The Vaccine

Has something been needling you the past year? Has something been jabbing at your brain? Has something pricked the bubble of your hopes and dreams for 2020? Of course! It’s COVID 19! Now, finally, there may be light at the end of the tunnel with the coronavirus vaccine. How does the new vaccine work and what does the data show?

 

Vaccines work by training the immune system to recognize and kill a foreign invader, such as a virus. Older vaccines work by injecting a dead virus or a weak live viruses to stimulate an immune response.  Newer vaccines work by injecting proteins found on the virus and teaching the immune system to mount a defensive response. Vaccines typically take years or even decades before they are ready to be used by the public. The development of a coronavirus vaccine is somewhat of a scientific miracle; the first COVID 19 case was described on December 1 2019, the coronavirus genetic code was sequenced on January 10 2020 and a vaccine was approved by the FDA on December 11 2020.  The coronavirus vaccine is not a single vaccine, there are at least six different methods companies are using to attack the virus.  Despite the quick turn around on the coronavirus vaccine, the technology behind it has been in development for decades. One method (the vaccine platform used by both Pfizer and Moderna) uses two key components: messenger RNA and the spike protein found on coronaviruses. Messenger RNA takes instructions encoded in the DNA into cells to turn on protein manufacturing. Messenger RNA vaccine technology was invented in the 1990’s and has been constantly refined since then. Work on a spike protein vaccine accelerated after pandemics with severe respiratory syndrome (SARS) in 2003 and Middle East respiratory syndrome (MERS) in 2012, viruses that are similar to coronavirus. The vaccine, containing messenger RNA in a lipid shell, works as follows. The messenger RNA carrying a copy of the spike protein enters a cell. The cell reads the instructions for the spike protein and starts making copies of it.  The spike protein moves to the outside of the cell where the immune system detects it. The immune system then learns how to recognize the protein and releases defense mechanisms to kill the infected cells. The second method uses a viral vector (AstraZeneca, Johnson and Johnson and Oxford use this approach). The coronavirus spike protein is introduced into an adenovirus that infects only chimpanzees. The vaccine contains an empty adenovirus with the spike protein inside. This is injected and stimulates the immune system to recognize the spike protein and mount an immune response. Both vaccines teach the body’s own immune system to find and kill the coronavirus.

 

The data on Pfizer’s messenger RNA vaccine was just reported.  The trial enrolled 43,448 people, all 16 years of age or older.  The vaccine was administered in two doses, 21 days apart and patients were followed for two months. The efficacy of the vaccine in preventing symptomatic COVID 19 was excellent at 95%. The efficacy was good for all groups: 94% for those over 55 years old, 96% for men, 94 % for women, 95% for whites, 100% for blacks, 94% for Hispanics and 94% for those with hypertension. For comparison, the efficacy of the measles vaccine is 97%, the chicken pox vaccine is 82% and the flu vaccine varies from 50% to 60%. Side effects were generally mild and included pain at the injection site, fever, fatigue, headache and muscle or joint pain.  In general, reactions were milder and less common in older patients (> 55) compared to younger patients.  Reactions were more common after the second dose compared to the first dose. Side effects are similar to the reactions seen after the shingles vaccine.  It is not known whether the vaccine can prevent COVID 19 in children under 16 years old, pregnant women and immunocompromised patients. In addition, the study could not determine whether the vaccine prevents asymptomatic infection. Lastly, patients in the placebo arm will have to be offered the vaccine since the FDA approved it. It is unethical to withhold vaccine for these people. This means that long-term efficacy and safety will be determined by real world experience. Based on this data, the FDA gave the Pfizer vaccine emergency use authorization on December 11 2020. The first dose of this vaccine was given to a 90-year-old woman in England on December 8 2020.  Moderna is conducting a 30,000 person trial with a similar vaccine. The preliminary results show good efficacy (also 95%) and safety but the final results are still pending. 

