Monday, November 16, 2020

New Jersey Just Legalized Marijuana. Is This Good News For the Heart?

The big news in this month's election is not the contested presidential race. It's not undecided Senate seats. The big news is that New Jersey voted to legalize recreational marijuana use! Is this a recreational activity that is good, or even safe, for those with heart disease or risks for heart disease?


Marijuana is a greenish mixture of leaves, stems, and flowers derived from Cannabis plants.  It contains many different chemicals, called cannabinoids.  The two major, active chemicals are delta 9-tetrahydrocannabinol (THC) and cannabidiol (CBD).  THC is the most psychoactive chemical, producing the euphoric effects of marijuana. CBD is anti-inflammatory. There are also synthetic cannabinoids which are used for medical purposes in the treatment of epilepsy and to relieve severe nausea and vomiting in cancer chemotherapy patients.  Cannabinoids are either smoked or eaten, with 77% of users reporting inhalation as their method of choice. There has been a dramatic increase in marijuana use over the last ten years.  In 2017, more than 39 million Americans reported using marijuana at least once.  Marijuana consumption is not just for the young. In the older population, marijuana is used to treat chronic illnesses.  Marijuana consumption increased by 4.5 times in people over age 55 between 2002 and 2014. 


Paralleling the increase in consumption is an increase in the legalization of marijuana at the state level.  The medical use of cannabis is legal (with a doctor’s prescription) in 35 states.  New Jersey legalized medical marijuana in 2010. The law allowed marijuana to be acquired at state licensed treatment centers. As of 2017, there were six centers in the state, with about 12,000 patients enrolled in the program.  On November 3 2020, New Jersey voted, by a 66% to 33% margin, to legalize the recreational use of marijuana, joining 14 other states. The law will take effect on January 1 2021, potentially opening a huge market (estimated at $2 billion) as New Jersey is the most populous state on the East Coast to legalize marijuana.


The general public opinion is that marijuana use is safe, maybe even healthy. How true is that assumption? What are the physiologic effects of marijuana? Is marijuana consumption safe for heart patients?  Smoking marijuana causes an immediate increase in heart rate and blood pressure as well as an increase in the work of the heart. In addition, it activates the body’s release of adrenaline. Marijuana impairs the blood’s oxygen carrying capacity, resulting in less oxygen to the heart muscle. Marijuana can cause inflammation and blood clots within the heart arteries. None of these effects are beneficial for heart patients.  Multiple case reports have linked marijuana with heart attacks and strokes.  The victims are usually young (average age 45), males, and without cardiac risk factors. The risk of a heart attack rises 5 fold within one hour of smoking marijuana.  Angina, chest pain, also occurs frequently after smoking marijuana due to the decrease in oxygen to the heart.   Cardiac rhythm problems may also occur with marijuana smoking, due to the stimulation by adrenaline.  The most common rhythm disturbances are atrial fibrillation (an irregular rhythm from the upper chambers of the heart) and ventricular fibrillation (cardiac arrest).  The average age of patients suffering from marijuana-associated arrhythmias is only 24 years old.  About 3% of marijuana users experience an arrhythmia. On the other end of the spectrum, at higher doses of THC, slow heart rates can occur, sometimes necessitating a pacemaker. Most of the effects described are with inhalation of marijuana. However edible forms are not safer and may be more dangerous. Oral marijuana gets into the blood stream slower than inhaled marijuana. Since the favorable psychogenic effects take longer, more is consumed, leading to higher concentration of chemicals and a higher rate of complications. Lastly, marijuana interacts with many cardiac medications including antiarrhythmic agents, calcium channel blockers, beta-blockers, statins and warfarin. 


While there is evidence linking marijuana to adverse cardiac events, the studies are not robust. Given the increasing use of marijuana in the general population as well as the population with heart disease or heart risks, high quality studies are needed. However, the adverse effects of marijuana seem to be as bad as cigarette smoke. It can be concluded that inhaling particulate matter of any kind is harmful to the heart and blood vessels. That’s food for your head before you go to the head shop in January 2021. 


Tuesday, October 20, 2020

Time Restricted Eating. Time for a Change?


