tag:blogger.com,1999:blog-66195061635573194202024-03-19T05:39:07.496-07:00SportsCardiologyA blog examining heart disease in athletes, as well as general topics in heart diseaseUnknownnoreply@blogger.comBlogger116125tag:blogger.com,1999:blog-6619506163557319420.post-90185334384511260152024-02-27T15:26:00.000-08:002024-02-27T15:26:51.934-08:00The Dawn of a New Day<p style="text-align: left;"> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgSlCsWApEmgxGIcf1CZZxaDButpByb1hk-s64n5-0inCkBVam0kp7nRLk16q_OINx_kFxTDze0SG8g5p8aAhSZhyScUymZaDOsgylmy2AUaMhrWKWBr9ZVcVZDT459S-nLU9x0ux1gTUua90P5373TzxDyIuu-S4qQ02VGCPineAf-aktsaldDZ5T34PY/s4032/IMG_4634.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="3024" data-original-width="4032" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgSlCsWApEmgxGIcf1CZZxaDButpByb1hk-s64n5-0inCkBVam0kp7nRLk16q_OINx_kFxTDze0SG8g5p8aAhSZhyScUymZaDOsgylmy2AUaMhrWKWBr9ZVcVZDT459S-nLU9x0ux1gTUua90P5373TzxDyIuu-S4qQ02VGCPineAf-aktsaldDZ5T34PY/s320/IMG_4634.JPG" width="320" /></a></div><p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><i>When the child of morning, rosy-fingered Dawn, appeared, <a name="11"></a>Odysseus rose and led the way to the place of assembly, <a name="12"></a>which was near the ships</i>.<o:p></o:p></p><div class="separator" style="clear: both; text-align: center;"><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;">Book VIII, The Odyssey<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;">Homer<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;">The phrase “rosy-fingered dawn” is an epithet (a descriptive term) used many times by Homer in both the Iliad and the Odyssey to say, “the break of day”. The term also signifies a fresh start to a new day and a tribute to the trials and tribulations of the day. How does the body handle the “rosy-fingered dawn” and rising from sleep to face a new day? What physiologic changes occur and how do those changes impact heart health?<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;">The human body ticks to a 24-hour clock. This clock determines changes in our bodily functions which guide us between a rest stage (sleep) and an active stage. Our internal rhythms are synchronized with the world through interactions with light. These variations are called circadian rhythms (the term circadian is from Latin, circa which means around and dies which means day; around the day). As the rosy-fingered dawn breaks, we sense the presence of light. This results in the secretion of a number of hormones which serve to rouse us, “rev” us up, to get ready for a new day. The hormones include adrenaline and cortisol, which result in an increase in blood pressure and heart rate, increase our wakefulness, increase body temperature and get us ready to be become active. On the other hand, as light fades, the body secretes melatonin and decreases adrenaline and cortisol, getting us ready for the rest phase, sleep. Disruptions to the well-controlled circadian rhythm can lead to various chronic illnesses including heart disease. <o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;">Circadian rhythms are controlled by a number of biological clocks. A central clock is located deep in the brain and regulates the clocks located throughout the body. These peripheral clocks are found in nearly all of the tissues of the body, especially in the gastrointestinal system, the nervous system, the liver and the heart. The circadian clocks are molecules within the cell that provide feedback loops timed to a 24-hour cycle. There are clocks in the heart muscle as well as in the wall of blood vessels. The heart muscle clocks orchestrate cellular processes, ensuring that they occur at the right time of the day. Growth and repair of heart tissue takes place during sleep or rest periods. If this circadian pattern is broken, then cardiac pathology ensues. During a normal day, there are fluctuations of up to 20% in various cardiac parameters. For example, blood pressure is lowest during sleep and highest in the early morning hours. This is due to the release of the hormones responsible for rousing us at the beginning of the day. Similarly, the greatest risk for a heart attack or stroke is around 6 AM. This is a direct result of the early morning changes with increased blood pressure and heart rate leading to increased stress with the heart’s blood vessels and an increase in clotting factors caused by the release of hormones. In addition, life threatening arrhythmias and sudden cardiac arrest peak around 6 AM. <o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;">Maintaining normal circadian periodicity is important for preventing disease and maximizing longevity. Disruption of the normal circadian rhythm is detrimental and leads to a variety of chronic illnesses. Disruption can be genetic, environmental or behavioral. Irregular sleep and eating schedules misalign the clocks. It is important to keep sleep timed with lack of light, i.e. night-time. Irregular sleep schedules throw off the biological clocks so they can’t synchronize properly with the light-dark cycle. Changes such as jet lag and daylight savings time can disturb internal clocks and lead to cognitive impairment and increased risk for heart attack. Shift workers who sleep during daytime are especially prone to circadian disturbances. Shift work is a risk factor for heart disease, diabetes, obesity and hypertension. It increases cholesterol and triglyceride levels and increase inflammation. Sleep timing is important as well. Evening types, people who have later wake up and bedtimes, are at increased risk compared to morning people. Evening types have a higher incidence of cardiac disease, diabetes and obesity. Therefore, it is important to keep a regular sleep schedule. Meal timing is another factor as food serves to synchronize the biological clocks. Eating late at night also leads to cardiac disease, diabetes, obesity and high cholesterol. Shifting food toward the beginning of the day reduces those risks. This was proven in a recent study. Late eaters, people whose largest meal of the day was after 12:38 PM, had higher risk for obesity than people whose main meal is at lunch time. Having smaller meals throughout the day was better than eating three “square” meals. In addition, intermittent fasting, food intake restricted to early morning to 6 PM with an overnight fast, can reduce weight and protect against metabolic disease. <o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;">To every rule, there is an exception. In this case, the exception lies in a Blue Zone. Blue Zones are areas around the world where there is exceptional longevity, with many people in the population reaching 100 years of age. Blue Zones have been identified in Japan, Costa Rica, California and on the Mediterranean island of Ikaria, Greece. The Mediterranean lifestyle seems to counter the circadian rhythms noted above. Dinner is served after 9 PM at night and bedtime occurs late as well. In addition, there is a day time siesta, so sleep patterns are irregular. On the other hand, the main meal is lunch. <o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;">There are numerous factors involved in greeting many rosy-fingered dawns. Listening to our biologic clocks and following our circadian rhythms can help stave off disease and increase longevity. In order to do this, regular sleep habits and timing sleep patterns to light and dark seem prudent. In addition, shifting caloric intake to earlier in the day, eating smaller meals and doing some overnight fasting will improve the chances of seeing the dawn of a new day. <o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;"><o:p> </o:p></p></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-42427710292360978432024-02-06T15:37:00.000-08:002024-02-06T15:37:03.627-08:00Cold-Hearted<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMd-4N1aRqXjxRkAHBfSpsgWbuRtQhvmUsLHg2R-6FE2OtBVI2F5bFkemYf1C597oU6SCP-D9GPovABTTAUIHl5kn-CqCgjmsI4hE7oq1vn9VZG_JAQMaOq-8AHd9dHeSanyLDpLzOzbtwpEEq_C4obmM6NjRy0S-GHAtON6Z4-KaTDuVeEjYA7BaM0O4/s612/istockphoto-868098786-612x612.