Tag Archives: aspirin

Eliquis, over-prescribed but better than Coumadin.

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Eliquis (apixaban) is blood thinner shown to prevent stroke with fewer side effects than Warfarin (Coumadin). Aspirin does the same, but not as effectively for people over 75. My problem with eliquis is that it’s over-prescribed. The studies favoring it over aspirin found benefits for those over 75, and for those with A-Fib. And even in this cohort the advantage over aspirin is small or non-existent because eliquis has far more serious side effects; hemorrhage, or internal bleeding.

Statistically, the AVERROES study (Apixaban Versus Acetylsalicylic Acid to Prevent Stroke in AF Patients Who Have Failed or Are Unsuitable for Vitamin K Antagonist Treatment) found that apixaban is substantially better than aspirin at preventing stroke in atrial fibrillation patients, but worse at preventing heart attack.

Taking 50 mg of Eliquis twice a day, reduces the risk of stroke in people with A-Fib by more than 50% and reduces the rate of heart attack by about 15%. By comparison, taking 1/2 tablet of aspirin, 178 mg, reduces the risk of stroke by 17% and of heart attack by 42%. The benefits were higher in the elderly, those over 75, and non existent in those with A-Fib under 75, see here, and figure. Despite this, doctors prescribe Eliquis over aspirin, even to those without A-Fib and those under 75. I suspect the reason is advertising by the drug companies, as I’ve claimed earlier with Atenolol.

The major deadly side-effect is hemorrhage, brain hemorrhage and GI (stomach) hemorrhage. Here apixaban is far worse than with aspirin (but better than Warfarin). The net result is that in the AVERROES random-double blind study there was no difference in all-cause mortality between apixaban and aspirin for those with A-fib who were under 75, see here. Or here.

To reduce your chance of GI hemorrhage with Eliquis, it is a very good idea to take a stomach proton pump drug like Pantoprazole. If you have A-Fib, the combination of Eliquis and pantoprazole seems better than aspirin alone, even for those under 75. If you have no A-Fib and are under 75, I see no benefit to Eliquis, especially if you find you have headaches, stomach aches, back pain, or other signs of internal bleeding, you might switch to aspirin or choose a reduced dose.

A Japanese study found that half the normal dose of Eliquis, was approximately as effective as the full dose, 50 mg twice a day. I was prescribed Eliquis, full dose twice a day, but I’m under 70 and I have no A-Fib since my ablation.

Life expectancy has dropped in the US to undeveloped world levels. Biden blames COVID and racism. I think it’s too much drugs, and too few opportunities.

I’m struck by the fact that US life expectancy is uncommonly low, lower than in most developed countries. Lower too than in many semi-developed countries, and our life expectancy is decreasing while other countries are not seeing the same. It dropped by about 3 years over the last 2 years as shown. I wonder why the US has suffered more than other countries, and suspect we are over-prescribed. Too much of a good thing, typically isn’t good.

Robert Buxbaum, September 16, 2022. As a side issue, low dose aspirin may forestall Alzheimers and other dementias. See current article here. Also another study here.

Atenolol, not good for the heart, maybe good for the doctor.

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Atenolol and related beta blockers have been found to be effective reducing blood pressure and heart rate. Since high blood pressure is a warning sign for heart problems, doctors have been prescribing atenolol and related beta blockers for all sorts of heart problems, even problems that are not caused by high blood pressure. I was prescribed metoprolol and then atenolol for Atrial Fibrillation, A-Fib, beginning 2 yeas ago, even though I have low-moderate blood pressure. For someone like me, it might have been deadly. Even for patients with moderately high blood pressure (hypertension) studies suggest there is no heart benefit to atenolol and related ß-blockers, and only minimal stroke and renal benefit. As early as 1985 (37 years ago) the Medical Research Council trial found that “ß blockers are relatively ineffective for primary treatment of hypertensive outcomes.”

End point. Relative risk. 95% CI. All-cause mortality Cardiovascular mortality MI Stroke Carlberg B et al. Lancet 2004; 364:1684–1689.

There lots of adverse side-effects to atenolol, as listed at the end of this post. More recent studies (e.g. Carlsberg et al., at right) continue to find no positive effects on the heart, but lots of negatives. A review in Lancet (2004) 364,1684–9 was titled, “Review: atenolol may be ineffective for reducing cardiovascular morbidity or all cause mortality in hypertension” (link here). “In patients with essential hypertension, atenolol is not better than placebo or no treatment for reducing cardiovascular morbidity or all cause mortality.” It further concluded that, “compared to other antihypertensive drugs, it [atenolol] may increase the risk of stroke or death.” I showed this and related studies to my doctor, and pointed out that I have averaged to low blood pressure, but he persisted in pushing this drug, something that seems common among medical men. My guess is that the advertising or doctor subsidies are spectacular. By contrast, aspirin has long been known to be effective for heart problems; my doctor said to go off aspirin.

The graph at right is from “Trial of Secondary Prevention with Atenolol after transient Ischemic Attack or Nondisabling Ischemic Stroke”, published in Stroke, 24 4 (1993), (see link here). a Thje study involved 1473 at-risk patients, randomly prescribed atenolol or placebo. It found no outcome benefit from atenolol, and several negatives. After 3 years, in two equal-size randomized groups, there were 64 deaths among the atenolol group, 58 among the placebo group; there were 11 fatal strokes with atenolol, versus 8 with placebo. There were somewhat fewer non-fatal strokes with atenolol, but the sum-total of fatal and non-fatal strokes was equal; there were 81 in each group.

“Trial of Secondary Prevention with Atenolol after transient Ischemic Attack or Nondisabling Ischemic Stroke”, published in Stroke, 24 4 (1993).

Newer beta blockers seem marginally better, as in “Effect of nebivolol or atenolol vs. placebo on cardiovascular health in subjects with borderline blood pressure: the EVIDENCE study.” “Nebivolol (NEB) in contrast to atenolol (ATE) may have a beneficial effect on endothelial function …. there was no significant change in the ATE and PLAC groups.” My question: why not use one of these, or better yet aspirin. Aspirin is shown to be beneficial, and relatively side-effect free. If you tolerate aspirin, and most people do, beneficial has to be better than maybe beneficial.

Among atenolol’s ugly side effects, as listed by the Mayo Clinic, there are: tiredness, sweating, shortness of breath, confusion, loss of sex drive, cold fingers and toes, diarrhea, nausea, and general confusion. I had some of these. There was no increase in heart stability (decrease in A-fib). My heart rate went as low at 32 bpm at night. My doctor was unconcerned, but I was. I suspected the low heart rate put me at extreme risk. Eventually, the same doctor gave me ablation therapy, and that seemed to cure the A-Fib.

Following my ablation, I was told I could get off atenolol. I then discovered another negative effect of atenolol: you have to ease off it or your heart will race. If you have A-fib, or modest hypertension, consider aspirin, eliquis, ablation, or exercise. If you are prescribed atenolol for heart issues and don’t have symptoms of very-high blood pressure, consider other options and/or changing doctors.

Robert Buxbaum, August 14, 2022