Mediterranean, Pesco-Mediterranean, Keto, Paleo, Atkins, DASH, vegetarian, lacto- vegetarian, ovo-vegetarian, vegan. There are a staggering number of diets, but which one is right? Each has their proponents and their opponents. All of these diets tout weight loss, cholesterol lowering, prevention of heart disease and longevity. Unfortunately, the research behind the claims of these diets is shaky. Nutritional research is plagued by poorly conducted scientific studies. What is lacking in dietary studies? First, the method used by most studies is an observational model rather than the more rigorous randomized controlled trial. In addition, outcomes such as heart disease or death take a long time to develop, so diet studies must be carried on for years to see a possible effect. Lastly, nutritional studies are often funded by industry and thus subject to bias. It is therefore very difficult to recommend a particular diet, with scientific certainty, to promote health and reduce heart disease. However, what if the key to health lies not in the food we eat, but in not eating at all?


Of course we need to eat to survive and to live a long and healthy life. However the benefits of fasting have recently come into focus.  Early in the course of human evolution, energy rich food was not always available. We evolved to handle periods of feast and famine. We adapted by storing energy as fat. During times of fasting, the stored fat was metabolized into energy.  Nowadays, with the round-the-clock availability of energy dense food coupled with inactivity, fat stores in the body grow, are not mobilized and obesity, diabetes, heart disease and early death are the result. Not eating, fasting, may be a good thing. In fact, many studies have shown that reduced calorie intake over the course of a lifetime, increases the life span. For example, the exceptional longevity of the people on Okinawa can be partially attributed to a constant low level of calorie intake. 


Three types of fasting have been studied: alternate day fasting, 5:2 fasting (fasting 2 days per week) and time restricted eating. Time restricted eating, limiting the intake of calories to a short window between six and twelve hours per day, is the best studied and the most in vogue in the medical literature.  This strategy is attractive in that it does not require time consuming measurements and adherence to a strict diet. After a twelve hour overnight fast, the body mobilizes fat stores. This decreases intra-abdominal fat tissue and leads to weight loss. The stress of fasting challenges the body to come up with ways to tolerate or overcome the period of fasting. Most of the organs in the body are able to do this. With repeated bouts of fasting, these adaptive changes allow the body to resist a broad range of potentially damaging stresses. Fasting does stress the body, but low levels of stress are good.  Consider the analogy with exercise. Everyone agrees that exercise stresses the body and can make people feel uncomfortable. No Pain No Gain! However that stress produces positive benefits by improving fitness, helping with weight loss, lowering blood pressure, decreasing the risk for diabetes and heart disease.  If the stress of exercise is good, so too is the stress of fasting. Time restricted eating has been shown to prevent obesity as well as lower blood pressure, decrease heart rate, lower cholesterol and triglycerides, reduce inflammation and prevent diabetes.  In addition, intermittent fasting may prevent dementia. In trials with older adults, intermittent fasting improved memory. Whether these beneficial effects translate into a lower risk for heart disease and death has not yet been determined. 


There are downsides to time restricted eating. First, the timing of meals is often dictated by work schedule or cultural norms or even weather (Mediterranean countries often eat at 9 or 10 PM, after the sun is down and it is cooler). In addition, fasting for prolonged periods makes people jittery and irritable. It makes them hangry! We have to rationalize that that uncomfortable feeling does stress the body, but it produces positive adaptations. Intermittent fasting results in weight loss. However the amount of weight lost is similar to the weight loss on a reduced calorie diet. Fasting can lead to the loss of muscle mass and bone density in people who are not obese. In fact, the overall effects of intermittent fasting in nonobese patients is not known. Lastly, the studies on time restricted eating were mostly in animals, with some observational human trials. In addition, no studies have determined the optimal time window for eating. Clearly more research is needed before the widespread prescription of time restricted eating. 


Until further research is done, what recommendations can be made?  Certainly an easy adaptation would be to restrict food intake to a tight window. There are a couple of possible options. One is unrestricted eating but only between 9 AM and 6 PM, with no nighttime snacking. The other approach is eating only between 12 PM and 8 PM, while skipping breakfast. Both methods provide more than a twelve-hour window of fasting.  In addition, restricting total calories intake is always a good recommendation. Remember: Eat less, live longer


Monday, September 7, 2020

COVID Fact or COVID Fiction?

