New Heart Guidelines: Aspirin OUT! - Prescriptive Optimization

Just like that, another dogma is reversed. I learned way back in pharmacy school that low dose aspirin, while not free of risk, was a good way to prevent cardiovascular risk. I even remember the Costco sized bottle of 81mg aspirin I took daily – in my late 20s!

I learned enough to become a pharmacist, but was still clueless on the effects of dogma and group think.

The Backstory

Cardiovascular disease is a major killer. Among the contributors identified is an excess of clotting, leading to blockages. This is what aspirin is after. It can irreversibly bind to platelets (which live about 7 days) so they cannot take part in the clotting cascade. By advocating a lower dose, typically less than 100mg, the theory was downgrading the clotting response could help prevent events where clotting is contributory.

We took this advice as a given. There were precautions surrounding gastrointestinal (GI) bleeding concerns, especially with any history of ulcers, but the number of low dose aspirin consumers became vast – for prevention and treatment alike. They even have people taking acid-reducing medications with low dose aspirin to mitigate GI bleeding risks¹. Pardon the tangent, but to see the profound consequences of altered acid levels, please read my 30+ page whitepaper, Addressing GERD by Increasing Acidity.

The new guidelines now recommend against taking aspirin for primary prevention in most cases. It may be used in some active treatment protcols, please consult your doc before implementing a therapy modification.

Cause of Excess Clotting

We have an identified problem, excessive clotting. Aside from some rare disorders, we are missing what can precipitate excessive clotting for such a large percentage of the population.

The guidelines came close to providing information on the cause, but glossed over the association with blood sugar and blamed cholesterol (to advocate aggressive statin usage).

T2DM (Type 2 Diabetes) remains a highly prevalent disease and a major ASCVD risk factor. An aggressive, comprehensive approach to ASCVD risk factor treatment in adults with T2DM reduces ASCVD events. Management of cholesterol and hypertension in adults with T2DM is discussed in the relevant sections of the present guideline.
2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease²

Cholesterol as a causative agent in ASCVD is controversial. It plays a role, but not singularly causal for most cases. Certain types of cholesterol-carrying proteins Lp(a), apoB, and various presentations of these lipoproteins (sugar modified and altered structure (small dense LDL) are relevant in cardiovascular disease – but these tend to be effects rather than causes. Lp(a) is a fascinating topic for another day, and I recommend having that measured and monitored. Interestingly, it precipitates increased clotting activity, so there is an angle for this lipoprotein to cause excess clotting.

The development of small dense LDL and sugar modified LDL are both accelerated by diet. Specifically, sugar and carbohydrate excess.

Now we are getting somewhere! I can almost smell a real cause!

Hyperglycemia and Hyperinsulinemia Cause Excess Clotting

High blood sugars from dietary carbohydrates cause an increased insulin response to transport glucose from the bloodstream into cells. When the cells are full, we ignore the insulin signals, resulting in more insulin production to get that glucose out of the blood. This is insulin resistance (and resultant hyperinsulinemia), caused by too many net carbohydrates.

As I wrote about in my detailed whitepaper, Avoiding Insulin in Type 2 Diabetes, insulin impacts many biological signaling pathways – and they are NOT consequence free.

On our topic:

present data strongly suggest that hyperglycemia due to insulin resistance renders the patient more susceptible to thrombotic events by an insulin-driven impairment of fibrinolysis and a glucose-driven activation of coagulation
³.

It isn’t just one article, there are lots more asserting the same finding.

Here is the first takeaway, we can reduce our clotting propensity thru diet! This is powerful, and much better than taking aspirin and statins. High blood sugar and insulin cause both increased clotting AND consequential cholesterol alterations.

Your Fork in the Road

You have a choice, follow the dogma or retake control. Getting exercise and avoiding tobacco are easy recommendations. But let’s look at the current recommendation for diet (2 clips from the guidelines):

“All adults should consume a healthy diet that emphasizes the intake of vegetables, fruits, nuts, whole grains, lean vegetable or animal protein, and fish and minimizes the intake of trans fats, processed meats, refined carbohydrates, and sweetened beverages. For adults with overweight and obesity, counseling and caloric restriction are recommended for achieving and maintaining weight loss.”

