James Marroquin

With all the attention Covid-19 has received over the past two years, it’s easy to think it’s the only infection that matters. But, of course, other viruses, along with parasites, fungi, and bacteria continue to pester us. One of the most common infectious threats is the bacteria Streptococcus Pneumoniae. It causes pneumonia (infection of the lungs), sinus infections, meningitis (infection of the lining of our brain and spinal cord), ear infections, and sepsis (bacteria in the bloodstream). Just as there are multiple forms of Covid such as alpha, delta, and omicron, there are also multiple forms of Strep Pneumoniae we call serotypes.  

There are fortunately vaccines that protect us from many of Strep Pneumonia’s serotypes. To stimulate our immune systems to respond to the bacteria, the vaccines contain materials from the capsule that surrounds Strep Pneumoniae. One vaccine that we have long given to reduce the risk of infections from Strep Pneumoniae is called Pneumovax-23. It protects against 23 serotypes of Strep Pneumoniae. 

While Pneumovax-23 reduces the risk of bacteria entering the bloodstream if you get pneumonia, but doesn’t protect against pneumonia itself. That’s because presenting our immune system with the bacteria’s polysaccharide doesn’t provoke a very robust, enduring immune reaction. To solve this problem, scientists attached bacteria’s polysaccharides to a protein that causes a stronger immune response, creating what are called conjugate vaccines. Conjugate vaccines activate parts of the immune system called memory B cell and T cells. For many years, the only conjugate vaccine that protects against Strep Pneumoniae was called Prevnar-13. 

Until recently Centers for Disease Control (CDC) guidelines were to give people 65 and older one shot of Prevnar-13 and then 1 year later Pneumovax-23. Each shots were given once in people’s lives after age 65. We also gave Prevnar-13 and Pneumovax-23 to younger people with certain health conditions that made them higher risk of getting a severe infection with Strep Pneumoniae. 

Recently two new conjugate vaccines for Strep Pneumoniae were created and approved for use by the FDA. They protect against more serotypes of Strep Pneumoniae than Prevnar-13 and thus replace it. The pneumococcal conjugate vaccine 15 (PCV15) called Vaxneuvance protects against 15 Strep Pneumoniae serotypes. The pneumococcal conjugate vaccine 20 (PCV20) called Prevnar-20 protects against 20 Strep Pneumoniae serotypes.

Under the new CDC guidelines people 65 years and older and those 19-64 years old who are immunocompromised or have underlying health conditions and haven’t received Prevnar-13 should receive Vaxneuvance (PCV15)  or Prevnar-20. If Vaxneuvance (PCV15) is used, Pneumovax-23 should be given one year later. If Prevnar-20 (PCV20) is used, no further pneumococcal vaccines are needed. If you already received Prevnar-13 and Pneumovax-23, CDC guidelines state you do not need to receive Prevnar-20 or Vaxneuvance.

One other new recommendation from the CDC is that the shingles vaccine called Shingrix is now recommended for people 19 and older who “have weakened immune systems because of disease or therapy.” For people with normal immune systems, Shingrix is still only recommended for people 50 years and older.

In other vaccine news: There are reports that the CDC will soon offer a 4^th shot of the Covid vaccine as an option for people 50 years and older whose 3^rd shot was 4 or more months earlier. As time permits, I’ll address this in a future post. 

Understanding and preventing dementia is something in which I have a strong interest since I’ve observed its enormous impact on patients and their families. Dementia is defined as cognitive impairment severe enough to interfere with daily life. There are multiple causes of dementia including Alzheimer’s disease and the accumulated effects of strokes called vascular dementia.

A recent study published in the journal Alzheimer’s & Dementia assessed the connection between having an elevated heart rate and dementia. Your heart rate or pulse is how many times per minute your heart contracts and pushes out blood to the rest of your body. Your pulse normally goes up with physical activity or stress as your bodies senses it needs more blood with oxygen. A resting pulse is your pulse when you aren’t engaged in physical activity.  This study performed in Stockholm observed 2,147 individuals 60 years old and older over a period of up to 12 years. It found that individuals with a resting heart rate of 80 beats per minute or higher on average had a 55% higher risk of dementia than those with a heart rate of 60-69 beats per minute. Individuals with higher resting heart rates were older, less educated, and more likely to be smokers and sedentary and to have hypertension. Since these are risk factors for dementia they could explain much of the association observed between having a higher resting pulse and dementia.