As the COVID-19 pandemic continues around the globe, the world’s researchers learn more and more about the virus, some of which is quite surprising.  With the nonstop media reporting about coronavirus, it is sometimes difficult to separate what is true about the disease and what is not.  Let’s delve into some COVID information and decide whether it is a COVID fact or COVID fiction.


Saliva is as good as mucous for COVID detection

COVID fact or COVID fiction?


Currently there are two main types of tests for COVID: The PCR (polymerase chain reaction) test and the antibody test.  The PCR test is performed by a health care worker who swabs a patient’s nose or throat. The mucous is combined with a chemical (a reagent) and run on a machine in a laboratory. It detects whether the virus is present in the nose or throat. Antibody testing requires drawing blood and reflects the body’s immune response to the virus, rather than detecting the virus itself.  The antibody test looks at the immune response. If the test is positive for IgM it means that the infection is still active. If the test shows that IgG is positive, it means there was a previous infection. These current methods are both limited in the following ways. They require expensive machines to run the tests and since the tests are run in batches, it takes several days for the results. The reagents used for the tests are also expensive and scarce. In addition, health care workers are exposed, since they must collect the specimens to run the tests.  Now, new tests are available that can overcome these limitations. One test requires a patient to collect saliva and send it to the lab.  It was developed by Yale University, uses commonly available reagents and a sterile urine specimen cup for collection. When evaluated the saliva test was as accurate as the nasal swab test. This method is currently being used at the University of Illinois to test students and faculty in an effort to remain open during the pandemic. Another test uses mucous (collected by the patient) placed on a card, about the size of a credit card. Reagents are added to the card and the results are available in 15 minutes. The cards can be mass-produced, 50 million are estimated to be available starting in October, and cost only $5.  These new tests provide rapid results (in minutes rather than days), require no expensive machinery, use reagents that are commonly available, do not expose medical personnel to the virus and are cheap.   Once these new tests become widely available, they can test asymptomatic people (such as children going back to school, workers going back to the office, or hospital staff) and can identify asymptomatic carriers before they infect others and spread the virus. This will control the pandemic and get the economy back on track.



Once you have COVID you can’t be reinfected

COVID fact or COVID fiction?

Once someone has COVID, the body produces antibodies to fight the infection. If the infection is successfully fought off, the antibodies remain.  Unfortunately, it has been shown that the level of antibodies in the blood diminish over time and disappear within a few months, potentially putting the person at risk for another COVID infection. Until recently, there had been no documented cases of reinfection. In August, two cases came to light. The first one occurred in Hong Kong. A young healthy person was infected with two distinctly different strains of virus 142 days apart.   Another patient from Nevada, who is 25 years old, was infected twice, 48 days apart. In both cases, the second infection was asymptomatic, suggesting the immune system did its job of protecting the patient. This teaches us that patients who have had COVID still need to comply with wearing masks and social distancing. In addition, they should receive a vaccine, once one becomes available.  Unfortunately this also tells us that a vaccine may not provide protection for life and a periodic booster may be necessary.

COVID fiction


The optimal separation for social distancing is six feet

COVID fact or COVID fiction?

Why do health officials recommend staying six feet apart to reduce the risk of infection? Why not five feet, or ten feet, or three feet? It turns out the current rule on safe physical distancing is based on outdated science.  The study of respiratory droplet emission started in the 1800’s.  In 1897, it was determined that six feet was a safe distance since it was observed that droplets did not travel further than six feet.  Modern science has shown that droplet spread is more complicated. For example, droplets come in different sizes and travel different distances based on the force of emission (for example coughing or sneezing sends droplets further), ventilation patterns and whether one is indoors or outdoors.  A more nuanced approach to social distancing should take into account all of these factors. If one is in a high-risk setting (indoors, poor ventilation), physical distancing should be enforced. If one is outdoors or in another low risk setting, distancing can be less.

COVID fiction


This winter’s flu season will be worse than in the past

COVID fact or COVID fiction?