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="408" data-original-width="612" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMd-4N1aRqXjxRkAHBfSpsgWbuRtQhvmUsLHg2R-6FE2OtBVI2F5bFkemYf1C597oU6SCP-D9GPovABTTAUIHl5kn-CqCgjmsI4hE7oq1vn9VZG_JAQMaOq-8AHd9dHeSanyLDpLzOzbtwpEEq_C4obmM6NjRy0S-GHAtON6Z4-KaTDuVeEjYA7BaM0O4/s320/istockphoto-868098786-612x612.jpg" width="320" /></a></div><br /><p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><i><span style="color: #555555; font-family: "Helvetica Neue"; font-size: 10.5pt;">CLEOPATRA: Ah, dear, if I be so,<br />From my cold heart let heaven engender hail,<br />And poison it in the source<o:p></o:p></span></i></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><i><span style="color: #555555; font-family: "Helvetica Neue"; font-size: 10.5pt;"> </span></i></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;">The expression cold-hearted means showing no understanding, no feeling towards another. It is unsympathetic, unemotional, uncaring and cruel. If used in a sentence it might look like this: “The cold-hearted landlord evicted the poor family with a sick child”. The first known use of the adjective cold-hearted is in Shakespeare’s play, “Antony and Cleopatra”. Certainly, Cleopatra could be considered cold-hearted due to her various plots to overthrow her brother and rule Egypt. Heart attacks can also be considered cold-hearted. A heart attack does not discriminate; it can affect men or women, young or old, rich or poor. It can strike at any time of the day or night, often without warning. Despite that, heart attacks do have some predictable variation. For example, heart attack risk changes with the season of the year and is associated with extremes of temperature, both hot and cold. The only known example of Cleopatra’s handwriting is a single Greek work, <span style="background: white; color: #222222;">γ</span><em><span style="color: #222222;">ίνεσθοι,</span></em> which she wrote on a papyrus addressed to a tax collector in 33 BC<span style="color: #222222;"><i>. </i>It translates to, “so be it” or “make it happen”. Heeding the queen’s order, we will now “make it happen” and outline when heart attacks are the most cold-hearted. </span><span style="color: #222222;"><o:p></o:p></span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><span style="color: #222222;"> </span></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><em><span style="color: #222222; font-style: normal;">A heart attack occurs when a plaque in a heart artery breaks open. When the blood is exposed to foreign material (such as an exposed plaque), it does what it is supposed to do and forms a blood clot within the artery. If the clot totally obstructs the flow of blood, the type of resulting heart attack is called a STEMI (ST elevation myocardial infarction). If there is still some residual blood flow through the blockage and clot, then the heart attack is a nonSTEMI. For both types of heart attack, there is a U-shaped association with temperature. There is an increased risk for heart attack on very cold and on very hot days. Since we are in the throes of winter, we’ll concentrate on the cold weather effects on the heart. An increase in heart attacks and heart attack deaths in the winter was first noticed in the 1930’s. A large database studied heart attacks from the 1980’s and 1990’s and quantified the risk. A seasonal distribution was confirmed; there were 50% more heart attacks in the winter months compared to the summer time. The peak number of cases were in January, followed by February, March, November and December. Another series, also from the 1990’s, concluded that coronary events were 20-40% more likely to happen in the winter and spring versus other times of the year. One other study (1980’s-1990’s) also showed that the month with the highest mortality rate due to a heart attack was January. Lastly, a study from Minnesota (1979-2002) showed that a temperature below 0 degrees Celsius (32 degrees Fahrenheit) was strongly associated with death due to a heart attack.<o:p></o:p></span></em></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><em><span style="color: #222222; font-style: normal;"> </span></em></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><em><span style="color: #222222; font-style: normal;">A lot has changed in the 25 to 30 years since this data was reported. At least two factors have changed significantly. First, heart attack care has vastly improved. Catheterization and coronary stenting during the acute event (especially STEMI) restores blood flow and subsequently fewer patients die from their heart attack. Secondly, there is global warming. Since the 1950’s each decade is hotter than the previous one. Globally, the temperature has risen 0.17 degrees Fahrenheit each decade, with steeper rise since the 1970’s. Has the combination of warmer weather and improvement in cardiac care reduced the risk for having a heart attack in winter? To answer this a group from Germany looked at temperature and heart attacks in two distinct periods, 1987 to 2000 and 2001 to 2014. During those time periods, the average daily maximum temperature rose from 14.5 degrees C (58.1 degrees F) during 1987-2000 to 15.1 degrees C (59.2 degrees F) in 2001-2014. They found no significant decline in cold related heart attacks when comparing the two eras. Heart attack risk remained high with very cold temperature. Another group studied data from five European countries between 1994 and 2010. They also found that cold weather was associated with an increased risk for heart attack, without change over time. With a drop in temperature from 5 degrees C (41 degrees F) to – 5 degrees C (23 degrees F) there is about 20% increased risk for heart attack and cardiac death. Lastly, a study from Taiwan looking at data from 2000 to 2017 showed that below 15 degrees C (59 degrees F), every 1 degree drop in temperature increased the risk for heart attack by 0.9%.<o:p></o:p></span></em></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><em><span style="color: #222222; font-style: normal;"> </span></em></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><em><span style="color: #222222; font-style: normal;">The relationship between cold weather and heart attack has been seen across the globe, in different eras, with different populations and with different weather conditions. It even holds up locally. Over the past five years, the month with the second highest risk for STEMI at Robert Wood Johnson Somerset has been January. How does cold affect the heart and who is at risk? Elderly patients (over 65 years old) are more susceptible to cold related heart attacks than younger people. The highest risk are older patients with hypertension (high blood pressure). Cold weather increases blood pressure and causes spasm of the heart arteries. This leads to an increase in the work load of the heart. Cold weather increases the thickness of the blood, increases clotting factors and increases inflammation. All of the factors can cause a vulnerable heart plaque to open and trigger a heart attack. The winter months also increase the risk for respiratory infections (for example, flu) which act as a trigger for a heart attack. Other cold related factors include less physical activity, weight gain and holiday stress adding to the risk for heart attack in the winter. <o:p></o:p></span></em></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><em><span style="color: #222222; font-style: normal;"> </span></em></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><em><span style="color: #222222; font-style: normal;">For the elderly heart patient, the cold weather can be as deadly as an asp. For those with significant heart disease, here are some cold weather recommendations. Skip strenuous activity outdoors when the temperature (or the wind chill) is below 30 degrees F and do your exercising indoors. When outside, try to cover all exposed skin. Make sure the heating system in the house is working and use it! The World Health Organization suggests keeping the indoor temperature above 68 degrees F. Lastly, relax with a cup of tea by the fire and count the days until spring. <o:p></o:p></span></em></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><em><span style="color: #222222; font-style: normal;"> </span></em></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><em><span style="color: #222222; font-style: normal;"> </span></em></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><em><span style="color: #222222; font-style: normal;"> </span></em></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><em><span style="color: #222222; font-style: normal;"> </span></em></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-38622127405202371882024-01-09T15:29:00.000-08:002024-01-09T15:29:35.536-08:00Vive La Resistance (Training)!<p style="text-align: center;"> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHVpyZgbZRYNssmWEM_PyEjB_0KWbo7VGacyfycUdfHiPmTm_dkimV5ihz3XNrbLR3BdKGeVIRLCIp86SjfamCXvEuagNqAemWOSQOqV5wM_8wL7uBDrecTnOQJMsEth9JqsZl07UFdj7KlzyLn_A-VE53ANCF1fs3C6PfET6eAztYUYZ2oDIhaYlHifg/s4032/IMG_4850.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="3024" data-original-width="4032" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHVpyZgbZRYNssmWEM_PyEjB_0KWbo7VGacyfycUdfHiPmTm_dkimV5ihz3XNrbLR3BdKGeVIRLCIp86SjfamCXvEuagNqAemWOSQOqV5wM_8wL7uBDrecTnOQJMsEth9JqsZl07UFdj7KlzyLn_A-VE53ANCF1fs3C6PfET6eAztYUYZ2oDIhaYlHifg/s320/IMG_4850.jpg" width="320" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><br /></div><p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;">The holidays are over. It’s a new year. The decorations are stored away and the New Year’s resolutions are made. What are the top New Year’s resolutions? According to Forbes magazine, the number one New Year’s resolution for 2024 is to improve fitness and exercise more. That is a worthy goal, but what type of exercise should be targeted in 2024? Another top resolution per Forbes is to lose weight. That is also a good goal, but how long will it take to get the holiday weight off?