This study was observational so that it cannot establish a causal relationship between an elevated pulse and the risk of developing dementia. Nonetheless, here are my takeaways: First, an elevated pulse can be a marker of poor cardiovascular health. In a well-functioning cardiovascular system, the heart doesn’t have to beat as often to supply the body with its need for oxygenated blood. So this study fits with other studies suggesting poor cardiovascular health increases the risk of dementia. This makes sense since our brain, like all other organs in our body needs good blood flow to function. 

A second takeaway from this study is the impact of emotional stress on brain health. A higher resting pulse might mean your fight or flight response called the sympathetic nervous system is more often activated. This can be sign of emotional stress. There is evidence suggesting chronically elevated stress levels can increase the risk of dementia. One possible mechanism for this link is the effects of elevated levels of the hormone cortisol that is released with stress. High cortisol levels may have an adverse effect on the hippocampus, a structure in the brain that plays an important role with learning and memory.  

Here are my takeaways from this study. To protect your brain health:

1) Take steps to promote your cardiovascular health. Exercise regularly. Don’t smoke. Eat a Mediterranean style diet. Control cardiovascular disease risk factors such as elevated blood pressure, blood sugar, and cholesterol.

2) Take steps to control emotional stress. Make time to relax and have fun. Prioritize enriching time with friends and family. Consider stress-reducing activities such as yoga or meditation. Give yourself a chance for 8 hours of sleep every night. Avoid committing to more than you can reasonably handle.

Here is a link to the study:

https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/alz.12495

This past week has brought new information about the Omicron variant of Covid first identified in southern Africa. Omicron has now been found in many additional countries around the world, including the United States. Modeling by infectious disease scientist Trevor Bedford suggests Omicron has a substantial transmission advantage over Delta, the Covid variant that is responsible for over 99% of Covid cases in the U.S. This increases the probability Omicron will ultimately overtake Delta as the dominant variant in the U.S. A more contagious variant here would result in many more Americans becoming infected, potentially straining our health care system’s clinics and hospitals.

There is evidence that immune protection through previous Covid infections and vaccinations is eroded with Omicron. But the extent of such erosion is unclear. Experts expect that some degree of immune protection from infections and vaccines will remain and that getting a booster shot will offer further protection. This is, in part, because Omicron will still be vulnerable to the body’s second line of defense called T-cells that are primed by vaccines and prior Covid infections. They work with our immune system’s antibodies to ward off infection and the development of disease. If a virus escapes the attacks of antibodies, T-cells then get to work killing infected cells.

It is too early to draw confident conclusions, but early data from South Africa hint that Omicron may cause less severe disease.  A report from several hospitals in Gauteng Province, where Omicron was first spotted states that most hospitalized patients who tested positive for Covid did not need supplemental oxygen. Few developed Covid pneumonia or required high-level care, and fewer still were admitted to intensive care. But it’s important to note this report included too small a sample of patients to infer much about Omicron’s severity. In addition, many of the hospitalized patients were of a younger age in which Covid infections are often less severe. Even if Omicron turns out to cause less severe disease, if many more people are infected due to its contagiousness, this could still overwhelm clinics and hospitals.

Most current treatments for Covid will likely retain their efficacy against Omicron since they aren’t impacted by its mutations. For hospitalized patients, these treatments include medicines like Dexamethasone and Actemra that decrease inflammation caused by Covid as well as the antiviral medicine Remdesivir.

The most effective treatment for preventing hospitalizations and death from Covid are monoclonal antibodies. Once infused in a patient, they bind to and neutralize the virus. I’ve used them successfully on many of my patients infected with Covid.  Early lab studies show that GlaxoSmithKline’s monoclonal antibody called Sotrovimab could be effective against Omicron. On the other hand, there is data suggesting that the monoclonal antibodies created by Regeneron and Eli Lily may be less effective against Omicron. 