As fall and winter approach, health officials are anxious and bracing for a new onslaught of patients. The addition of a flu season on top of the coronavirus pandemic could push hospitals’ capacities to the limit. No one knows the impact of flu (plus other respiratory viruses typically prevalent in the winter) and COVID. Will patients be twice as sick? Will a recovered patient be more or less susceptible to other viruses after recovering from COVID? There is much to learn but there is some encouraging data coming from the Southern hemisphere (which is just at the tail end of it’s winter and flu season). Countries such as Chile and Argentina have noted that the flu has “practically disappeared” this year. Chile had 1,100 flu cases this year versus 20,000 cases in 2019 while Argentina reported 151,000 infections this year compared with 420,000 last year. Other Southern hemisphere countries, South Africa, Australia, New Zealand, are reporting similar results. Officials attribute the decline of the flu to mask wearing, social distancing, travel restrictions, school closures and telemedicine (patients aren’t sitting in doctor’s offices being exposed to viruses).  In addition, there has been an increase in flu vaccination rates. Despite the good news from the other side of the world and to mitigate the potential one-two punch of flu and COVID in the Northern hemisphere, it is prudent to get the flu vaccine in September or early October (to ensure immunity is in place as flu season hits).  The vaccine manufacturers are doing their part, announcing a major surge in vaccine production to meet the demand this year. 

COVID fiction- probably


The coronavirus directly attacks the heart

COVID fact or COVID fiction?

Myocarditis, or inflammation of the heart, can be due to a variety of agents including viruses. Now there is evidence that the coronavirus directly infects the heart, causing inflammation of the heart and myocarditis.  Symptoms of myocarditis include shortness of breath (due to congestive heart failure, fluid in the lungs), chest pain (mimicking a heart attack) and irregular heart rhythms (which can lead to sudden cardiac death).  Many patients with COVID display the effects of myocarditis for weeks or months after the acute illness. A German study showed 60% of patients had myocarditis up to two months after the initial diagnosis. A study of healthcare workers found evidence of myocarditis 10 weeks after recovering from COVID.  There is no specific treatment for myocarditis. Sometimes steroids work, but the data is not conclusive. Mostly patients must rest for at least three to six months until the inflammation has resolved. Rest is important as activity or exercise can trigger irregular heart rhythms and sudden cardiac death. This is especially important in clearing athletes who have had COVID to return to their sport. This has become a big issue in the sports world as more data has emerged about myocarditis in athletes.  A Boston Red Sox pitcher was diagnosed with myocarditis and shut down from pitching for the season. A college football player was diagnosed with myocarditis. In fact, two college conferences cancelled their football seasons over fears of myocarditis. This was triggered by a study showing that about 15% of college athletes with prior COVID had myocarditis. 

COVID fact


To decrease your risk for COVID, wear a mask and follow social distancing keeping in mind the relevant factors such as venue (indoors or outdoors), crowd size and ventilation patterns.  In addition, get your flu vaccine earlier rather later. Lastly, consider sitting out the 2020 college football season.


Monday, August 10, 2020

Coffee or Tea?

“Drink no liquid that isn’t at least a thousand years old (wine, water, coffee). Eat nothing invented by humans,” opines the polymath and philosopher Nicholas Taleb.  The idea is that if a beverage has been around for many years, it is likely healthy and will be drunk for another thousand years. On the other hand, something that was recently produced has not withstood the test of time, both in terms of its sustainability and its health effects.  How good is this advice? In a face off between ancient drinks and modern concoctions, who is the winner in terms of heart health?


