet at all times, “just in case”. What he was waving overhead was a mega dose of the anti-platelet drug clopidogrel (Plavix 600 mg – about nine times the standard therapeutic dosage that heart patients take) along with the statin/cholesterol drug rosuvastatin (Crestor 20 mg) – to be taken together at the first symptoms of possible heart attack. He told us, quite emphatically:
“We used to recommend aspirin, but this Plavix/Crestor combo is better!”
I was surprised to learn of this protocol. So I contacted him following his presentation and asked if he could send me links to any published science-based evidence for this change; I wanted to help spread the word to my readers, many of whom are heart patients already considered at high risk for future cardiac events.
But his reply to me was this: he had not actually ever seen this recommendation in writing, but had heard about it while attending a medical conference in Montreal. He did, however, refer me to an “excellent resource” if I wanted to learn more: an employee of the pharmaceutical company Bristol-Myers Squibb/Sanofi Aventis (makers of Plavix) – in fact, his drug rep (who is apparently married to a physician, so I guess that’s worth something). He also wrote:
“Medicine is such a dynamic field, constantly changing rapidly and constantly improving, I have said that if you practice medicine the same way you did two years ago, you are practicing museum medicine.
“As one who is constantly having to stay abreast of the latest developments to be able to write and do a radio show where I take calls from all over the nation on any topic, I can tell you that change in medicine is by the day in this exciting biomolecular revolution we are in.
“Who knows what will be in my wallet next year?
Meanwhile, I’ve been unable to find anything among credible resources to even hint that our basic aspirin protocol is considered less effective for patients during early symptoms of heart attack than this Plavix/Crestor therapy.
Nothing on HeartWire. Nothing from the Harvard Heart Letter. Nothing on MedPage. Nothing on Journal Watch Cardiology. Nothing on Medpedia. Nothing on the physicians’ site Up To Date. Nothing from The Heart and Stroke Foundation or the American Heart Association. Nothing from Health Canada. Nothing from the U.S. Office of Disease Prevention and Health Promotion. Nothing from the European Society of Cardiology. Nothing from WomenHeart: The National Coalition For Women With Heart Disease. Nothing from Mayo Clinic. Nothing from the Cleveland Clinic (widely considered to be the #1 heart institute in North America).
Couldn’t even find anything on the official Bristol-Myers Squibb/Sanofi Aventis company website for their Plavix drug. You get my drift . . .
Can you help? Do you have any evidence that the current recommended patient protocol of chewing one full-strength aspirin at the first sign of heart attack is now out of favour in the medical community?
Many thanks.
Regards,
Carolyn Thomas
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To: Carolyn Thomas, Heart Sisters
From: Dr. James Wright, Editor-in-Chief, Therapeutics Letter, Therapeutics Initiative, University of British Columbia, Vancouver, BC Canada
Carolyn,
Excellent question. We should never embark on new treatments without evidence from randomised controlled trials (RCT) that the benefits outweigh the harms. I am not aware that any such RCT evidence exists. Thus the only setting where a patient should be given this new regimen is if it is within an RCT comparing the new regimen with ASA.
If you have any further questions, let me know.
Kind regards,
Jim Wright
Editor-in-Chief
Therapeutics Letter
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And for those of you still wondering about Axe the Aspirin, consider this from Up To Date for those who feel the first signs of heart attack symptoms:
“Aspirin can be life-saving for people who are actively having a heart attack to help stop new blood clots from forming in coronary arteries. Health care providers recommend that anyone who believes they may be having a heart attack immediately call 911, and then take 162 to 325 mg of plain aspirin (one half to one whole adult aspirin tablet) unless you are allergic or your physician has warned against taking aspirin.”
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♥ Please remember: see your own physician for health advice. Read our disclaimer for more info.
,
* The Therapeutics Initiative was established in 1994 by the Department of Pharmacology and Therapeutics in cooperation with the Department of Family Practice Medicine at The University of British Columbia in Vancouver, BC, Canada. Its mission is to provide physicians and pharmacists with up-to-date, evidence-based, practical information on prescription drug therapy.
To reduce bias as much as possible, the TI is an independent organization, separate from government, pharmaceutical industry and other vested interest groups. Their commitment:
“We strongly believe in the need for independent assessments of evidence on drug therapy to balance the drug industry-sponsored information sources.”
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Q: Are you familiar with “Axe the Aspirin”? And if you’re a physician, are you too carrying a Plavix/Crestor combo in your wallet “just in case” you have a heart attack?
Heart Sisters 
Aspirin is one of the best pain relievers and anti-inflammatory with great safety record.
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There can be some serious side effects to Plavix and especially such a mega dose. I think it is rather irresponsible of a doctor to wave a baggie of meds and claim it as a life saver. Prescription meds are controlled meds for a reason.
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I thought so too, Rose.
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Carolyn, I think I met this doctor’s brother at a walk in clinic after my open heart surgery last summer. Except his “miracle” drug was Atenolol. Not bothering to check any vitals he merely expounded on the merits of this drug and in fact told me it should be added to the water system in every town and city.
This kind of misinformation is irritating to us, but could be scary for others who are not as informed.
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Hi Lauren – I’ve also heard doctors speak as enthusiastically about adding statins to our drinking water, too.
Atenolol after heart attack, like other beta blocker drugs for treating high blood pressure, is considered by The National Center for Quality Assurance (which accredits managed care organizations) to be “an indicator of high-quality health care” – but according to this 2010 report called Beta Blockers for Acute Myocardiac Infarction, such enthusiasm may be questionable.
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A year ago last February I was in the ER (Tucson Med Ctr) with chest pain and other signs of a heart attack, the blood work hadn’t come back yet. I was given this dosage of plavix and I questioned why and was told to prevent clotting in the blood to prevent damage if I was having a heart attack.
So I think there has been a change in protocol not widely known by the public. I have put a plavix in my container holding my nitro tabs and if I think I’m in trouble I’m taking it.
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Hi Julia – that “loading dose” (usually 300-600 mg) of clopidogrel (Plavix) given in the E.R. to potential heart attack patients (those identified with Acute Coronary Syndrome) is not new, and actually already widely accepted. More info in this 2009 article from the Journal of the American College of Cardiology.
What this particular doctor written about here was talking about, however, is for non-heart patients to carry the Plavix/Crestor combo with them “just in case” – to replace the existing aspirin protocol.
Non-heart patients, of course, would never even have access to Plavix – unless they begged, borrowed or stole the drugs from their heart patient-friends = NOT a good idea.
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I think, just in case of thinking having a heart attack, it is better to have a nitro spray in your pocket than aspirin.
That is what a doctor gave to my friend, as she told her having had heart attack symptoms a day before. I was so angry when she told this to me at phone (she lives 500 km of my home).
She was afraid to call ER and the pain went over after half an hour. The date for a stress test was given weeks after. I do not know the results yet. I told her to call ER, if the pain comes again and take nitro spray. She is living alone after having lost her hubby 2 months ago.
Taking plavix/crestor would be too dangerous.
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Hi Mirjami – your friend’s case is upsetting. I hope her outcome is positive. Your advice to call the ER is excellent, and would be the standard practice if heart attack symptoms continue, no matter what you’re taking.
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