Fluvoxamine and inhaled corticosteroids such as budesonide are other medicines that have good evidence for shortening duration of symptoms from Covid and reducing the risk of hospitalization. They should continue to help when used in patients with the Omicron variant. Once the antiviral pills created by Pfizer and Merck are available for use, they should retain the benefit they provided when studied against other Covid variants such as Delta.

Our current antigen and PCR tests for Covid will effectively detect Omicron. Thus, home Covid tests will continue to be a helpful tool.

So what should we do in response to the latest information about Omicron? Get vaccinated if you haven’t. If it’s been 6 months since your second Moderna or Pfizer shots or 2 months since your J&J shot, get a booster shot with either Moderna or Pfizer. Continue to wear a mask indoors with people outside your household. Gathering outside is very low risk for infection. If gathering indoors without masks with highly vulnerable people, consider checking home tests beforehand to ensure nobody is bringing an asymptomatic Covid infection. Mentally prepare yourself for some disruption in the next few months if a more contagious variant of Covid becomes common in the U.S. Remember that health involves much more than avoiding a viral infection. Continue to do the things that promote well-being like regular exercise, a nutritious diet, avoiding excessive alcohol use, getting enough sleep, and taking time to relax. Most importantly, engage in activities that bring you joy and fulfillment such as connecting with friends and family.

On Thanksgiving, reports emerged that a new concerning variant of Covid was identified in southern Africa. Later named Omicron by the World Health Organization, the variant has since been identified in several locations around the world, including England, Israel, Italy, Netherlands, and Hong Kong. It has not yet been detected in the U.S., but this may be because America doesn’t as frequently test for specific variants of Covid compared to some other countries. According to many experts, there’s a good chance it’s already here.

So why is this variant especially concerning? First, there is evidence that it may be more transmissible than previous versions of the coronavirus. One important data point in this regard is the variant’s rapid rate of spread in South Africa. But it will take more data collection over time to confirm if Omicron is genuinely more contagious. A second concern is that our current vaccines may be less effective at protecting us against the Omicron variant. This is based on mutations in the genes that code for the spike protein the vaccines neutralize. If Omicron’s spike protein is different previous variants, our current vaccines might bind to it less effectively and thus be less successful at preventing the virus from entering our cells. Experts think it’s unlikely Omicron will completely evade or escape our current vaccines. According to reports from vaccine manufacturers we should know how well current vaccines work against Omicron in around 2 weeks.

There is no solid evidence at this point on the question of whether Omicron causes a different severity of disease compared to other Covid variants.  

Even if the vaccines are less effective against Omicron, it’s not like we’re back to square one. First, again, there is good reason to believe our current vaccines they will still offer some measure of protection against Omicron. Indeed, booster doses of the current vaccines can, at least for a time, elicit such sky-high levels of antibody that they can broadly withstand a mutated virus, even if the antibodies aren’t targeting the specific viral proteins as well. So that’s more reason to get a booster ASAP if you haven’t already.

It’s also important to remember we now have knowledge we didn’t have when the pandemic began. We know transmission is very low risk outdoors. We know masks, of which we have abundant supply, work. We know improving ventilation through opening windows and using air filtration devices lowers transmission indoors.

We also have tools we didn’t have when at the outset of the pandemic. We have home tests to know if we’re contagious with Covid before we gather with family and friends. We know how to more effectively treat Covid in the hospital with meds like dexamethasone and tocilizumab. For outpatient therapy, even if current monoclonal antibodies don’t work against this new variant, inhaled steroids and fluvoxamine will still help, along with the antiviral medicines from Pfizer and Merck when they become available in likely the next 1-2 months. If Omicron is resistant to our currently available monoclonal antibodies, they would likely be able to be updated to target this new variant. Most importantly, the mRNA platform for creating vaccines is versatile, allowing updated vaccines that target the Omicron variant to be created and available in a much shorter time than it took to create the current vaccines. I have read reliable experts estimate that, if necessary, vaccines updated for Omicron could available in the spring. One exciting possibility being researched is a vaccine that would protect against all possible variants of SARS-CoV-2. 