<o:p></o:p></p><div class="separator" style="clear: both; text-align: center;"><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;">If you are feeling bloated and have gained weight during this holiday season, you are not alone. A study tracked the change in weight for participants in three countries, the US, Germany and Japan. In these three diverse countries, weight started to go up in November and peaked on New Year’s Day. On average, it took until March to lose the weight gained and get back to the pre-holiday weight. How can holiday weight gain be prevented? One strategy is to have smaller meal portions at the family table and eat fewer desserts. Another is to exercise. It has been shown that people who continue exercise training during the holidays can prevent weight gain.<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;">It is established that exercise will help with losing weight. It is established that exercising more is the top New Year’s resolution, but what kind of exercising should be done? Aerobic training has well known benefits. The scientific evidence is vast and consistent in showing that cardio exercise (such as running, cycling, swimming or hiking) has many cardiovascular benefits, in addition to increasing longevity. Therefore, aerobic exercise should be a main component of any exercise regimen. What about resistance training? It has been perceived that aerobic exercise is better than resistance training but in fact each is important. It has been estimated that only 28% of US adults perform any form of resistance exercise. Resistance training lowers the risk of dying from any cause by 15% and lowers the risk for cardiovascular disease and death by 17%. Resistance exercise will lower systolic blood pressure by 4 mmHg and diastolic blood pressure by 2 mmHg. It will lower fasting blood sugar by 2 to 5 mg/dl, increase HDL cholesterol (2 to 12 mg/dl), lower total cholesterol (by 8 mg/dl) and reduce triglycerides (7 to 13 mg/dl). Combining resistance and aerobic training gives even greater benefit in terms of weight reduction, diabetes prevention, cholesterol lowering, cardiovascular disease prevention and mortality reduction. <o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;">In addition to cardiovascular prevention, resistance training has another very important benefit. As we age, there is progressive decrease in muscle mass and strength. With age, activities such as standing up, sitting down, climbing stairs and maintaining balance are as important as cardiac fitness. Most of the loss of muscle mass occurs after age 60. Men will lose, on average, 33% of their muscle mass between the ages of 60 and 97. Women will lose 26%. With the loss of muscle mass and strength, significant health problems may ensue as the risk for falls increases by 60% and risk of bone fracture increases by 84%. Resistance training helps to build and maintain muscle strength. Resistance training improves muscle mass (by increasing leg and total body musculature) and muscle strength (by improving handgrip strength, chest and leg press) as well as overall physical performance (by improving sitting to standing, walking speed). <o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;">What does a resistance training prescription look like? Resistance training can include free weights, body weight (for example push-ups, squats), machine weights or resistance bands. Resistance training doesn’t necessarily lead to “bulking up” and can be done without great expense (a gym membership or a major set of weights aren’t needed). Ideally 8 to 10 different exercises involving major muscle groups are done (for example, push-up, squat, abdominal crunch, biceps curl). Each exercise is performed for 8 to 12 repetitions. Weight and intensity can be increased gradually over time. Resistance training should be done two or more times per week for maximal muscle strengthening and cardiovascular benefit. <o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;">As we get older, we are limited by our heart and/or our orthopedics. Resistance exercise helps with both. So this year resolve to pump up your fitness, build some muscle, lose weight and improve your cardiovascular profile by incorporating resistance training into your exercise routine. <o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;"><o:p> </o:p></p></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-56923094633406303422023-12-12T15:27:00.000-08:002023-12-12T15:27:28.926-08:00Jolly Old Visceral Fat<p style="text-align: center;"> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhG5csh-2_wLDp8mCvQfm2mKIEjwrmW-lPBzFcTfUUrBoCeoYTlGfgH9my_qSJx0Xydz-TWsxfRPIC_aMRKtRIPQSuCngYwQqksbj4T8AcyCFwLHABRyCdgMdasJn_2JSAPBIuYMLk8EWq3O42sxHyVuMGTAScUileBA2DEjspu2WfV5fbhSUOcEe3zEwQ/s998/merry_old_santa_claus_by_thomas_nast.jpg.webp" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="998" data-original-width="800" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhG5csh-2_wLDp8mCvQfm2mKIEjwrmW-lPBzFcTfUUrBoCeoYTlGfgH9my_qSJx0Xydz-TWsxfRPIC_aMRKtRIPQSuCngYwQqksbj4T8AcyCFwLHABRyCdgMdasJn_2JSAPBIuYMLk8EWq3O42sxHyVuMGTAScUileBA2DEjspu2WfV5fbhSUOcEe3zEwQ/s320/merry_old_santa_claus_by_thomas_nast.jpg.webp" width="257" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;">It is holiday season and no single figure dominates this time of year like Santa Claus. The figure of Santa Claus is likely based on a combination of ancient legends including St Nicholas (a Greek saint known for his gift giving), Father Christmas (England) and Sinterklaas (a Dutch legend). The name “Santa Claus” was first used in the US press in 1773. The caricature of Santa Claus as a jolly, rotund, white bearded, red suit wearing elf was first defined by Thomas Nast (a famous political cartoonist who lived in Morristown New Jersey) in an illustration for Harper’s Weekly in 1863. How rotund is Santa? According to NORAD (the North American Aerospace Defense Command), who tracks Santa’s course across the world on Christmas Eve, Santa is 5 feet 7 inches tall and weighs about 260 pounds. This would put Santa’s Body Mass Index (BMI) at 40.72 kg/m2 which places him squarely in the obese category. How does Santa’s obesity, his round belly and visceral fat affect his risk for heart disease? Should we be worried about Santa?<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;">It is estimated that 42% of the adults in the United States are obese. Being overweight (BMI 25-29 kg/m2) or obese (BMI >30 kg/m2) increases the risk for cardiovascular disease and cardiovascular death. The BMI was invented in the 1830’s by a Belgian astronomer who was trying to categorize different types of people. The mathematical formula for BMI relies on only two variables, height and weight. Since its inception, the BMI (and similar calculations) have been used by insurance companies to calculate the risk of dying. Since 1972, the BMI has been used to define obesity, even though it is not a perfect measure. Amongst its flaws, it cannot distinguish between fat and muscle. Consider a 6-foot 9-inch 250-pound man. His BMI is 26.8 kg/m2 putting him in the overweight category. However, if this man is a muscular perennial NBA All Star, then no one would consider him overweight. His higher BMI is due to muscle, not fat. Another flaw is that the BMI cannot distinguish between subcutaneous fat (fat deposited under the skin; think “pinch an inch” or those love handles that have popped up over the years) and visceral fat. Visceral fat is fat deposited in and around the organs in the abdomen and chest. Visceral fat poses many more health risks than subcutaneous fat. Visceral fat interferes with blood sugar regulation and lipid storage, leading to diabetes, elevated triglycerides, high blood pressure and subsequent heart disease. Waist circumference may be a better measure of visceral fat than BMI. Obesity is defined by a waist circumference >40 inches in men and > 35 inches in women. An elevated waist circumference is associated with heart artery disease and increased risk for cardiac death. Body fat percentage is an even better indicator of obesity than body weight or BMI. Body fat percentage greater than 30% in men and 35% in women is considered obese (the acceptable range is 20-29%).