Proceeding chronologically, water is the oldest drink on the list, having been around since the dawn of time. Water, of course is necessary for life and has no risk. Water is clearly in the healthy column. The next beverage was drunk from gold chalices in ancient Greece and Rome and had deities named for it. Wine has been around for about 8000 years. Wine has complex interactions on health and on the heart, with both beneficial and detrimental effects. A full and complete discussion would be very lengthy, so let’s table the wine for now and put it a neutral category. Tea drinking began in China in the 3rdcentury BC, making tea service available for about 2300 years. Tea, especially green tea, is known to have favorable bioactive substances such as flavonoids, which help with heart function, decrease inflammation, reduce hypertension and lower cholesterol. Studies on tea consumption and heart disease from around the world point to a lower risk of heart disease and death in tea drinkers.  In a study of 100,000 people from China, habitual tea drinkers (defined as 3 or more cups of tea per week) had fewer heart attacks, strokes and deaths compared to non-tea drinkers.  The authors conclude that habitual tea drinkers might develop heart artery disease 1.4 years later or die 1.3 years later than non-tea drinkers. Tea seems to be solidly in the healthy drink category. Coffee was first roasted and brewed, in a manner similar to how it is prepared today, in Arabia in the 15th century. Coffee, therefore, is about 500 years old making it the newcomer in this group. Coffee is one of the most popular beverages worldwide. In the US, about 85% of adults drink coffee daily, averaging 1.5 standard cups per day.  Coffee also has substances which may be beneficial for health as well as increasing exercise performance, mental alertness and concentration. On the other hand, coffee and caffeine are thought to increase the risk for arrhythmias (irregular heart rhythms).  Which is it, is coffee good or bad? Despite the perception, coffee and the low dose of caffeine in coffee does not increase the risk for arrhythmias including atrial fibrillation (an irregular rhythm from the upper chambers of the heart) in people with no history of heart rhythm disease.  In fact, coffee consumption of up to 5 cups per day actually lowered the risk for arrhythmias.  However, in patients with arrhythmias, coffee has triggered events. Therefore, if you have a history of arrhythmia, it is important to listen to your body and discuss potential triggers with your doctor.  Does coffee increase the risk for cardiovascular disease?  A recent study showed that drinking 3 or more cups of coffee per day actually reduced the risk for plaque (blockage) in the heart arteries (based on CT scan).  Multiple studies have shown that moderate (3 to 5 cups per day) coffee consumption is associated with lower risk for heart attack, stroke  and cardiovascular death. So, with the caveats noted above, coffee seems to be a healthy drink.


Cola was invented by an Atlanta pharmacist in 1886. In the ensuing 130 years there has been an explosion of manufactured beverages including soft drinks, sweetened bottled water and fruit drinks.  These sugar-sweetened drinks are popular with half of the US population consuming one of these drinks on a daily basis. These soft drinks contain a sugar called fructose which is metabolized in the liver, leading to fatty liver disease, obesity and diabetes. In fact consuming one or more sugar-sweetened beverage per day was linked to a higher risk for diabetes, heart attack and stroke.  Clearly soft drinks must be placed in the unhealthy category.  Another new category of beverages is sports and energy drinks. It has been reported that 33% of teens and young adults drink these beverages. The drinks are used to improve performance in school and sports and help with concentration and hydration.  There have been huge marketing campaigns touting these beverages and claiming improved hydration compared to water. However, these drinks contain high amounts of sodium, sugar and caffeine which are potentially harmful.  Energy and sports drinks have been associated with high blood pressure, obesity, liver disease and increased emergency room visits. While low levels of caffeine in tea and coffee are safe, energy drinks contain much higher doses of caffeine. For example, a cup of green tea contains 35 mg of caffeine while an energy drink can have 160-500 mg. This higher concentration of caffeine is associated with arrhythmias. Young patients without underlying heart disease present with significant arrhythmias shortly after consuming these drinks. In addition, energy drinks may promote blood clotting, which can lead to heart attacks and strokes. Clearly energy and sports drinks are in the unhealthy category as well.


It’s time for the final summary and totals. The ancient grog group, including water, wine, tea and coffee, has three drinks that are healthy and one that is neutral. Moderate consumption of these beverages can be part of a healthy lifestyle. On the other hand the recent refreshments all are detrimental to health. So it seems the philosophy is sound; try to drink mostly those old, tried and true beverages.


Monday, July 6, 2020

Covering COVID Concerns

As the coronavirus, SARS-CoV-2, continues to spread and as the illness it causes, COVID-19, runs rampant, what can you do to stay safe? How does the virus spread? How can you avoid a superspreader? Should you wear a mask and, if so, which one? Should you go for antibody testing?

The coronavirus spreads by respiratory droplets or aerosols. Every time we sneeze or cough or even speak we emit respiratory droplets. If a person is infected, the coronavirus is carried in these respiratory droplets and can spread to another person.  The density of the virus in the air and the amount of time one is exposed to the aerosols are significant factors determining whether one becomes infected. An emergency medical technician riding in an ambulance with a sick, coughing patient or a nurse in a closed room with a patient who is short of breath are both at high risk for infection. On the other hand, passing an afflicted person on the street is much less likely to cause an infection.  Coronavirus can live on surfaces and cause infection but surface contamination and fleeting encounters are much less worrisome than close, person-to-person exposure for prolonged periods. No one knows the minimum amount of contact, one guideline is 10 minutes or more spent with an infected person, but the longer the contact, the greater the chance of infection. 