“A diet high in fruits, vegetables, and whole grains is best. Fish, legumes, and poultry are the preferred sources of protein. Minimizing the consumption of trans fats, added sugars (including sugar-sweetened beverages), red meats, sodium, and saturated fats is also important. Clinicians should work in partnership with patients to assess their readiness for sustained lifestyle improvements, identify potential barriers to change, and encourage them to try to achieve measurable goals and continue to monitor their progress”

This is not all bad. Yes, avoid refined carbohydrates and sweetened beverages. However, if you follow these recommendations to a T, your blood sugar and insulin response will continue on the same march toward diabetes and ASCVD.

Vegetable Oils

I exposed this recommendation here before, but vegetable oils are trash and will do more to precipitate ASCVD than almost any other single indiscretion. Canola (and similar oils) set off a pronounced oxidative reaction (think rust) in the vasculature. Oxidation leads to inflammation, and both damage cholesterol (LDL is considered and antioxidant). Just throw them out and avoid at all costs.

Sodium Restriction

I also debunked the low salt charade previously. Unfortunately, this advice is dead wrong and precipitates the things we are trying to avoid.

When you don’t have enough salt, it activates a process called the Renin-Angiotensin-Aldosterone (RAS) system. Besides constriction blood vessels causing high blood pressure, it increases CLOTTING! Guess what? It is this same system we prescribe common medications called ACE inhibitor s (lisinopril) and Angiotensin Receptor Blockers (losartan) for – to the tune of millions of prescriptions annually.

You read that right: restrict salt, activate RAS, prescribe medication to block RAS. Pass the salt, please.

Here is another.

SODIUM RESTRICTION INCREASES INSULIN RESISTANCE.

When you start restricting your salt intake, your body will do anything to try to hold on to it. Unfortunately, one of the body’s defense mechanisms is to increase insulin levels. It does this by creating a state of insulin resistance. When insulin resistance kicks in, the body is less able to shuttle glucose into cells, and it needs to secrete more insulin in order to control blood glucose levels. Also, remember that when a person’s intake of dietary salt is on the paltry side, hormones that compensate to help the body retain salt (such as renin, angiotensin, and aldosterone) are released in greater amounts. Well, these hormones end up increasing fat absorption, too. In essence, compared to someone who hasn’t slashed his or her salt intake, a low-salt diet may cause you to absorb twice as much fat for every gram you consume.
The Salt Fix: Why the Experts Got It All Wrong–and How Eating More Might Save Your Life⁴

Seriously, can this advice get any worse?

Red Meats / Saturated Fats

Quality pasture raised, grass fed meats are nutritious and are not causative in heart disease. Saturated fats from these sources are healthful. Other advisories have removed this restriction⁵ as the emerging science is beating back the dogma stigmatizing these food groups. Pass the grass-fed butter please.

The guidelines advocate poultry, without specifying how they were raised and fed. This is not an ideal food source.

Whole Grains

Whole grains will raise your blood sugar, just slightly less than processed grains. Slightly.

FOOD	Glycemic index (glucose = 100)
HIGH-CARBOHYDRATE FOODS
White wheat bread*	75 ± 2
Whole wheat/whole meal bread	74 ± 2⁷

A diet high in whole grains will precipitate hyperglycemia and hyperinsulinemia. If these are not organic that just adds one more mechanism to precipitate diabetes, see this recent article.

The whole part of these grains is the protecting shell around the grain, its job is to defend the seed via its lectins. These lectins precipitate immune responses in anything trying to eat it, including us. Many people are sensitive to lectins. Further, these lectins can precipitate a host of other problems such as gallbladder disease.

A Better Path

A diet full of well sourced, single ingredient (ie when the label reads steak or asparagus) foods, combined with periods of intermittent fasting is an excellent path to health. Foods advocated in these guidelines will continue to drive improper blood sugar and insulin levels in the blood. And with those bad levels, your risk of ASCVD will continue to rise with the rest of the population under the standard of care’s guidance.

There is a better way. Please reach out if you want assistance to taking back control over your health, please reach out for a free consultation. After all, even these guidelines suggest, properly, clinicians should work in partnership with patients.