 

The Oxford adenovirus vector vaccine was studied in 23,849 people over the age of 18. This was also a two-dose regimen. The efficacy was 62% in patients who received two standard doses and 90% in those who received a low dose followed by a standard dose. The side effect profile was also very low.  Johnson and Johnson’s vaccine works in a similar fashion.  A 60,000 person trial was put on hold due to a serious adverse reaction but has recently resumed. Results from the trial are pending. 

 

To contain coronavirus, it is estimated that 60% of the population will need to be vaccinated to achieve herd immunity.  This may be difficult for several reasons. First, enough vaccine must be manufactured and distributed. There are many logistical obstacles. Next, enough people must consent to take the vaccine.  A recent poll of Americans found that 29% would definitely take the vaccine and 31% would probably take it. That adds up to 60% with no room for error. In addition, a poll among health care workers in New Jersey revealed only 50% were planning on taking the vaccine. This is disappointing since the CDC guidelines will have health care personnel vaccinated first along with long term nursing home residents in Phase 1a.  Phase 1b will be essential workers (police, fire, corrections officers, transportation workers, food and agriculture workers and teachers). Phase 1C will include adults with high-risk medical conditions and adults over age 65. 

 

Some caveats:

The efficacy of the vaccine is excellent (better than the annual flu vaccine with an efficacy of only 50-60%). 

It seems that the vaccine-induced immune response is stronger than that of the natural COVID 19 infection.

The side effect profile is similar to other vaccines (such as the shingles vaccine). 

The coronavirus is not being injected. You cannot get COVID 19 from the vaccine.

The vaccine will not alter your DNA.

 

So once it is available, please line up to get your vaccine. It will help your herd tremendously. 

 

 

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. 

  

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

 

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.

COVID Fact

 

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.

 

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 3^rdcentury 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.

 

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.

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.

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. 

Coronavirus Exposes the Downside to a Healthy Community

What do people who live a long life have in common? First, it helps to have good genes. Beyond that there are several recurring themes and three lifestyle pillars that are found in cultures with many nonagenarians and centenarians. The first two are exercise and diet. The third pillar is social connections. The trifecta of social networks, food and exercise come together to form a healthy community.  In medicine every intervention (medication, surgery, procedure, or therapy) is thought of in terms of its risk and benefit.  It is felt that exercise, a good diet and social connectivity each have a vast benefit in promoting a healthy lifestyle with little or no risk. Is this true? Can one over exercise? Is a healthy diet really that healthy? Can social connections be detrimental?

“Exercise is king. Nutrition is queen. Put them together and you have a kingdom”, said Jack LaLanne, a noted celebrity fitness expert who passed away at the age of 96.  Exercise is the key to living a long healthy life and you don’t have to be a world-class athlete to obtain the benefits. Moderate walking every day will increase lifespan by one and a half years while more vigorous walking will increase it by three years. The recommended amount of exercise to reduce the risk of heart disease and lower the death rate is 150 minutes of moderate exercise per week or 75 minutes of vigorous exercise per week. The second pillar is diet. Plant based protein diets and the Mediterranean diet have become the standards for heart healthy eating. The Mediterranean diet emphasizes olive oil, fresh vegetables, nuts, whole grains over refined grains, fish and plant-based protein over red meat, herbs and spices to flavor food over salt, and fresh fruit for dessert instead of refined sweets. The Mediterranean diet can lower the risk for heart attack, stroke and cardiac death by a substantial 30%, a risk reduction similar to taking medications such as statins to lower cholesterol.  