So what should you do now? Get vaccinated if you haven’t already. Get your booster 6 months after your second shot of Pfizer or Moderna or 2 months after your first shot of J&J. Wear a mask in indoor crowded spaces, especially if you don’t know if people around you are vaccinated or symptomatic. If gathering around a person more vulnerable to a bad case of Covid, such as the immunocompromised or elderly, consider having everybody take a home Covid test beforehand to help rule out an asymptomatic infection.  

The emergence of the Omicron variant shows why we need to vaccinate the entire world. If a virus is circulating at high levels anywhere, this increases the chance a more challenging variant will occur. And in our connected world, a dangerous variant is likely to travel around the globe quickly.  We’re all in this together.

One of my chief tasks as a primary care physician is preventing illness. Today we can thankfully prevent or at least postpone some of the most common causes of premature death and disability. By identifying and controlling risk factors such as high blood pressure and high cholesterol, we can largely prevent heart attacks and strokes. By controlling diabetes, we can prevent the most common cause of kidney disease. Through vaccines we can lower the risk of suffering hospitalization and death from infectious diseases like flu, covid, and bacterial pneumonia. We can screen for colon, prostate, breast, lung, and cervical cancer and thereby often provide curative treatment. But there are still many conditions we cannot screen for and prevent. These include several cancers such as pancreatic, bladder, kidney, bile duct, and thyroid.

Enter a blood test called Galleri that screens for 50 types of cancer. It does so by looking for cell-free DNA (cfDNA) that cells shed into the bloodstream. Galleri uses genetic sequencing technology to scan for changes in cfDNA that come from cancer cells. In a study of people already diagnosed with cancer, Galleri accurately detected cancer in 51.5% of people. It predicted the location of the tumor 89% of the time. 

Since this study was published this June 2021, I’ve been intrigued by the potential benefits of Galleri and had several patients ask about it. But further analysis shows it isn’t ready for widespread use. One limitation is that the test only found cancer in 16.8% of the patients with stage I cancer. It was much better at finding cancer at later stages in which treatment options are limited. In addition, I question the value of screening the general population for many of the cancers it seeks to detect. Some of the cancers it screens for are very rare. These include cancers of the small intestine, ampulla of vater, and adrenal gland. For some of the other cancers in the panel, including cancers of the cervix, colon, prostate, and breast, we already have screening tests. Other cancers included in the screening occur almost exclusively in people with certain behaviors or risk factors. For instance, mesothelioma usually presents in people with a large amount of exposure to asbestos. Galleri includes leukemia as one of the cancers it detects. But, if present, leukemia shows up on a complete blood cell count (CBC) that is part of an annual physical. Galleri screens for testicular cancer and yet in the population in which Galleri is seeking an indication—50 years and older—testicular cancer is very rare. 80% of cases occur in men between 20-34 years old. I could go on, but you get the point. The bottom line is that many of the cancers Galleri screens for are quite rare and it’s not very good at detecting them at an early enough stage to effectively impact treatment. 

Nonetheless, the technology is promising. There is clearly a need for screening tests for pancreatic, ovarian, kidney, and lung cancer (in non-smokers). Right now these malignancies are often detected at too late a stage to allow for curative treatment. I’d encourage researchers to focus on more sensitively identifying these more common cancers. Ongoing studies will shed further light on Galleri’s strengths and limitations. Over time, I think it’s likely innovations will enable Galleri and other similar screening tests to detect cancers at an earlier stage. When that occurs,  hopefully in the not too distant future, such testing will be a valuable preventative tool.

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In an earlier post I discussed exercise and sleep as important strategies for protecting our mind as we age. This week, I’ll discuss some other steps we can take to lower our risk of dementia.

