Watch now | Last week, John was at the European Society of Cardiology conference in Madrid, and Adam was at the Preventing Overdiagnosis 2025 International Conference in Oxford. A conversation about what we learned.
This is my favorite Fortnight so far. It offered lots to digest, even for a surgeon who really doesn't deal with most of the issues discussed, except the issue of aspirin and anticoagulation (discussed below), and occasionally having to deal with "decontextualized information". I hope you are able to get a follow-up discussion on that topic on Sensible Medicine.
The use of aspirin in the setting of chronic anticoagulation study was particularly interesting. I do wonder about the mechanism of action responsible for the finding of a higher incidence of atherothrombotic events in patients taking aspirin versus those who were not. An increased risk of bleeding, and particularly GI bleeding, is intuitive, but an increased risk of atherothrombotic events is not.
Any thoughts about why aspirin might cause an increased risk of atherothrombotic events in patients on chronic anticoagulation? I see patients in my clinic regularly who are on both, and will now suggest they stop taking aspirin regularly, based upon this study. But, how about the occasional use of aspirin, or the occasionally or regular use of other NSAIDs such as ibuprofen or naproxen?
In the AQUATIC trial how did the authors explain the excess thrombotic events in the group receiving anti-platelet therapy compared to the group not receiving anti-platelet therapy? I don't have access to the full article and it seems like that is a finding that warrants an explanation in the discussion.
I was very pleased to say hello in Oxford. Adam. What I observe in the several POD conferences I have been to are not two camps, but large numbers of people (including clinicians, especially in primary care) who are in two minds. They have not clarified - and not been encouraged/allowed to clarify - whether they are practising population medicine or clinical medicine. Overdiagnosis is a construct only in population medicine and is the inevitable consequence of aggregated clinical decisions that are almost always risk averse (not risk neutral). The clinical/ethical issue is whether the degree of risk aversion exhibited by individual patients (and the level of population level overdiagnosis thereby produced) is based on the best available information. In most cases it is light years away from that, particularly in the screening/case finding, and particularly in cancer. 'Informed' consent is illusory.
Thank you for another great discussion that covered a lot of practical areas in decision making. It felt like I was sitting down with two old friends and colleagues. Although long retired from clinical practice, it made me feel like I was still learning useful information. I would have intuitively agreed with Adam's concise summation to ditch the beta blockers and aspirin and use the digoxin when needed, but it was nice to hear all the reasons for doing so. I am very happy that I came across Sensible Medicine a couple of years ago. Well worth the price of subscription.
Great talk. I stopped a anticoagulated patient’s aspirin yesterday. Please please don’t stop what you’re doing.
This is my favorite Fortnight so far. It offered lots to digest, even for a surgeon who really doesn't deal with most of the issues discussed, except the issue of aspirin and anticoagulation (discussed below), and occasionally having to deal with "decontextualized information". I hope you are able to get a follow-up discussion on that topic on Sensible Medicine.
The use of aspirin in the setting of chronic anticoagulation study was particularly interesting. I do wonder about the mechanism of action responsible for the finding of a higher incidence of atherothrombotic events in patients taking aspirin versus those who were not. An increased risk of bleeding, and particularly GI bleeding, is intuitive, but an increased risk of atherothrombotic events is not.
Any thoughts about why aspirin might cause an increased risk of atherothrombotic events in patients on chronic anticoagulation? I see patients in my clinic regularly who are on both, and will now suggest they stop taking aspirin regularly, based upon this study. But, how about the occasional use of aspirin, or the occasionally or regular use of other NSAIDs such as ibuprofen or naproxen?
In the AQUATIC trial how did the authors explain the excess thrombotic events in the group receiving anti-platelet therapy compared to the group not receiving anti-platelet therapy? I don't have access to the full article and it seems like that is a finding that warrants an explanation in the discussion.
I was very pleased to say hello in Oxford. Adam. What I observe in the several POD conferences I have been to are not two camps, but large numbers of people (including clinicians, especially in primary care) who are in two minds. They have not clarified - and not been encouraged/allowed to clarify - whether they are practising population medicine or clinical medicine. Overdiagnosis is a construct only in population medicine and is the inevitable consequence of aggregated clinical decisions that are almost always risk averse (not risk neutral). The clinical/ethical issue is whether the degree of risk aversion exhibited by individual patients (and the level of population level overdiagnosis thereby produced) is based on the best available information. In most cases it is light years away from that, particularly in the screening/case finding, and particularly in cancer. 'Informed' consent is illusory.
Thank you for another great discussion that covered a lot of practical areas in decision making. It felt like I was sitting down with two old friends and colleagues. Although long retired from clinical practice, it made me feel like I was still learning useful information. I would have intuitively agreed with Adam's concise summation to ditch the beta blockers and aspirin and use the digoxin when needed, but it was nice to hear all the reasons for doing so. I am very happy that I came across Sensible Medicine a couple of years ago. Well worth the price of subscription.