Following a good exercise regimen and eating a healthy diet are largely individual interventions. A healthy lifestyle can be accomplished on one’s own, but a healthy community requires a social network. There are places in the world where people live much longer than average. In these places, residents walk before and after dinner, eat healthy meals together and dine with friends and family.  This is shown in the picture above, a town in Italy where everyone is out, walking, talking, eating, socializing, and connecting with each other. Much of the social support is in the home, where multiple generations live together. On the other hand, social isolation increases the risk for heart disease and stroke by 30%. People who are socially isolated tend to engage in negative health behaviors such as smoking, drinking excess alcohol and not exercising or eating correctly. Social networks are a major factor in improving longevity. Having supportive friends and family can make life easier by providing emotional support, providing help when needed, reducing stress and providing the impetus to go out and walk and connect with others.  The depth and quality of the social connections matter as well.  Having one friend bests being alone, but having a larger network is better still.  In some cultures, people brag about how much money they have. In cultures with longevity, they brag about how many friends they have. People with adequate social relationships tend to live nearly four years longer than those without support. All cardiac rehab programs combine these three elements as well. Cardiac rehab programs are structured as cohorts; similar patients with similar cardiac problems exercise together, eat together and support each other. In effect, a good cardiac rehab program is a type of healthy community. There does not seem to be a down side to developing a strong social network.  Or is there?

Unfortunately, all three pillars have a down side. For example, it is possible to over exercise and that risk is associated with some harm. The highest risk of cardiac death is in the sedentary individual. Exercising will decrease the risk of dying from heart disease. The more exercise, the lower the risk of cardiac death, up to a point. As one exercises more, the risk of dying continues to go down and eventually plateaus. However, in athletes who exercise ten times or more than the recommended amount (for example training for and running multiple marathons in a year), the risk of cardiac death actually stops going down and starts trending upward. In other words, the extreme athlete may be at higher risk than the person who walks 150 minutes per week.  So, exercise has its down side, but how about the vaunted Mediterranean diet? Recently, it lost some of its luster as the major study which proved the Mediterranean diet’s worth was found to have flaws. The diet is still good, but the evidence is now much weaker. What is the downside to a wide social network and lots of friends? Coronavirus. 

The novel coronavirus has caused a global pandemic.  The virus is transmitted via respiratory droplets; an infected person passes on the virus by coughing, sneezing, talking or breathing. This method of transmission worsens with close personal contact, thus the need for social isolation to contain it.  The fatality rate for coronavirus is age-specific. The death rate is low for children under 9 years of age ( < 1%) and goes up with advancing age. The rate accelerates after age 60 (the death rate at 60 to 65 is about 5%) and is highest in those over 80 with rate nearing 15%. Multigenerational households are especially hard hit; younger adults come home with no or mild symptoms, but pass the virus to their elderly family members who live with them. This may be one reason why lower income areas of cities are vulnerable.  Even though these areas have a high proportion of people with medical problems (such as high blood pressure, obesity and heart disease) putting them at risk for infection, they also have multiple people living in each household and several generations cohabiting.  Paradoxically, countries such as Italy and Spain, home to many healthy communities with presumably low rates of high blood pressure and heart disease, have been harshly affected by the coronavirus.  There are many reasons for this, including a country’s response to the pandemic. However, there are intrinsic characteristics of these countries which may be contributing. For example, Italy has the second oldest population in the world with 23% over age 65 (Spain has 19% over age 65, the US 16%). In addition, these countries have dense kinship networks and are known for the support that elderly parents receive from their adult children. They have extended households with more than one adult couple living in the same house. In Italy 34% of people over 65 had an adult child in the house. In Spain it is 38%. For comparison, in northern European countries the rate is 2%. These Southern European countries, with their family centered cultures, are normally areas with many healthy communities and good overall health but now their living arrangements and social closeness potentiate the spread of the virus. 

In 1931 Kurt Godel published his Incompleteness Theorems, transforming mathematical logic. The theorems state (as interpreted by a cardiologist and not a mathematician) that every formal system is either incomplete or inconsistent.  This is important because the theorems show that it is impossible to create a set of rules that explain everything in math.  What does a mathematical theory have to do with a pandemic and public health? The coronaviruses’ effect on healthy communities proves Godel’s theorem; nothing is perfect.

What Could Possibly Be New in the World of Hypertension?