<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;">The heart is considered a visceral organ and thus prone to fat accumulation. Normally fat is present in two areas in the heart. Epicardial fat is present between the heart muscle and the pericardium (the sac that encompasses the heart). Epicardial fat provides a layer of fat on the heart muscle and around the heart arteries. It has beneficial effects both anatomically and functionally. It acts as a buffer and provides mechanical protection for the heart arteries. Epicardial fat also secretes a variety of active substances and since it is in close proximity to the heart arteries these substances help in the regulation of the internal environment of the arteries. These fat depots also store fatty acids and act as an energy supplier for the heart. During times of high demand, the fatty acids are released into the heart muscle. Unfortunately, excess epicardial fat increases inflammation which in turn promotes and worsens blockage in the heart arteries and increases the risk for atrial fibrillation. Pericardial fat is the second type of fat seen in the heart and is located between the two layers of the pericardium (the pericardium surrounds the heart and the visceral layer is adjacent to the heart muscle while the parietal pericardium faces outside the heart). Like epicardial fat, pericardial fat provides mechanical protection for the heart and helps keep the heart contracting smoothly and friction free (you could say the heart is a well-greased machine!). Also, like epicardial fat, an excess of pericardial fat is detrimental. Excess pericardial fat is associated with congestive heart failure. Both types of fat can be detected and quantified by cardiac CT or MRI scan. CT scan for coronary calcium also provides the opportunity to look for excess epicardial and/or pericardial fat.<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;">After Santa has given out all of his gifts on Christmas Eve (and eaten a billion cookies in the process), how should we treat Santa’s obesity and visceral fat? Obesity management involves 5 interventions: behavioral changes, nutrition, physical activity, medications and surgery. Lifestyle modifications can produce 5% to 10% weight loss. Newer medications have been quite effective in reducing weight. Semaglutide (Ozempic) can reduce weight by 10-15% while tirzepatide (Mounjaro) can result in 15-20% weight loss. On average, surgical procedures reduce weight by 20-30%, but even greater reductions can occur. Do these weight loss strategies reduce cardiac outcomes and cardiac fat? Surgery reduces the risk for dying from any cause by 37%, heart failure by 54% and heart attack by 37%. Semaglutide has recently been shown to improve cardiac outcomes by 20%, especially in the those with established cardiac disease or diabetes. Lastly weight loss by lifestyle modification or surgery reduces epicardial fat thickness by 9% to 32%.<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;">So, this year instead of leaving Santa milk and cookies on Christmas Eve, perhaps a plate of vegetables and a prescription for Ozempic would be better for his health.<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><o:p> </o:p></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-14644123856356902472023-11-07T15:55:00.000-08:002023-11-07T15:55:07.379-08:00The Trouble With Triglycerides<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2felKR1KR-OMpTjUlOGuLTSEOgyGyiKwxh2JvaRJ0LeGORtWK8n7PaIO_KXa_Ag_wN8hYBySRdjXnWYCINhyj2sp7criPl95-ArFQpInzlObaMs-uG_rgHzxJqdh3QnzpEDoOQakB1F70xf7rPLf7HGLswlNmvlrSRULUsLFt4RqOOLqDcZSxG2DQwIE/s4032/IMG_4790.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="3024" data-original-width="4032" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2felKR1KR-OMpTjUlOGuLTSEOgyGyiKwxh2JvaRJ0LeGORtWK8n7PaIO_KXa_Ag_wN8hYBySRdjXnWYCINhyj2sp7criPl95-ArFQpInzlObaMs-uG_rgHzxJqdh3QnzpEDoOQakB1F70xf7rPLf7HGLswlNmvlrSRULUsLFt4RqOOLqDcZSxG2DQwIE/s320/IMG_4790.jpg" width="320" /></a></div><p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;">In the classic Star Trek episode, “The Trouble with Tribbles”, the crew find themselves on an alien planet. A trader gives a tribble to one of the officers, who brings it on board the Enterprise. The tribbles are purring balls of fluff that ease human anxieties. They are instantly loved by the crew. Unfortunately, the tribbles reproduce rapidly, taking over all of the space on the ship and eating all of the food on board. Because the tribbles are killing their hosts, they have to be removed.<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;">Triglycerides transport the fat that we eat to the cells in the body to use for energy. Unlike tribbles, triglycerides are not cute and fuzzy, although high levels of triglycerides make the blood look milky and cloudy. Also, like tribbles, as triglycerides accumulate (the blood level goes up) it can kill its host (the risk for heart disease goes up). Elevated levels of triglycerides are either primary (genetic, running in families) or secondary to other medical conditions or lifestyle choices. Secondary causes include type 2 diabetes, thyroid disease, or fatty liver disease. Lifestyle factors include obesity, being sedentary, smoking, alcohol use, or a diet high in saturated fats or processed sugars. Hypertriglyceridemia is defined as blood levels above 150 mg/dl. World-wide more than 25% of people have high triglycerides. High triglyceride levels have been strongly and significantly associated with elevated cardiovascular risk, independent of LDL (“bad cholesterol”) levels. People can have normal or low LDL values, but if their triglycerides are high, they are still at risk for a heart attack. In addition, a very high level of triglycerides is a risk factor for pancreatitis (a potentially life-threatening inflammation of the pancreas). The trouble with triglycerides is how to treat them or whether to treat them at all.<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;">The first step in treating elevated triglycerides is lifestyle modification. This starts with reducing excess weight, alcohol intake and dietary carbohydrates. Additional measures include exercise, smoking cessation and diabetes control. Together, these interventions can lower triglycerides by 60%. Medications for high triglycerides include statins, fibrates and omega-3 fatty acids. Certain statins (for example, atorvastatin) lower triglycerides as well as LDL cholesterol and should always be the initial agent chosen. Atorvastatin (Lipitor) reduces triglycerides by about 25%. Fibrates (such as fenofibrate) have the highest potency in reducing triglycerides. However, despite lowering triglycerides by 30-50%, fenofibrates have not been shown to reduce the risk of cardiac events. There are three omega-3 fatty acid formulations in clinical use. These are: eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and icosapent ethyl (IPE, a highly purified form of EPA). EPA is found in plants and fish. Medications with high dose EPA reduce triglycerides by 14-33%. One study showed that EPA reduced cardiac events by 19%. Another study looked at IPE in patients with heart disease or diabetes on a statin. High dose IPE reduced cardiac events by 25%. However, triglycerides were only modestly reduced in the study and it was felt that other factors improved the outcomes (possibly anti-inflammation or anti-oxidant effects of IPE). On the other hand, a large review of multiple trials did not show a reduction in cardiac events with omega-3 fatty acid therapy. In addition, a study of EPA and DHA did not show a reduction in outcomes. The reason for this discrepancy is currently being hotly debated in the cardiology community. <o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><o:p> </o:p> </p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;">It is well established that higher triglyceride levels are associated with higher cardiac events. However, while there is strong evidence for lowering LDL (the current principle is lower is better) to reduce cardiac risk, the data regarding triglyceride treatment is less conclusive. So, what should we do about high triglycerides? Should we ignore them and not treat them since there is no therapy that unequivocally reduces outcomes? Should we treat them with our current agents and hope that future research proves these therapeutics useful? Should we beam up to the Enterprise and find a new planet? Right now, there is no definite answer, but a few recommendations can be made. The first and strongest recommendation is to start atorvastatin (Lipitor) in patients with established heart artery disease or high risk for heart artery disease (for example diabetics) and elevated LDL and triglyceride levels. A second recommendation can be made for the high-risk patient (as defined above) who has triglyceride levels above 150 mg/dl and whose LDL is at goal with a statin. This type of patient should be started on high dose IPE. Lastly, patients with triglyceride levels over 300 mg/dl should start fenofibrate to reduce the risk for pancreatitis. What about the lack of data? Never fear, the science officers are combing the galaxy, doing the research, trying to find an answer to the triglyceride question. Stay tuned.<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;"><o:p> </o:p></p>Unknownnoreply@blogger.com2tag:blogger.com,1999:blog-6619506163557319420.post-4693109630229921142023-10-10T16:20:00.000-07:002023-10-10T16:20:20.834-07:00My Watch Says I Am in Atrial Fibrillation. What Should I do?