Control blood pressure

Hypertension is when we have persistently elevated blood pressure. A growing body of research shows hypertension increases the risk of dementia. Blood pressure is the amount of pressure in our body’s arteries at a given time. Arteries are blood vessels that take oxygen and other nutrients to our body’s tissues, including our brain. The top number, systolic blood pressure, is the pressure when the left side of heart is contracting. The bottom number, diastolic blood pressure, is the pressure when the left side of the heart is relaxing. When blood pressure is persistently elevated, it damages the arteries. Think of a hose that you always filled with a massive amount of water pressure. Over time, the lining of the hose would wear out. The same thing happens with arteries in hypertension. When arteries are damaged they become less effective at supplying tissues including the brain. Parts of the brain die when they don’t get the oxygen and other nutrients they need. This is what we call mini-strokes and stroke. 

For many health conditions, we develop symptoms that tell us we have a problem. Not so with hypertension. That’s why it’s known as the silent killer. The only way to know it’s present is to measure your blood pressure. Fortunately, that’s relatively easy to do. Buy a home blood pressure cuff. I recommend the brand Omron and using a cuff that takes measurements at the arm rather than the wrist. When you measure blood pressure, have your feet flat on the ground. Place your arm at chest level, resting it on a desk of table. And wait a few minutes to check the pressure to give yourself time to relax. It’s the average that matters. Enter the readings into app like BP Companion that calculates the average of your readings. Check at least once daily for at around two weeks to get a sufficient sample size. An average above 135 systolic or 85 diastolic is when it’s worth contacting your doctor to discuss if a medicine might be needed. For people with vascular conditions like coronary artery disease, chronic kidney disease, or cerebrovascular disease, we aim for an average less than 130/80. 

While there are several inexpensive, well-tolerated medicines to lower blood pressure, a number of behavioral steps are also effective at doing so. Regular exercise lowers blood pressure. So does a diet low in salt and sugar and high in fruits and vegetables. Taking time to relax and manage stress if helpful. As is getting enough sleep every night. 

Eat Mostly Plants

Multiple studies show a Mediterranean-style diet lowers the risk of developing dementia. It consists of olive oil, nuts, fish, whole grains, fruits, and vegetables. Minimize cheese, sweets, red meats, fried food, and processed foods like white pasta, white rice, white breads, crackers, and chips. A large study over 10 years of a Mediterranean diet called the MIND diet found impressive benefits. People who followed the diet the least had the fastest rate of cognitive decline. People who most followed the diet had a 53% reduction in the risk of developing Alzheimer’s. This makes sense since a healthy diet lowers the risk of conditions like diabetes and hypertension that are harmful to the brain. 

Avoid excessive alcohol

There are long-term risks to brain health from excessive alcohol intake. Current recommendations are for men not to exceed 2 alcohol drinks daily and for women not to exceed one alcohol drink daily. 

Keep Your Mind Active

The idea of “use it or lose it” applies to the brain as much as the rest of your body. When you maintain social connections and participate in stimulating activities you build what is called cognitive reserve. It gives you a buffer or a back-up if your brain is injured by an accident or a disease like Alzheimer’s. Autopsy studies show that different brains of people with the same pathological findings can exhibit very different behaviors when they were alive. One person with signs of Alzheimer’s in their brain may have displayed signs of advanced dementia, requiring continuous caregiving. While another person with identical findings in their brain tissues may have shown no signs of cognitive impairment. The difference in such cases seems to be the cognitive reserve that was present. People who “built up their brain” with regular engagement could afford to lose a bit of it and still effectively function. So how do we create cognitive reserve? Maintain demands on your brain that keep it thinking, strategizing, and solving problems. Focus on activities that are enjoyable, but demand effort. Examples of doing so are learning a new language, musical instrument, or game. Activities that involve other people are especially helpful due to the cognitive demands and benefits of social interaction. 

Prioritize Relationships

Research shows people with few social connections have higher stress hormones, disrupted sleep patterns, altered immune systems, and increased inflammation. The psychiatrist and researchers Dr Robert Waldinger reports that “being in securely attached relationship to another person” is protective for the brain. Waldinger further reports that “one of the key ingredients was that people in relationships where they really feel they can count on the other person in times of need had their memories stay sharper longer.”  