Hypertension, high blood pressure, has been recognized as a clinical entity since the late 1800’s. Accurate blood pressure measurements started after the invention of the sphygmomanometer, the blood pressure cuff, in 1896. Hypertension is a major factor in heart disease and stroke and has been intensively studied for more than 100 years.  Despite all of the years of research, 90-95% of hypertension is still deemed idiopathic; doctors don’t know what causes it in the vast majority of cases. Given that background, what could possibly be new in the field of hypertension? Apparently a lot. The discussion first gives some background on hypertension, and then delves into new findings.

What is the definition of high blood pressure?

In late 2017 the American College of Cardiology published new guidelines redefining the threshold for high blood pressure. In the new system, blood pressure is considered elevated if the systolic pressure is over 120 and the diastolic pressure is over 80. Stage 1 hypertension occurs with blood pressure over 130/80. Stage 2 hypertension is defined as a blood pressure of 140/90 or greater.  All patients with blood pressure over 120 should be treated initially with lifestyle modification (to be discussed). Those with blood pressure over 140/90 should be started on medication.  In addition, medications are recommended for patients with systolic pressure > 130 and who already have established heart disease or those whose estimated ten year cardiac risk is greater than 10% (based on the cardiovascular risk calculator cvriskcalculator.com).  Hypertension is diagnosed if blood pressure readings are elevated on three separate occasions, several weeks apart. 

"My blood pressure is all over the place"

Blood pressure is never a single, solid, static number. Blood pressure will vary with the time of day, activity and after taking medications. Think of the blood pressure as waves on the ocean, it will have highs and it will have lows.  It is best to avoid wild swings between the peak and the trough.It is desirable to have gentle waves with small swings from high to low; this represents a well-controlled blood pressure. Very high blood pressure readings, followed by very low blood pressures, like tsunami waves, are not good as large fluctuations are associated with an increased risk for heart disease..

Where is the best place to measure the blood pressure? 

The doctor’s office is not the ideal location for blood pressure checks. Patients are often stressed about getting to the office on time and are often nervous. They are rushed into the exam room, and not given time to relax. These measurements may not be a true reflection of the blood pressure. More accurate readings occur when patients take their blood pressure at home, where they are relaxed and comfortable. Another reliable method is an ambulatory blood pressure monitor, a blood pressure cuff worn for 24 hours, which gives an average blood pressure reading during the day and at night.  Both methods, home blood pressure readings and an ambulatory blood pressure monitor, can confirm hypertension in patients who have high readings in the office or white coat hypertension (high readings in the office but normal at home) to avoid over diagnosis and over treatment.  In addition, ambulatory blood pressure monitoring is a stronger predictor of cardiac disease and mortality than office blood pressure values.   

When is the best time to take blood pressure medication, in the morning or at night?

The blood pressure normally varies through the course of a day. It is highest in the mornings when hormones are secreted that arouse us from sleep and stimulate us to get us ready for the day.  The blood pressure is at its lowest when are sleeping. This is significant because the mean blood pressure during sleep is a more important indicator of cardiovascular disease than daytime office blood pressure or the average blood pressure over a 24-hour period. Recent research has shown that taking blood pressure medication at night controls the blood pressure better and lowers the risk for cardiovascular events compared to taking meds in the morning. Taking medication at night also reduced the risk of kidney disease and lowered the cholesterol. 

Which is more important, the upper (systolic) number or the lower (diastolic) number?

Systolic blood pressure is the force of the blood pumped by the heart into the aorta, the main artery leading from the heart. It is the force the heart pumps against. The higher the systolic blood pressure, the harder the heart has to work to get blood to the body. The diastolic number is the pressure in the heart and aorta after a heartbeat, when the circulatory system is relaxing.  A high diastolic blood pressure means that the heart cannot relax properly. For hypertension, which number is more important to follow? Since the Framingham Heart Study published their results in the 1960’s, it has been felt that the systolic level was more important.  In fact, the American College of Cardiology risk calculator uses systolic blood pressure as a variable, but doesn’t ask for the diastolic number.  However, new research has shown that systolic and diastolic blood pressure are each independently associated with cardiovascular outcomes. Even though systolic pressure had a greater effect, diastolic readings should not be ignored.  