<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcXGK0BL8LmbRSbGW7qom1oluUYPftcoh0iK2qUjh8cUywSQmYT6PhvKbrmUwxp9O7CMU8nJSwm0RKIlWn36H_dn8FzJtCZnh7xHMGBMicsQQMvGfDPw-47az13p9TaaMqp37MwdYGNUDntJ59vzTIk-BWMfK5Kxht4ySwgZLcukvJjlcEYPiGlpHwlPY/s4032/IMG_4774.HEIC" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcXGK0BL8LmbRSbGW7qom1oluUYPftcoh0iK2qUjh8cUywSQmYT6PhvKbrmUwxp9O7CMU8nJSwm0RKIlWn36H_dn8FzJtCZnh7xHMGBMicsQQMvGfDPw-47az13p9TaaMqp37MwdYGNUDntJ59vzTIk-BWMfK5Kxht4ySwgZLcukvJjlcEYPiGlpHwlPY/s320/IMG_4774.HEIC" width="240" /></a></div><p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in;">Recently there has been an explosion in consumer wearable smart devices. It is estimated that 1.1 billion devices were in use worldwide in 2022. These devices can detect and monitor a variety of health-related parameters including heart rate and arrhythmias (abnormal heart rhythms). Devices include smartwatches worn on the wrist, fitness bands with chest strap, and a stand-alone handheld single lead electrocardiogram (EKG) monitor. Smart devices can monitor heart rate and determine if there is an arrhythmia using two methods. The first method is photoplethysmography (PPG). The second way is to obtain an actual EKG strip, either a single lead or multiple leads, using electrotrodes as would be done with an EKG in a doctor’s office. PPG works by sending light pulses to the skin. The intensity and pulsatility of light reflected from the blood vessels can determine heart rate and algorithms can provide an estimate of whether there is an arrhythmia. Smartwatches such as Apple Watch (series 4 or later) and Samsung Galaxy Watch 3 utilize both PPG and EKG. PPG is used for routine monitoring, but the user can be prompted to obtain a single lead EKG by holding the crown of the watch for 30 seconds. The KardiaMobile device is connected to a phone but is a stand-alone monitor. It has two pads and the user places a finger on each pad to record a single lead EKG. Smartwatches using PPG can accurately detect heart rate, but accuracy drops off with activity. One study showed a 30% reduction in accuracy during exercise. For a more accurate determination of heart rate with exercise, a chest strap using PPG can be used. Patients often see their doctor for advice about arrhythmias that are detected on their smart devices. How accurate are the readings? What should one do if the device says there is atrial fibrillation (Afib)?<o:p></o:p></p><div class="separator" style="clear: both; text-align: center;"><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;">Before diving into wearable devices and Afib, a few words about Afib itself. Afib is a very common arrhythmia. In this condition, the upper chambers of the heart (the atria) fibrillate, beat chaotically, not in a regular coordinated manner. When the atria fibrillate, blood doesn’t flow into the lower heart chambers (the ventricles) efficiently and blood can stagnate in the atria. If blood is not flowing it can form clots. These clots break off and can cause a stroke. To treat this and prevent a second stroke in someone who already has had a stroke, blood thinners are prescribed. How important is the Afib/stroke connection? In a patient with a stroke, or a “mini-stroke” (TIA), a cause for the stroke cannot be found in 30%. This is called cryptogenic stroke, a stroke of unknown origin. It turns out that Afib is a major cause of cryptogenic stroke. If a patient is hospitalized with a stroke and a cause cannot be found, they often are prescribed a monitor to wear for one month to see if they have Afib. If Afib is found, they are prescribed a blood thinner. The use of blood thinners in Afib is quite effective, but comes at a cost. These medications can cause bleeding. In a patient with Afib, who should be placed on a blood thinner? The answer is not easy and there is lots we know, and still lots we don’t know. Some Afib patients are straightforward and should be on blood thinners. These include patients who are known to be in Afib for 48 hours of more. Also, patients with Afib and a history of stroke or mini-stroke should be on one of these agents. Patients with Afib who haven’t had a stroke but who are at high risk for a stroke (older patients, women, diabetics, heart failure patients, hypertensives, and patients with vascular disease) should be on a blood thinner. If a patient is not in one of these categories, how much Afib is needed before committing them to a blood thinner: an hour of Afib? several hours of Afib? a day of Afib? Unfortunately, we don’t yet know that answer, but a recent study did shed some light. The study looked at pacemaker patients without prior history of Afib. A pacemaker can be interrogated and can tell precisely how long a patient has an arrhythmia such as Afib. The study looked at pacemaker patients who had short duration episodes of Afib; the average time in Afib was about three hours. Patients who were given a blood thinner did not have fewer strokes than patients who were not on a blood thinner. In fact giving the blood thinner caused harm, more patients had bleeding. So, putting patients on a blood thinner for short duration episodes of Afib does not prevent strokes and may be causing harm. We still do not know the burden of Afib necessary to start treating to prevent a stroke. <o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;">How accurate are smartwatches and KardiaMobile devices in detecting Afib? More and more studies are being performed to check the validity of these devices. One study found that Apple Watch and Samsung Galaxy Watch were 80% accurate in picking out Afib, while KardiaMobile was 74% accurate. One issue with the devices was the high number of inconclusive tracings: Apple 18%, Galaxy 17%, KardiaMobile 26%. Another study of KardiaMobile also showed 74% accuracy and 16% of tracings could not be classified. The bottom line is that these devices are readily available, not very expensive (KardiaMobile is less than $100), reasonably accurate and the technology will only continue to improve. <o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;">So, what should you do if your smartwatch tells you that you are in Afib? First, realize that these devices should only be used as a screening tool. See your doctor, bring your phone or tracings for your doctor to review. Afib should be confirmed with medical grade devices such as a Holter monitor (worn for one to three days) or an event monitor (worn for two to four weeks) or an implantable recorder (used for months to years). Next discuss with your doctor whether you should be on a blood thinner, remembering that short duration episodes of Afib likely don’t need to be treated. However, if you have had a stroke, or mini-stroke (TIA) especially if cryptogenic, then starting a blood thinner may be appropriate. Even if the detection of Afib by your smart device doesn’t lead to a blood thinner, it can make a difference in your treatment plan. Medications may be changed to try to avoid Afib. In addition, triggers for Afib can be discussed and corrected (treating high blood pressure or sleep apnea, decreasing or eliminating alcohol, starting an exercise program or weight loss). Listen to your body and watch your watch.<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri, sans-serif; margin: 0in; text-align: start;"><o:p> </o:p></p></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-61858678857436046102023-09-05T15:38:00.001-07:002023-09-05T15:44:43.430-07:00Deconditioning and the Flabby Heart<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhGbDIz_IXfDtV9x2jxmuLpA5-PaZzeZrhJwiX2e_XJu56I-UPGKCqeCXyTuj5_pdpJ8alvv5yrGTo_sX4Y_X9SpG1wPwDFGawSAKEq8tjfYbGSL44HutMM7ux_sMw5WRexFaaOMs2USjsWTgSS429Y1OXacWwN1rm4C_eSvsEInP1rpEsowjDatelm15s/s4032/IMG_4738.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhGbDIz_IXfDtV9x2jxmuLpA5-PaZzeZrhJwiX2e_XJu56I-UPGKCqeCXyTuj5_pdpJ8alvv5yrGTo_sX4Y_X9SpG1wPwDFGawSAKEq8tjfYbGSL44HutMM7ux_sMw5WRexFaaOMs2USjsWTgSS429Y1OXacWwN1rm4C_eSvsEInP1rpEsowjDatelm15s/s320/IMG_4738.jpg" width="240" /></a></div><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">You know the feeling. Every weekend warrior knows the feeling. You spend time building up your exercise capacity by biking, running, swimming, hiking, or going to the gym. Then for some reason (illness, injury, other obligations) you have to stop exercising for weeks or months. When you return to your activity, you are more short of breath, you don’t have the same exercise capacity, and you feel “out of shape”. What happens to the heart during deconditioning (the medical term for “out of shape”)? Does deconditioning occur with elite athletes or astronauts? Does it happen on weekdays to weekend warriors?