Top medical flip-flops: How should doctors counsel patients now?

When time-honored medical advice does an about-face—like the reversal on aspirin use for preventing heart attacks, or the ever-changing COVID-19 guidance—doctors and patients alike may be left scratching their heads.

But it’s worth remembering that shifting medical recommendations are a reflection of evolving scientific understanding.

The nature of evidence is dynamic: As new research is done, new data emerges. Medical guidelines are reviewed and revised—and sometimes reversed.

Scientific advancement is a good thing, but nonetheless, the cognitive whiplash from reversals in medical advice can be confusing for patients. Here are four notable medical flip-flops, along with suggestions for communicating these changes to those in your care.   

Compression stockings

Compression stockings are a familiar sight in med-surg units. But, recent research indicates that they may be unneeded in cases of elective surgery.

In a recent article published in the BMJ, researchers investigated whether graduated compression stockings (GCS) provided any benefit compared with pharmaco-thromboprophylaxis in 1,905 inpatients receiving elective surgery. Patients were randomly assigned to receive low molecular weight heparin (LMWH) pharmaco-thromboprophylaxis alone or LMWH pharmaco-thromboprophylaxis and GCS.

The primary outcome in the study was imaging confirming lower limb deep vein thrombosis with or without the presence of symptoms or symptomatic pulmonary embolism at 90 days post-surgery.

The primary outcome occurred in 1.7% of patients on LMWH vs 1.4% of patients on LMWH and GCS, with a risk difference of 0.30%, which on further analysis, supported noninferiority between the treatments.

“These findings indicate that GCS might be unnecessary in most patients undergoing elective surgery,” the authors wrote. 

The BMJ provides more detail about revising GCS guidelines here.

Aspirin use

Bad news for aspirin aficionados: the US Preventive Services Task Force (USPSTF) deemed that in adults aged between 40 and 59 years with a 10% or greater risk of heart disease, the decision to start low-dose aspirin for the primary prevention of CVD should be individual. The evidence suggests that the net benefit of aspirin use in these patients is small.

On the other hand, patients who could benefit are those who are not at higher risk for bleeds and willing to take aspirin. 

“Decisions about initiating aspirin use should be based on shared decision making between clinicians and patients about the potential benefits and harms,” according to the USPSTF. “Persons who place a higher value on the potential benefits than the potential harms may choose to initiate low-dose aspirin use. Persons who place a higher value on the potential harms or on the burden of taking a daily preventive medication than the potential benefits may choose not to initiate low-dose aspirin use.”

On a related note, the USPSTF recommends against starting low-dose aspirin as primary prevention in those aged 60 years or more.

Coffee

For many professionals—doctors included—giving up that morning cup of joe would be difficult. Some concern, however, has been raised about the cardiac effects of coffee consumption. Luckily, recent research assuages these worries.

In a recent study published in Circulation: Heart Failure, investigators used machine learning to assess how lifestyle and behavioral factors may affect coronary heart disease, stroke, and heart failure. They used data from the Framingham Heart Study, the Cardiovascular Heart Study, and the Atherosclerosis Risk in Communities study.

Based on their analysis, the researchers suggested that coffee consumption was associated with a lower risk of heart failure in all three studies. They noted that further research is needed to understand whether drinking coffee is a modifiable risk factor.

Another study published in JAMA looked at whether moderate, habitual coffee intake was linked to arrhythmia risk. The authors mined data from a large, prospective, epidemiological cohort representing more than 300,000 participants and found that each additional daily cup of coffee was linked to a 3% decreased risk of developing an arrhythmia. Genetic variants that affect caffeine metabolism did not change this association. Read more about coffee here.

Mammograms

The optimal age for undergoing mammography has been a topic of hot debate in medicine.

Currently, the USPSTF cannot make a statement recommending the benefit of mammography as primary prevention in all women, based on a dearth of evidence.

Mammographies can lead to false positives and unnecessary biopsies, putting women at risk for overdiagnosis and overtreatment.

Of all age groups, those between 60 and 69 years are most likely to avoid breast cancer death via mammography screening, and the USPSTF recommends screening in this group.

“The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years,” according to the website. “The balance of benefits and harms is likely to improve as women move from their early to late 40s.”

Importantly, women with a parent, sibling, or child with breast cancer are at higher breast-cancer risk and may benefit from starting to screen in their 40s.