Which is better, a wrist blood pressure cuff or an arm cuff?

The blood pressure reading taken from the upper arm is not equal to the blood pressure in the wrist. Again, if we think of blood pressure as a wave, a certain pressure is needed to get blood to the arm. The wave then propagates and a higher pressure is needed to get blood to the hand and fingers. New research has shown that the systolic blood pressure averaged 5.5 mmHg higher in the wrist than in the upper arm. Many people had a blood pressure difference greater than 15 mmHg. This has implications for home blood pressure monitors. It must be kept in mind that wrist cuffs will give higher readings than arm cuffs.

Is alcohol good or bad for the blood pressure?

The American Heart Association recommends no more than two alcoholic drinks per day for men and one for women. Is that a safe amount for a patient with hypertension? A drink is defined as 12 ounces of beer, 4 ounces of wine or 1 ounce of spirits. Many studies have shown that heavy drinkers (> 14 drinks per week) are more likely to have high blood pressure than nondrinkers. New research has shown that moderate drinkers (7-13 drinks per week), a range within the American Heart Association guidelines, are 1.5 to 2 times more likely to have hypertension. In addition, binge drinking (4-5 drinks within a two hour period) also is associated with hypertension, even if consumption is low at other times. However, all is not lost. Light drinkers (1-6 drinks per week) did not have elevated blood pressure.

Diet and exercise are first line treatments for hypertension. How well do they work?

After a diagnosis of hypertension is made, lifestyle intervention is started and includes diet, exercise, weight loss, decreasing alcohol intake and smoking cessation. Cardiologists are taught that blood pressure increases with age. However a new study questions that teaching.  When looking at two communities in the Venezuelan rain forest, researchers concluded that diet rather than advancing age caused high blood pressure.  Blood pressure readings that go up with age may not be from aging, but rather the effect of a poor diet building up over time or genetics. Another study showed how detrimental a Southern diet (a diet high in fried food) is for the development of hypertension, especially in African-Americans. Diet is so important that just by following the DASH (Dietary Approaches to Stop Hypertension) diet, one can expect to lower the systolic pressure by 11 points and the diastolic pressure by 8 points. These reductions are as good as those achieved with some medications.  

Exercise lowers blood pressure to the same degree as diet and an expensive gym membership is not needed.  One recent study showed that a brisk morning walk of about 30 minutes lowered blood pressure in obese adults.  Blood pressure is down immediately after the walk and the effect lasts for 8 hours afterwards. On the other hand, another study concluded that men should exercise at night to lower their blood pressure. So which is it, morning or evening exercise? Very likely the time of day matters less than actually doing exercise. Any type of exercise, at any time of day, is better than being sedentary. Lastly, a huge review of nearly 400 studies evaluating nearly 40,000 patients showed that exercise lowers blood pressure by about 9 points, again similar to medication.

If you have hypertension, the choice is simple: medication or lifestyle changes. Lifestyle modification is a good place to start as this can lower blood pressure, is less risky and makes economic sense.  You can send your hard earned cash to the pharmaceutical companies or spend it on fresh fruits and vegetables (DASH diet), drink less alcohol (saving more money) and exercising (which can easily be done for $0). Start with lifestyle changes but keep in mind medication may still be necessary as you work with your doctor to lower your blood pressure. 

The Cardiac Consequence of Sound

Waterfalls are a wonder of nature. They are often the prizes found after a long hike through the woods. Waterfalls are a worldwide phenomenon. However, the number of waterfalls are not easy to determine due to differing definitions; California is estimated to have as many as 400. The world’s longest waterfall is Angel Falls in Venezuela at 3212 feet; the tallest waterfall in the US is Yosemite Falls at 2425 feet. Victoria Falls in Zimbabwe is felt to be the largest at 5604 feet wide and 304 feet high. Its roar can be heard 25 miles away!  Waterfalls are nice to look at, but if you live near one would the constant roar of the water be soothing or annoying?