<o:p></o:p></p><div class="separator" style="clear: both; text-align: center;"><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;">The heart is a muscle. With training athletes can build up their arm and leg muscles. The same process builds up the heart muscle as well. The cardiac effects of long-term exercise include increases in the size of the heart, the thickness of the heart’s muscle and the cardiac mass. (The heart enlarges to accommodate the increased blood flow during exercise. The walls of the main pumping chamber, the left ventricle, thicken and become more muscular to pump the excess blood. Cardiac mass is the weight of the heart and represents the long-term effective of blood pressure on the heart). A larger, thick walled heart is called an athlete’s heart. Unfortunately, a thick muscular athlete’s heart resembles a form of cardiac pathology, hypertrophic cardiomyopathy (a congenital abnormality where the heart muscle is very thick and there is a risk for arrhythmia). Congenital hypertrophic cardiomyopathy is the most common reason for sudden cardiac arrest in the athlete. Athletes are screened to see if they have hypertrophic cardiomyopathy and, if present, vigorous exercise is prohibited. Unfortunately, it is difficult to differentiate between pathologic hypertrophic cardiomyopathy and an athlete’s heart. One way to tell the difference is to have the athlete stop exercising for a period of time, a method called detraining. If the heart muscle reverts to normal thickness during detraining, then it is an athlete’s heart. Studies on Olympic athletes have shown that after about 12 weeks of detraining left ventricular thickness rapidly decreases (thickness goes down by 15-33%). In addition, cardiac mass decreases quickly as well, within 4 to 8 weeks. For full regression of left ventricular thickening, detraining should last 6 months.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;">The healthy heart needs exercise, but it also needs gravity. Both of those items are in short supply to astronauts on a long-term space mission. The lack of gravity has the same effect as prolonged bed rest on the heart, worsening the deconditioning that takes place in space. Studies performed on astronauts who spend months in space show that space flight causes significant cardiac atrophy. After only a few weeks in space, there is a reduction in the heart’s muscle mass. It is estimated that cardiac muscle mass decreases about 1% per week in flight. This deconditioning has obvious consequences for prolonged space missions. A recent study followed astronauts on the International Space Station. The astronauts were in flight for many months and spent 2 hours each day doing endurance and resistance training. Cardiac work load was 12% lower in space than on Earth due to zero gravity and the confines of the station. Despite the lower work load, the astronauts’ heart muscle mass stayed intact. It seems that exercise can preserve the heart’s structure and function offsetting space flight deconditioning. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;">Most people don’t have to worry about their heart becoming too thick from exercise or losing cardiac muscle mass on a space flight. However, deconditioning occurs in the average person, with changes similar to the detrained athlete or the astronaut in space. Deconditioning is defined as the adaptation of the body to a less strenuous environment and the decreased ability to function with physical exertion. The body resets to a lower level of functioning so that when it is asked to increase physical activity, it is unable to meet the demand. Deconditioning occurs when people stop exercising; the most extreme example is bed rest. Many studies of patients during bed rest show that skeletal muscle strength is lost rapidly (10-20% in a week, 50% in 3 to 5 weeks). Skeletal muscle mass also decreases 3% within a week of bed rest. In addition, bone density decreases as well. From the cardiovascular standpoint, blood volume goes down and heart rate goes up with bed rest. This means that the body cannot compensate when going from a supine to a standing position; blood pressure drops on standing and patients can pass out. Lastly, bed rest causes cardiac atrophy. With 2 weeks of bed rest, there is a reduction in cardiac muscle mass of 5%, similar to what happens with astronauts in space and the detrained athlete.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;">Can the “weekend warrior”, someone who only exercises one or two days per week, become deconditioned during the work week? Likely this is not the case as loss of cardiac structure and function occurs after weeks to months of inactivity. In fact, a recent study showed that as long as weekend warriors exercised for 150 minutes per week or more, they had similar reductions in their risk for heart attack, stroke, atrial fibrillation and heart failure as people who exercise daily. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;">You worked hard to build up your exercise capacity. Don’t stop now and let your heart become flabby and deconditioned. Keep active and keep exercising a minimum of 150 minutes per week, even if it is only two days a week.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><o:p> </o:p></p></div><p><br /></p>Unknownnoreply@blogger.com1tag:blogger.com,1999:blog-6619506163557319420.post-26238580646294992912023-08-08T16:06:00.001-07:002023-08-08T16:06:52.886-07:00The Café Coffee Culture and Cardiac Disease<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPL44eDfv-M7W47vkjBuSekp-Snt1hDvbzELqJ4vod8Zv20fzLuzasmP5S18_GYkm612b6x_CjuEuCMclDzMJLzkKQiJZYKR_jFoMiLOfBpuo_j10f_rnAQO690RsxxqHbYFfxhvCbDXIn3wBgo2nOnv4dCg1k6KEjFu0vRCKXo8VeoqMP7aruot1Hc6Y/s1024/thumb_IMG_4612_1024.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1024" data-original-width="768" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPL44eDfv-M7W47vkjBuSekp-Snt1hDvbzELqJ4vod8Zv20fzLuzasmP5S18_GYkm612b6x_CjuEuCMclDzMJLzkKQiJZYKR_jFoMiLOfBpuo_j10f_rnAQO690RsxxqHbYFfxhvCbDXIn3wBgo2nOnv4dCg1k6KEjFu0vRCKXo8VeoqMP7aruot1Hc6Y/s320/thumb_IMG_4612_1024.jpg" width="240" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Imagine yourself walking down a street in a French town. You spot a picturesque café in the square, perhaps one that had been painted by Van Gogh. People are in the café, relaxed, sipping their coffees. It looks so inviting. You want to join them and order a nice café Americano, but you wonder how good is coffee for the heart? <o:p></o:p></p><div class="separator" style="clear: both;"><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #333333;">Before we drip into the medical data, some fun facts about coffee. </span><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">Coffee grows on a bush and the beans are actually the pit of a berry, which makes coffee a fruit. Coffee has been consumed for about 500 years. </span><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #333333;">In the US, about 85% of adults drink coffee daily, averaging 1.5 standard cups per day. </span><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">Brazil is the largest exporter of coffee in the world and Finland is the worldwide leader in coffee consumption.</span><span style="font-family: Times; font-size: 10pt;"></span><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">Now let’s pour over the physiological effects of coffee. </span>Coffee is not just caffeine; the beans have over 100 active substances which have a variety of metabolic effects. <span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">Drinking coffee causes </span>the heart rate and blood pressure to increase. Effective sleep may be suppressed. Caffeine increases catecholamines (adrenaline). Coffee stimulates the electrical system of the heart. For these reasons, many cardiologists recommend decreasing or stopping caffeine use. Is that recommendation justified?<span style="color: #222222; font-family: Arial; font-size: 10pt;"><o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Does coffee cause heart arrhythmias?<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Doctors have always felt that coffee may increase the number of premature atrial contractions (PACS) and premature ventricular contractions (PVCs). Increased PACS may result in atrial fibrillation (Afib) while increased PVCS may cause ventricular arrhythmias. A recent study in healthy volunteers showed that coffee did not increase the number of daily PACs, but may increase PVCs. The accumulated medical literature has shown that coffee drinkers have a lower risk for Afib than those who do not drink coffee. Drinking one cup per day lowers the risk for Afib by 20%. The reason for this may be that long-term coffee drinkers develop a tolerance to the electrical stimulating effects of caffeine. However, there is a lot of individual variation in terms of response to coffee. Approximately 25% of patients report coffee as a trigger for Afib. Clearly those patients should avoid it. Similarly, the literature does not show an increase in ventricular arrhythmias with coffee consumption, despite a possible increase in PVCs. This holds true even for patients with history of significant ventricular arrhythmias. It appears that drinking coffee is safe for most patients in terms of their potential for arrhythmia.