As more is learned about the virus’s spread, it is becoming clear that superspreader events play a significant role. Superspreader incidents occur when one person infects a large number of other individuals.  These events occur where large numbers of people are present, with close contact between people and in confined spaces with poor ventilation. Superspreader incidents have occurred in nursing homes, churches, manufacturing plants, schools, conferences, gyms, clubs, bars, prisons and ships. It is estimated that 10-20 percent of infected people are responsible for about 80 percent of cases. The reason for this is that many infected people do not have symptoms, so they do not know they are transmitting the disease.  If an asymptomatic person shows up at a large, indoor gathering the stage is set for a superspreader event. Stopping superspreader incidents would go a long way toward controlling the coronavirus’s spread. 

Since coronavirus is predominantly spread by respiratory droplets and due to the high number of asymptomatic spreaders, it would make sense that wearing a mask could reduce the risk of infection.  The theory is that a mask can prevent transmission of the virus from an infected person by trapping droplets from breathing or coughing and not allowing them to permeate into the environment. However, there is scant data on masks, especially in the community setting.  There are several types of masks including cloth masks, surgical masks and respirators. N95 respirators are the highest form of protection. The N95 blocks 95% of small airborne particles (the 95% blocking ability is where it derives its name).  There are two types of N95 respirators: N95 is the US standard and KN95 is the Chinese name; the two are nearly equivalent. N95 users must undergo stringent testing to ensure a tight seal around the mask and make sure there is no leakage. N95 respirators are used for close contact and recommended for health care workers. Due to worldwide shortage, these masks are not available for use in the community. Surgical masks trap the wearer’s secretions and block 10 to 90 percent of particles. Cloth masks can block particles as well. Cloth masks with a water resistant fabric, multiple layers and good fit around the face are better than single layer choices (such as a scarf or bandana).  Neither surgical nor cloth masks require special fitting and both may be useful in the community setting (although not necessary when at home unless a household member is infected).  Can the use of a mask reduce the risk of coronavirus spread? One study in the health care setting showed that N95 respirators were 96% effective at reducing infection while surgical masks were 67% effective.  The data for masks is lacking in the community, but starting to accumulate. One study showed the rate of infection was less in US states that mandated the use of face masks compared to states that did not require masks. Many Asian countries were able to control the epidemic by near universal mask wearing (90% wear masks) and social distancing. For example, Hong Kong, a densely packed city of 7.5 million had only six deaths due to COVID due to a 97% compliance with wearing masks.  In April there were conflicting messages from government agencies regarding wearing face masks. Now the evidence seems to be firmly in favor of masks to prevent spread. Besides, there are no risks to wearing a mask (and no medical contraindications). 

Would widespread testing slow the rate of infection? There are two types of tests for the coronavirus. The PCR (polymerase chain reaction) test detects whether the virus is present on a nasal or throat swab.  It can determine if the virus is present with reasonable efficacy but there is a high false negative rate (the test comes out negative, but the person has the infection). Because of that, if a patient has suspicious symptoms but a negative test, one or two more follow up tests are needed (and must come back negative) to rule out coronavirus. The PCR test is good if someone has been exposed to a person with COVID or if they have symptoms. The results can be used to quarantine and contain the virus.  Antibody testing requires drawing blood and reflects the body’s immune response to the virus, rather than detecting the virus itself.  The antibody test looks at two parts of the immune response. If the test is positive for IgM it means that the infection is still active. If the test shows that IgG is positive, it means there was a previous infection.  Unfortunately, there are problems with the antibody tests.  Patients with no or mild symptoms may not mount an immune response and the test may be negative. In addition, the test may be negative within the first 14 days after the onset of symptoms. Lastly, the antibodies seem to fade after a few months. Due to these issues, widespread antibody testing is not recommended at this time. Even if the test shows immunity, the patient must still wear a mask and practice social distancing. 

Therefore, to cover your COVID concerns and control the coronavirus catastrophe, remember to avoid the 3 C’s: Closed spaces, Crowded places, and Close contact settings. How do you know if a place is too crowded? People noise may be a good marker for an indoor gathering. The more noise you hear, the more dangerous the space. In addition, if you wish to wean the worst of the pandemic, do the 3 W’s: Wear a mask, Watch your distance and Wash your hands.