Sound is measured in decibels.  Decibels for some common sounds include normal conversation which is 60 decibels, whispering is 20 decibels, and a rock concert is 110 decibels. Constant exposure (more than 8 hours a day) to sounds over 85 decibels is considered hazardous and unhealthy. Noise is sound that is perceived as annoying.  Noise pollution, or environmental noise, is noise that affects a person’s health or behavior.  Many studies have shown that environmental pollution in the form of traffic noise (from cars, airplanes or trains) is associated with heart disease. Traffic noise confers an increased risk for high blood pressure, heart attack, stroke, atrial fibrillation and congestive heart failure.  Constant traffic noise increases the risk for high blood pressure starting at 45 decibels and increases every 5 decibels. Heart artery disease starts to occur with continued exposure to noise at 50 decibels and increases each 5 decibels in the evening and 10 decibels at night. The constant annoyance of traffic noise causes a stress reaction. It disturbs sleep, increases adrenaline, releases stress hormones, raises blood pressure and alters blood sugar and cholesterol metabolism. The effect is stronger if the noise occurs at night. Nighttime aircraft noise increases blood pressure further and heart disease is more strongly associated with people whose bedrooms face the road.   Unfortunately, noise pollution often goes hand in hand with air pollution. It may be difficult to determine which is the cause for heart disease: noise or air pollutants. There are other circumstances where noise may be implicated in heart disease. People who have long-term exposure to loud noise at work are two times more likely to have heart artery disease.  The intensive care unit (ICU) is another area where noise pollution is a factor. ICUs are noisy places; alarms go off, IV pumps beep and there is 24 hour per day chatter among the ICU personnel. The noise level in ICUs is a constant 50 to 75 decibels, even at night. Thus, sleep disturbance is a common problem for ICU patients. In addition, noise pollution in the ICU is associated with delirium (confusion) and worse outcomes among patients. 

Not all sound is bad for the heart. Music and sounds from nature may be beneficial for the heart. Listening to music may help heart patients by decreasing heart rate and blood pressure, relaxing arteries and improving blood flow and reducing stress. For example, patients who listened to music after heart surgery had less pain and less anxiety.   Music, however, is very personal; what one person perceives as soothing, another may find annoying.  Despite that, neuroscientists were able to test a number of songs on their ability to reduce anxiety. Their research produced a playlist of the most relaxing songs on earth.  Are nature sounds just as soothing as music? Not much is known about sounds found in nature. One group had patients undergoing heart bypass surgery listen to nature sounds (birds chirping, waves on the beach, jungle sounds and the sound of rain).  They found that natural sounds were able to reduce anxiety in patients around the time of surgery. 

So, are waterfalls soothing sounds from nature or noise pollution?  Consider the case of Niagara Falls, New York, one of the largest waterfalls in the world and one whose noise level is a constant 95 decibels.  According to an article in the Buffalo News from December 2016, the Buffalo Niagara area has one of the highest rates of heart attacks in the country.  There may be many reasons for that, but could it be from noise pollution from the Falls?  More research is needed on this question, but if you are planning to visit, consider bringing your noise cancelling headphones.

What's Your Score?

At the dawn of a new decade, what is the best way to assess a person’s risk for atherosclerosis (plaque in the heart arteries)? There are many different tools to choose from including several risk calculators, blood tests (for example C reactive protein) and imaging tests (such as stress tests or ultrasound of the neck arteries to determine if plaque is present). Of all of the approaches available, what is the optimal approach for someone who may have coronary artery disease? 