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Is it the caffeine?<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Coffee is the most commonly used stimulant in the world. Coffee activates the central nervous system, boosts alertness and has a variety of psychoactive effects. Are these effects due solely to caffeine? In an interesting study people were given coffee or plain caffeine in water and then underwent MRI scans of the brain. The coffee drinkers had a heightened state of preparedness, were more responsive and had higher executive brain functioning than the plain caffeine group. It appears there is more to coffee than just caffeine. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Does coffee raise blood pressure?<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">The effect of coffee on blood pressure is still not decided. Drinking a cup of coffee will transiently increase blood pressure for about 30 minutes. Coffee stimulates catecholamines and stimulates receptors in the blood vessels to constrict, causing an increase in blood pressure. However, this is counterbalanced by an increase in nitric oxide, which dilates blood vessels. Over time, the acute effect of a blood pressure bump with each cup is blunted in regular coffee drinkers. In fact, regular consumption of coffee is associated with lower overall blood pressure readings compared to nondrinkers. It appears that coffee doesn’t cause hypertension.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">What are the other metabolic effects of coffee?<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Coffee has both good and bad effects. Regular coffee drinking lowers body fat and reduces the risk for obesity. In addition, coffee lowers the risk for type 2 diabetes. On the other hand, coffee may increase cholesterol levels. The effect depends on the type of coffee, the degree of roasting and the type of brewing. Boiled, unfiltered coffee (such as Turkish or Greek coffee, made by boiling water with coffee grounds in a pot) raises cholesterol more than filtered coffee. Other nonfiltered coffees, such as espresso, are significantly associated with raised serum cholesterol levels. Filtered coffee can raise cholesterol but not as significantly as unfiltered coffee. There is no increase in cholesterol with instant coffee. It appears that drinking filtered coffee is the safer than alternatives. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Does coffee reduce the risk for cardiac events?<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">In the literature, coffee drinkers have consistently had a lower risk for heart problems and death. A study from Europe in 2017 showed that drinking 2 to 4 cups of coffee per day reduced the risk of dying by 15%, reduced the risk of cardiac death by 17% and reduced the risk of dying from cancer by 4%. A more recent study confirms and expands these findings. The study followed 500,000 people for 10 years. In people <b>withou</b>t known heart disease, drinking 2 to 3 cups of coffee per day lowered the risk for heart artery disease, heart failure, stroke and dying from any cause. People <b>with</b>heart disease also showed improved survival and no increased risk for arrhythmias. The relationship held regardless of instant versus ground coffee, or decaf versus caffeinated coffee. The reason for these favorable benefits may be coffee’s metabolic effects (lower risk for obesity and diabetes), as well as coffee’s anti-inflammatory and anti-oxidant properties. In addition, coffee drinkers consistently do more physical activity than nondrinkers. It seems that 2 to 3 cups of coffee per day is the sweet spot, a level of consumption where coffee is not only safe, it may be cardioprotective.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">It can be concluded that coffee is not associated with high blood pressure, significantly elevated blood cholesterol (if the coffee is filtered) or dangerous arrhythmia. It is associated with a lower risk for obesity, type 2 diabetes, heart artery disease, stroke and death. So find yourself a nice little café. Order one or two cups of (filtered) coffee. Then sit and watch the world go by, guilt free.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="color: #222222;"> </span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="color: #222222;"> </span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="color: #222222;"> </span></p></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-83457386192380191262023-07-04T15:29:00.001-07:002023-07-04T15:29:54.697-07:00Personality Traits And Cardiovascular Disease<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjFCtCztn7g7G3fIK0iZoJqQrYivZ7iJChzsVpkgMYTevZ7pCx0_I5qkcKeSdFcFwwan10-acY6Q567csUJ29UeC0TCtKhco9l9zZqHFH7NaUrl9sr-ahbGWYiElATRnAKq8BFXykpIVt-Um7q-NVVkMyxdicVTWrf19jYHgeIMmB3jbetk6WoprNGnzMQ/s4032/IMG_4680.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjFCtCztn7g7G3fIK0iZoJqQrYivZ7iJChzsVpkgMYTevZ7pCx0_I5qkcKeSdFcFwwan10-acY6Q567csUJ29UeC0TCtKhco9l9zZqHFH7NaUrl9sr-ahbGWYiElATRnAKq8BFXykpIVt-Um7q-NVVkMyxdicVTWrf19jYHgeIMmB3jbetk6WoprNGnzMQ/s320/IMG_4680.jpg" width="240" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">One of the classic scenarios in psychological evaluations is to show a person a glass that is 50% filled with water. Is the glass half full or half empty? How the person answers that question can determine a lot about their psychological state and may show their risk for future heart disease. <o:p></o:p></p><div class="separator" style="clear: both;"><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">For years the face of heart disease was a man who was highly ambitious, competitive, aggressive, impatient, goal- directed and willing to take risks. The type A personality was originally described in the 1950's by two cardiologists. They went on to show that the type A person had higher levels of cholesterol and a higher risk for heart disease. In addition, they found that the opposite of the type A, a relaxed, easy going, laid-back person, a type B personality, had a lower risk for heart disease. These stereotypes have persisted to this day. More recent data found no significant link between type A personality and heart disease. However, two components of the type A personality, anger and hostility, are strongly associated with cardiac disease. Studies have shown that anger and hostility significantly increase the risk for cardiac events in healthy people as well as those with established heart disease. Anger causes excess catecholamine (adrenaline) release, an increase in heart rate and elevated blood pressure which can lead to angina and a heart attack. An outburst of anger is a well-established trigger for an acute heart attack. Chronic anger and hostility lead to the initiation and progression of blockages in the heart arteries, especially in young men. A new personality type was identified in 2000 and named type D (or “distressed”) personality. The type D personality has two components. The person exhibits negative emotions (anxiety, worry, neurotic) and social inhibition (can’t express emotions, thoughts or behaviors in a social situation). It is often associated with anger, hostility and social isolation as well. The type D personality is associated with cardiac disease including angina, heart attack and an increased risk for cardiac death<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;"><o:p> </o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">Neuroticism is another personality trait tied to adverse cardiac disease. Neurotic individuals have emotional instability, difficulty handing stressful situations and “fly off the handle” when under pressure. On the other hand, those with low neuroticism scores are more emotionally stable, calmer, even-tempered and less reactive to stress. Individuals with high neuroticism scores have more anxiety, moodiness, fear, anger, frustration, pessimism, and loneliness than those with lower scores. They often turn to maladaptive behaviors (substance abuse, alcohol). In addition, people with high neuroticism scores were more likely to develop atrial fibrillation and to be diagnosed at an earlier age then those with lower scores. <o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-size: 10pt;"> </span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">On the other hand, certain personality traits are cardioprotective. These include optimism, conscientiousness, openness to new experiences and curiosity. Optimism is defined as the expectation of good things in the future (while its opposite, pessimism, is expecting something bad to happen down the road). Individuals with high optimism scores have lower risk for angina, heart attack, stroke, cardiac death and all cause death. Why is this? Optimists and people with psychological well-being have favorable physiologic parameters including lower blood pressure, better cholesterol levels and less sympathetic activation (lower adrenaline levels). They smoke less, exercise more, eat better and have less tendency for obesity. In addition, optimists are more likely to seek help in difficult social situations. They have larger and stronger social networks for support. They act on medical advice more readily. Lastly, optimists can weather the harmful effects of stress due to their inner and outer support systems. Meanwhile, pessimism has been shown to increase the risk for cardiovascular mortality.