Thursday, May 28, 2020

Heart Attacks and Hypertension in the Time of COVID-19

It is not cholera. It is not a love story set in uncertain times in the Caribbean. It is a real pandemic. The novel coronavirus, SARS-CoV-2, causes a unique illness with many manifestations called COVID-19.  Older patients and those with pre-existing conditions such as high blood pressure (hypertension) and cardiovascular disease are especially vulnerable. How has COVID-19 affected the treatment of hypertension and where have all of the heart attacks gone?

Older patients and men are much more prone to COVID-19 compared to women and children. Why is that? SARS-CoV-2 infects the body by entering cells through a protein called ACE2. ACE2 is found throughout the body and is especially concentrated in the lungs and the heart, which may account for the severity of respiratory problems with COVID-19. Elevated levels of ACE2 theoretically make more targets available for the coronavirus to infect. ACE2 also interacts with another protein called ADAM-17. It is hypothesized that the coronavirus activates ADAM-17, which then stimulates the hormonal system and worsens cardiovascular disease. It also causes a severe inflammatory response, causing damage to tissue throughout the body. It has been shown that men have higher concentrations of ACE2 than women. This may explain why men have worse outcomes with the virus compared to women. Similarly, older patients have worse outcomes while children have a low rate of infection. Studies have shown that ACE2 concentration was low in children and increased with advancing age.  Certain blood pressure medications can affect ACE2 and early in the pandemic there was a question whether these medications may make a patient more prone to the virus. 

ACE inhibitors (such as lisinopril or ramipril) and ARBs (such as losartan, valsartan or olmesartan) are pharmacologic mainstays in the treatment of hypertension and congestive heart failure. ACE and ARB medications work by increasing ACE2 in the body.  As a result of the increased ACE2 do these medications increase the risk of COVID-19 infection? Are these medications associated with worse outcomes with the virus? Now, after months of pandemic and millions of infections, the data is in.  Studies from China, Italy and New York City show that ACE and ARB medications are not associated with an increased likelihood for SARS-CoV-2 infection. In addition, ACE and ARB medications are not associated with worse outcomes. In fact, patients who were on an ACE or ARB had a lower risk of dying in the hospital than patients who weren’t on these meds. What about other hypertensive agents?  Data from New York City showed that patients on beta blockers (such as metoprolol), calcium channel blockers (such as amlodipine or diltiazem) or diuretics (such as hydrochlorothiazide) had no increased risk for a positive test or severe COVID-19 infection. Even before this information became available, the American College of Cardiology encouraged patients to continue their blood pressure medications. Now, with more data in, this is prudent advice.

Staying on cardiac medications is especially important, as the global pandemic has caused stress levels to go up worldwide.  Stress is caused by worrying about catching the virus and becoming severely ill.  The quarantine keeps people away from family and friends and increases social isolation.  Then there is the economic impact. Job loss and worry over how to pay the rent and bills all raise anxiety levels. Normally when psychological stress is increased, there is a concomitant increase in the number of heart attacks. That has not been the case with the current pandemic.  Studies from Italy, California and Boston show that heart attacks have gone down 48% during the pandemic as compared to a similar period a year ago.  This is not a local phenomenon; it has been felt globally.  In addition, about half of Americans have skipped or delayed medical treatment during the pandemic. On the other hand, cardiac arrests at home have soared since COVID-19 arrived (in New York City it was estimated that cardiac arrests at home increased 800% compared to the previous year).  So, are people having fewer heart attacks? Or are they ignoring symptoms for fear of catching COVID-19 in the hospital and then subsequently dying at home?

There are several lessons to be learned here. First, ACE2 and ADAM-17 are fun names for proteins. Second, take your blood pressure medication. Blood pressure medications are safe and they may have a protective effect against the detrimental cardiac effects of COVID-19.  Lastly, don’t ignore symptoms such as chest pain or shortness of breath. Don’t “wait it out” at home; call your doctor or head to the Emergency Room. It could save your life.

Monday, April 27, 2020

The Olive Tree

Olive Tree. Naxos, Greece

The olive tree, with its ancient roots, is strongly identified with a region and a cuisine. More than just a tree, it has come to symbolize peace, wisdom, persistence, longevity, healing, prosperity, stability, friendship, victory and tranquility.  Why is such importance attributed to this dusty, twisted, gnarly shrub?