The first step is to see a doctor, have a good physical examination and basic laboratory tests, including total cholesterol and LDL cholesterol (the “bad” cholesterol).  If the total cholesterol is over 200 or the LDL is over 100, the next step is to enter the data into the American College of Cardiology risk calculator (cvriskcalculator.com).  The calculator will give an estimate of the chance of a heart attack or stroke within the next 10 years.  The estimate can be broken into four categories:

Low Risk: 0- 5%

Borderline Risk: 5-7.5%

Intermediate Risk: 7.5-20%

High Risk > 20%

Low risk patients need no further testing or medication, but should continue with a heart healthy lifestyle. High risk patients should be started on aspirin, blood pressure medication (if appropriate) and a statin to reduce cholesterol. For those in the borderline and intermediate categories, additional consideration is needed. The next step is to assess whether the patient has other risk enhancers. These include:

LDL > 160 mg/dl,

high-sensitivity C reactive protein level (a measure of inflammation) > 2.0 mg/L, 

triglycerides > 175 mg/dl, 

peripheral arterial disease, 

chronic kidney disease, 

chronic inflammatory disease (rheumatoid arthritis, psoriasis, or lupus), 

metabolic syndrome (hypertension, diabetes, high triglycerides, obesity), 

family history of premature heart disease, or 

premature menopause

For the patient with borderline or intermediate risk and the presence of one or more risk enhancer, a statin should be initiated. If there is still uncertainty about starting medication or the patient is reluctant, the next step is to do a coronary calcium score. The coronary calcium score is obtained with a computed tomography (CT) scan. No contrast is used, so there is no preparation and no intravenous line is needed. The patient goes into the CT scanner, holds their breath and the scan is obtained. The whole process takes only a few minutes.  The down side of the scan is that a small dose of radiation is used and in many cases insurance doesn’t cover the cost. Fortunately, locally, the cost for a coronary calcium score is just $99. The scan measures the plaque burden in the heart arteries.  Plaque is formed by cholesterol deposition followed by inflammation and calcium build up. The scan can detect and quantify the amount of calcium seen in the heart arteries. The coronary calcium score is the sum of all of the calcium seen in all of the heart arteries. However, the scan does not show the amount of blockage in the arteries (plaque may be present only in the wall of the artery or it may be part of a plaque causing blockage to blood flow).  A coronary calcium score of 0 means there is no plaque in the heart arteries and the patient is at very low risk for a future heart attack. No statin is recommended. A calcium score between 1 and 99 means there is plaque present and a statin should be considered, especially for patients older than 55.  For patients with a coronary calcium score over 100, a statin is indicated and further testing, such as a nuclear stress test should be done to see if the plaque is causing significant blockage. 

It is important to realize that this approach is only for patients who do not have heart artery disease (primary prevention). For those with a history of disease (a heart attack or stroke, heart bypass surgery or a heart stent) or those who have diabetes with an LDL over 70, this approach should not be used and those patients should be on a statin. In addition, this approach is only for adults between the ages of 40 and 75.

What about patients who are 75 years old or older? Should they be on a statin? The risk for cardiovascular disease increases with older age. Taking a statin may help reduce that risk. On the other hand, other diseases (such as cancer or dementia) also rise with advancing age and limit the benefit of statins.  For patients with a history of heart attack, stroke or cardiac revascularization (secondary prevention), the data is clear: continue the statin, even in the very elderly.  For primary prevention in those over age 75 the data is less clear.  A recent trial of patients over 70 years old showed a lower risk of dying from any cause for those on statin versus those who were not on statin. In addition, the statin patients had fewer heart attacks and strokes.  Another study looked at patients over 75 who had their statin stopped.  The participants who came off their statin were at higher risk for hospitalization and cardiovascular events.  One of the reasons for stopping a statin in older patients is the perception that statins increase the risk for dementia. However, there never has been an increased risk for dementia in all of the studies done on statins. A recent study of statin patients 70 to 90 years old confirmed that there was no increased risk for dementia.  In fact the statin patients showed less cognitive decline, suggesting statins may be protective for brain function. 

So, take the steps necessary to reduce your risk for heart artery disease. If you are between 40 and 75 years old, see your doctor, have blood work, calculate your 10 year risk and see if a coronary calcium score is right for you. If you are over 75 years old, don’t stop the statin and discuss with your doctor the pros and cons of continuing medications.