Treat Hearing Loss

There is evidence that hearing loss increases the risk of dementia and that treating it with hearing aids lowers the risk. Theories for these findings are that hearing loss ups social isolation and that there is harm to the brain from receiving less information from the world. In contrast to wearing glasses, there is a stigma to wearing hearing aids. It’s seen as a sign somebody is old. Fortunately, many hearing aids are now designed in a way that makes them hard to notice. 

I hope this summary how to protect your age as you age has been helpful. If you’re interested in digging deeper, Dr Sanjay Gupta’s book Keep Sharp is excellent. I also recommend AARP’s website The Global Council on Brain Health https://www.aarp.org/health/brain-health/global-council-on-brain-health/

Since my last post on booster shots for Covid-19, the CDC issued important updates. Here’s an explanation of the latest recommendations.

What is a Covid vaccine booster?

A Covid vaccine booster is an additional shot beyond the initial regimen. Boosters are not a different formulation of the vaccines. The Moderna booster is half of the original dose. The Pfizer and Johnson & Johnson (J&J) boosters are the same dose. 

Why are boosters being given?

To further enhance immune protection from Covid-19. The additional shot reduces the risk of becoming infected, spreading the virus to others, and developing severe disease. 

Some people with weakened immune systems might not have achieved a sufficient immune response to their first two Covid shots. Common examples of this situation are people on medicines to suppress their immune system to treat autoimmune diseases or to prevent rejection of an organ transplant. 

But even in people with intact immune systems, immune protection from the vaccine gradually wanes over time. Receiving an additional shot restores and enhances protection. For instance, a randomized trial with the Pfizer vaccine showed that people who received a third shot had a relative vaccine efficacy of 95.6% compared to those who only received 2 shots.

Who should receive a booster?

People with weakened immune systems.

This includes people taking medicines that suppress their immune system to treat cancer or autoimmune conditions or to prevent rejection of a transplanted organ. It also includes people with conditions that impair the immune system such as certain cancers or AIDS. If you have a weakened immune system, you should receive a shot of Pfizer or Moderna vaccine at least 28 days after your second shot of Moderna or Pfizer or at least 28 days after your one shot of J&J. 

All people who received the J&J vaccine.

Even if you aren’t immunosuppressed, you should receive an additional Covid shot at least 2 months after your J&J vaccine. You can get the Pfizer, Moderna, or a second J&J shot. There is evidence that getting a Pfizer or Moderna shot will provide more protection than a getting second J&J shot. If you are a woman under 50 years old, I recommend you get a Pfizer or Moderna shot rather than a second J&J. This is because in this population the J&J vaccine has been associated with a very rare, but serious clotting disorder.

All people above age 65 who received either the Moderna or Pfizer vaccine.  

You should receive an additional shot of either Moderna or Pfizer 6 months after your second shot. 

People between 18 to 65 years old with chronic health conditions who received either the Moderna or Pfizer vaccine.

If you have chronic health conditions such as diabetes, coronary artery disease, or asthma, you should receive an additional shot of either Moderna or Pfizer 6 months after your second shot.

People between 18-65 years old who live or work in a setting that puts them at a higher risk of getting Covid and received either the Moderna or Pfizer vaccine.

This includes people who live in long-term care settings, along with teachers, grocery store workers, and health care workers. If you fall into this category, you can receive an additional shot of either Moderna or Pfizer 6 months after your second shot. 

If I received Moderna or Pfizer for my first two shots, for my third should I stick with the same vaccine or switch to another one?

It is acceptable to receive the same vaccine or switch. So if you received Pfizer for your first two shots, you can get a third Pfizer shot or switch to Moderna. Likewise, if you received Moderna for your first two shots, you can get a third Moderna shot or switch to Pfizer. The safety and efficacy of sticking with the same shot versus switching appear to be similar. 

