Welcome to my podcast. I am Doctor Warrick Bishop, and I want to help you to live as well as possible for as long as possible. I’m a practising cardiologist, best-selling author, keynote speaker, and the creator of The Healthy Heart Network. I have over 20 years as a specialist cardiologist and a private practice of over 10,000 patients.
Podcast Summary
Introduction
Dr. Warrick Bishop is a practicing cardiologist and author dedicated to educating patients about heart health, believing that informed patients receive better care. In this episode, Dr. Bishop discusses the concept of deprescribing—simplifying medication lists to reduce side effects and drug interactions—through a detailed patient case study that illustrates both the benefits and potential dangers of this approach. The episode highlights the critical importance of balancing medication simplification with individualized clinical risk assessment.
Key Takeaways
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Deprescribing aims to simplify medication regimens by removing unnecessary drugs and reducing the risk of medication side effects and interactions, but should not compromise clinical outcomes for high-risk patients.
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The patient in question was a 65-year-old asymptomatic man found to have significant plaque in his left main coronary artery through cardiac CT imaging, which was confirmed by stress testing and invasive coronary angiography.
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Dr. Bishop prescribed aspirin and aggressive cholesterol-lowering therapy (high-dose statins and ezetimibe) to achieve cholesterol levels below 1 millimole per liter, based on evidence of plaque regression and high-risk coronary anatomy.
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Three major recent trials (ASCEND, ARRIVE, and ASPREE) showed aspirin did not improve mortality in primary prevention populations due to bleeding risks, leading to guidelines against routine aspirin use in primary prevention settings.
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These aspirin trials did not use imaging to identify patients with actual arterial disease, so they may not apply to patients with documented severe coronary plaque who would benefit from aspirin's anti-clotting effects.
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The distinction between primary prevention (preventing a first event) and secondary prevention (preventing a second event) is clinically minimal—a heart attack patient is primary prevention only until the moment the event occurs.
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Recent data supports aggressive cholesterol lowering (LDL <1.6-1.7 millimoles per liter) in very high-risk patients, with the European Society of Cardiology recommending LDL targets below 1 millimole per liter for high-risk patients.
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A well-intentioned deprescribing decision by the patient's new GP—removing aspirin and reducing cholesterol medication—created significant clinical risk for a patient with complex, high-risk coronary disease.
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Deprescribing decisions must be individualized and made in consultation with relevant specialists who understand a patient's complete clinical picture and the specific reasons medications were prescribed.
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When a specialist prescribes a specific therapeutic regimen, there is often a detailed clinical rationale behind it, and medication changes should involve communication between the prescribing specialist and any other treating physicians.