The olive tree is a small evergreen tree that is indigenous to the Mediterranean basin. Olive groves ring the Mediterranean Sea from Portugal to Spain, Italy, Greece, Turkey, the Levant, Egypt and along the North African coast to Morocco. The olive has coexisted with people in the region for more than five thousand years. In fact, there are many olive trees in the Mediterranean that are over a thousand years old, many of which still produce olives. The olive tree likes hot, sunny weather and can tolerate droughts due to its extensive root system. Of course olive trees produce olives which in turn are made into olive oil. The olive is the most important crop in the Mediterranean and a staple in the Mediterranean diet.  The top ten olive producing countries in the world are from the region (led by Spain followed by Greece, Italy and Turkey).  Olive oil is produced by pressing olives and extracting the oil either by mechanical or chemical methods. There are various grades of olive oil. Extra virgin olive oil is the highest grade of olive oil and is extracted mechanically without chemicals. It has the lowest acidity and the best taste.  Virgin olive oil is also extracted by mechanical means, but it is slightly more acidic and slightly less flavorful. 

More than just a plant, the olive tree has deep cultural significance. In Greek mythology there was a competition between Poseidon and Athena for the soul of the major Greek city. Poseidon struck his trident on the rock and a salty spring burst forth.  Athena did the same and an olive tree grew.  The citizens felt that the olive tree was the more precious gift.  From that time on the city was called Athens and the olive tree was ingrained in the Greek psyche. In other Greek lore, the olive tree is a central theme in the Odyssey. Odysseus incorporates an old olive tree that is on his plot of land into the house that he builds. Stone walls were built around the tree and the trunk was used as a bedpost.  Since he builds his house around the tree, the tree itself becomes the focal point of the house. The old olive tree symbolizes permanence and stability as well as the love between Odysseus and his wife, Penelope, a connection that cannot be uprooted.  Olive oil has its own cultural, spiritual and culinary importance.  Keeping the focus on ancient Greece, athletes rubbed themselves with olive oil and the victors in the original Olympic Games were crowned with olive branches. The importance of olive oil cannot be overstated. Kings were anointed with it; it was burned in sacred lamps in temples and in the lamp for the eternal Olympic flame. Of course, olives were a staple of the ancient diet (along with grains and grapes) and olive oil remains an integral part of the Mediterranean cuisine from ancient times until today. 

In modern times, the Mediterranean diet has become the standard for heart healthy eating. The Mediterranean diet emphasizes fresh vegetables, fruit, nuts, whole grains, fish, plant-based protein and herbs and spices to flavor food. Of course, olive oil is a staple in the Mediterranean diet. Unrestricted use of olive oil in cooking and at the table increases the palatability of salads and vegetables, allowing people to consume more. Because of this, olive oil is felt to be the ideal culinary fat. Extra virgin olive oil is rich in monounsaturated fatty acids and polyphenols. Monounsaturated fatty acid in olive oil is the principal source of fat in the Mediterranean diet and when substituted for saturated fats or carbohydrates, lowers cholesterol and the risk for heart disease.  Polyphenols have antioxidant activity and further reduce cardiac disease, cholesterol and diabetes. The Mediterranean diet has been shown to lower the rate of heart attack, stroke and cardiac death by a substantial 30%, a risk reduction similar to taking medications such as statins to lower cholesterol.   Most of the information about olive oil has been obtained from Mediterranean populations. Recently, a large study (9,800 patients followed over 24 years) shed light on olive oil’s effects in a US population. The study found that using 1/2 tablespoon of olive oil each day reduced the risk of cardiac disease and cardiac death. The benefit of olive oil is still present, despite much lower consumption in the US group.  The US consumption of olive oil is about 12 grams per day while the Mediterranean consumption is more than twice as high (25 grams per day). It seems that olive oil can prevent heart disease in diverse populations, even in small amounts. 

So, by replacing butter, margarine, mayonnaise or dairy fat with an equivalent amount of olive oil you can live longer and have less heart disease. You might even feel like a king.

Disclaimer: the author’s family owned an olive orchard in southern Greece for many years, so olive bias may be at play.