Where should we get our Covid booster shot?

It is widely available at many pharmacies. It works best to make an appointment with the pharmacy online. When you sign up for the booster, you can indicate you are in one of the categories that makes you eligible. Some doctor’s offices and public health departments are also offering boosters.

Can I get my flu shot and Covid booster at the same time?

Yes. The CDC states it is safe to do so.

This week was supposed to be part 2 of Protecting Your Mind as You Age. But in the meantime, the US Preventative Task Force released guidance on Aspirin. Our office has received many calls asking for guidance. Thus, it will be this week’s topic.

Background

First, let me put Aspirin in context. Aspirin decreases your body’s ability to form blood clots by making cells called platelets less sticky. When you have a heart attack, a clot forms in an artery that supplies blood to the heart, thereby blocking the heart’s ability to get blood. The same thing happens in most strokes. So by lowering your tendency to form clots, Aspirin can lower the risk of heart attacks and strokes. 

Aspirin also decreases inflammation. Inflammation is an important part of our immune system’s response to sickness or injury. But prolonged inflammation can cause harm. Aspirin’s anti-inflammatory effect is thought to be the mechanism by which it may lower risk of developing colon cancer according to a number of studies.

But like most meds, Aspirin has downsides. Hindering your ability to form clots increases the risk of bleeding in your brain and digestive tract. As we age, the risk from bleeding increases. For instance, an older person who falls and hits their head might be more prone to bleed in their brain if they’re on Aspirin.

So Should I Take Aspirin?

It depends on your unique health situation, including your medical conditions and the other meds you take. So you should communicate with your doctor if you’re not sure what to do. In the interim, stay on Aspirin if your doctor instructed you to do so. Here are the principles your doctor will use to decide if Aspirin will help you.

Aspirin lowers risk of heart attacks and strokes in people with coronary artery disease and cerebrovascular disease.

If you’ve had a heart attack or been found to have significant narrowing in your coronary (heart) arteries, Aspirin has proven benefit. Likewise, if you’ve had a stroke, Aspirin has evidence of lowering the risk of having another one. So for many people with coronary artery disease and cerebrovascular disease, Aspirin continues to be beneficial. But even here the details matter. For instance, some with people with coronary artery disease or cerebrovascular take other meds that decrease clotting such as Plavix, Eliquis, Warfarin, or Xarelto. Adding Aspirin to these meds might do more harm than good. This kind of scenario is why there is no substitute for communicating with your doctor about your particular situation.

Aspirin doesn’t have strong evidence for preventing heart attacks and strokes in people without coronary artery disease or cerebrovascular disease.

If you don’t have significant narrowing in your coronary arteries or have never had a heart attack, there isn’t strong evidence Aspirin will lower your risk of having heart disease. Likewise, if you’ve never had a stroke or mini-stroke, Aspirin doesn’t have strong evidence for decreasing your risk of having a stroke. In these scenarios, you’re unlikely to benefit from Aspirin, but it will increase your risk of bleeding. The bad outweighs the good.

What the U.S. Preventative Task Force (USPTF) Recommended

USPTF is an organization that reviews evidence and provides guidance on how to prevent health problems.  After reviewing the latest studies on Aspirin, USPTF issued updated recommendations for people without a history of coronary artery disease or cerebrovascular disease. If you have a history of narrowing in your coronary arteries, having a heart attack, or having had a stroke or mini-stroke, these recommendations, don’t apply to you.

In people 60 years and older, do not start Aspirin to prevent cardiovascular disease. 

This is because Aspirin doesn’t have strong evidence to prevent heart disease. It does, however, increase the risk of bleeding–a risk that worsens with age.

In people 40-59 years old, discuss whether or not to start Aspirin with your doctor.

A risk calculator can estimate your risk of developing cardiovascular disease over the next 10 years. It takes into account risk factors such as diabetes, smoking history, cholesterol level, and family history of heart disease. If your estimated risk is over 10%, you and your doctor can discuss if the benefits of taking Aspirin outweigh the increased risk of bleeding.

Bottom Line

If your physician has instructed you to be on Aspirin, stay on it until you’ve communicated with him or her. If you’ve had a heart attack or narrowing in your coronary arteries that required a stent or bypass surgery, you’ll most likely need to stay on Aspirin. The same is true if you’ve had a stroke or mini-stroke. If you don’t have a history of coronary artery disease or cerebrovascular disease and are taking Aspirin, talk with your physician about whether it’s worth continuing to do so. There is no urgency in having this conversation. The risk from taking a low dose Aspirin (such as 81 mg) daily over a short period of time is low. 

When working with patients to control cardiovascular disease risk factors such as hypertension and high cholesterol, I find most people are more concerned with preventing a stroke than a heart attack. This is understandable. Our brain is responsible for so much of what makes life meaningful—talking, thinking, remembering, walking, feeling. Indeed, the brain is essential to who we are. It is the one organ we can’t transplant and still be the same person. People are justifiably concerned with protecting this most crucial organ.

Of course, strokes are not the only malady that can afflict our brains. Perhaps the most feared brain diseases are the dementias, the most common of which is Alzheimer’s. Although genes play a role in developing dementia, research tells us that there are a number of steps individuals can take to lower their risk of developing it. Prevention is especially important because unfortunately we currently do not have effective treatments for dementias such as Alzheimer’s.

Exercise

Exercise is the intervention with the most evidence for enhancing and protecting your brain. It does so through multiple mechanisms. Exercise lowers elevations in blood sugar and blood pressure levels that have been shown to be harmful to the brain. It also decreases inflammation and helps improve sleep. It increases our body’s production of endorphins which are chemicals that relief pain and lift our mood. Finally, exercise stimulates the release of growth factors that promote function of brain cells. 

Aim for at least 30 minutes every day of some form of exercise. This can include aerobic activities such walking, jogging, biking, or tennis. It also includes resistance training to keep our muscles strong. This can involve going to the gym for weight training or using our own body weight with push-ups, planks, squats, lunges, or yoga. There is some evidence that racquet sports like tennis, pickleball, or racquetball offer the most benefit since they involve connecting with other people as we move.

Sleep

During sleep our brain washes away metabolic debris, including the proteins that contribute to amyloid plaques found in Alzheimer’s Disease. Sleep also decreases inflammation which has been associated with neurodegenerative diseases like Alzheimer’s. Thus it is not surprising that lack of sleep has been associated with an increased risk of dementia.

One common form of sleep disruption is obstructive sleep apnea (OSA). In OSA, tissues in the back of throat collapse, thereby blocking the airway. The person stops breathing, preventing them from getting deep, restorative sleep. OSA is manifested by the bed partner reporting the individual is snoring or even gasps for breath. The person may not feel refreshed in the morning and feel the need to sleep later in the day, especially while engaging in non-stimulating activities such as watching TV or sitting at a stop light. If you’re concerned you might have OSA, schedule an appointment with a sleep physician to schedule a sleep study. 

Here are some keys to getting a good night of sleep:

1. Go to bed and get up at a consistent time. 
2. Expose yourself to sunlight for at least 5 minutes in the morning as soon as you get up.
3. Exercise.
4. Don’t drink caffeine after noon. It stays in your system and impairs deep, restorative sleep.
5. Don’t eat for four hours before bed.
6. Limit alcohol at night since it can hurt quality of sleep.
7. Keep the bedroom cool, quiet, and dark.
8. Keep your cell phone out of the bedroom
9. Set aside 30-60 minutes before bed for a relaxing bedtime ritual such as a bath, meditation, praying, reading, or calming music.
10. Don’t do anything in bed except sleep or sex. You want your mind to associate bed with sleep.
11. If you get up to go to the bathroom, don’t look at the time. This will cause anxiety and make it harder to get back to sleep. 
12. If you can’t get to sleep, go to a dimly lit room and read a boring book until you feel sleepy. Then go back to bed.

Next week I’ll discuss more evidence-based strategies for protecting your brain and lowering your risk of dementia as you age.