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">So, when confronted with the question about that glass of water, don’t get angry. Don’t become hostile. Don’t get depressed if you can’t come up with an answer. Look for the positives, try to maintain an optimistic viewpoint and say that it is half full. Your heart will thank you.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-92151207598095607142023-05-30T17:51:00.000-07:002023-05-30T17:51:41.275-07:00When Anthropology Meets Cardiology<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_1rLseTDIk1HgfXnq-DZcnloQE7IXJilQSK4hUCKQV4oQoch4MtlEXOc94oNWZTfAsocZB8y5JgMAqk1j54T_Fd6dWuNK_vPtr-fWGqjnjLuvrQXldweZWQbUjArvfB_eCQq4hIEDg950iWVP57RPiujoavu5cnCQTnPTA0NVUjNaVqrw5hnECVHM/s3648/P7274022.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2736" data-original-width="3648" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_1rLseTDIk1HgfXnq-DZcnloQE7IXJilQSK4hUCKQV4oQoch4MtlEXOc94oNWZTfAsocZB8y5JgMAqk1j54T_Fd6dWuNK_vPtr-fWGqjnjLuvrQXldweZWQbUjArvfB_eCQq4hIEDg950iWVP57RPiujoavu5cnCQTnPTA0NVUjNaVqrw5hnECVHM/s320/P7274022.JPG" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">When Mount Vesuvius, a volcano near Naples Italy, erupted in 79 AD, it caught the townspeople of nearby Pompeii and Herculaneum by surprise. Many were able to escape, but many died instantly, buried by lava and volcanic ash. Due to the nature of their death, their bodies were well preserved. Recently, scientists were able to study the bodies of these early Mediterranean people and were able to determine what they ate. How does the ancient Mediterranean diet compare to the modern version? How can the study of ancient peoples give us insight regarding heart healthy diets in today’s world?<o:p></o:p></p><div class="separator" style="clear: both;"><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">The Mediterranean basin has been called the cradle of civilization. It stretches from the Nile to Rome and has housed advanced civilizations for thousands of years, including the Egyptian, Assyrian, Babylonian, Persian, Phoenician, Greek and Roman. The Mediterranean diet is linked to the fertile land of the region. It is more than a diet; it is a way of life and based on traditions linking the land to the preparation, cooking and enjoyment of the food. The key elements of the Mediterranean diet include oil (especially olive oil), whole grains, wine, vegetables, sheep and goat cheese, seafood and very little meat. Whole grains include bread, cereals, couscous, pasta, rice, corn, oats and barley. The description of the ancient Mediterranean diet comes mainly from written accounts. For example, texts describe the diet of the ancient Greek Olympic athletes starting around 700 BC. The diet was mostly vegetarian, consisting of barley porridge, cheese, fresh vegetables, lentils, beans, seafood, eggs and fresh fruit, mainly figs. Sweets were frowned upon. Initially meat was not a part of the athlete’s diet, but as time went on, meat was incorporated more and more. Fast forwarding to Pompeii and the modern day, we now have concrete proof of what Roman era Mediterranean people actually ate. Scientists have been able to test the bones of the people frozen in time by the eruption of Mt Vesuvius. Using bioarcheological approaches they determined that the people of Pompeii ate a lot of fish, more than is consumed with the modern Mediterranean diet. In addition, locally grown fruits and vegetables were eaten. The majority of their food energy came from seafood and cereals, although grain consumption was less than today’s diet. After the fall of Rome, the Mediterranean diet faded during the Middle Ages. It rose again from the ashes and poverty following World War II when meat was scarce and people turned once again to what could be grown locally. The cardiac benefits of the Mediterranean diet were first described in the 1950’s by Ancel Keys, a University of Minnesota researcher who discovered that people in poor towns in southern Italy were healthier than wealthy people in New York City. He conducted the Seven Countries Study and showed that the Mediterranean diet resulted in low levels of cholesterol in the blood as well as low levels of heart artery blockages. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Anthropological data has shown that pre-agricultural hunter-gatherer populations derived a majority of their energy from animal based foods such as meat, fish, birds and eggs. The keto and paleo diets were developed to mimic these eating patterns. These diets are very low in carbohydrates and high in saturated fat. It is generally believed that hunter-gatherers had low levels of heart disease. Is this true? A recent study performed CT scans on mummies from four regions, including ancient Egypt, Peru, southwest US, the Aleutian Islands and going back 4000 years. Atherosclerosis (calcified plaque in the wall of an artery) was found in 34% of the mummies and was found in all four regions. In addition, atherosclerosis was present in 60% of the hunter-gatherers. Atherosclerosis is felt to be a modern disease, but it is clearly present in our ancient ancestors, including hunter-gatherers. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Since atherosclerosis seems to be a fact of human existence, which diets help protect the most against atherosclerotic heart artery disease? In 2021 the American Heart Association outlined its requirements for a heart healthy diet and ranked popular diets on how well they met the criteria. The recommendations included consuming:<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Fruits and vegetables<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Whole grains (rather than refined grains)<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Plant based proteins (such as legumes and nuts)<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Fish and seafood<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Low-fat or fat-free dairy products<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Lean meat or poultry<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Plant oils (such as olive oil) <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Minimally processed foods<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Minimal added sugar <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Little or no salt<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Low amounts of alcohol<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">The dietary patterns that aligned the most with these criteria included Mediterranean, DASH (Dietary Approaches to Stop Hypertension), pescetarian vegetarian (excludes meat and poultry, includes fish), vegan and low fat. At the bottom of the list were the keto and paleo diets. Is there data, some meat, to back these rankings? One study reviewed all of the literature on seven diets. It found that the Mediterranean diet lowered all deaths, cardiac deaths, stroke and heart attacks. The low fat diet lowered all cause deaths and heart attacks. All of the other diets, including the very low fat Ornish and Pritikin diets, had little or no benefit. Studies on low carbohydrate, high fat “keto-like” diets have not been good. One study had 1220 people and followed them for 12 years. The keto-like diet patients had high levels of LDL cholesterol and were twice as likely to suffer from cardiac events. Another study of 370,000 people, followed for 23 years, found a higher mortality rate for those on a low carbohydrate diet compared to a low saturated fat diet. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Clearly no randomized controlled trials were done in ancient times to see if any of the diets conferred benefit from heart disease. This was due to a lack of scientific knowledge as well as the fact that our ancestors succumbed at early ages due to infectious disease, famine, the tip of the sword from an enemy or volcanic ash, well before heart disease became manifest. What is clear from the study of mummies is that high fat diets, keto or paleo, did not protect against atherosclerosis. In addition, our modern studies show that these diets are detrimental to heart health. Heart patients should avoid these types of diets. On the other hand, the Mediterranean diet is a sustainable, lifelong eating plan that continues to sit atop Agamemnon’s throne as the king of the heart healthy diets. The Mediterranean diet, along with DASH, vegetarian, vegan and low fat diets should continue as staples for the heart patient. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-3092682081998275902023-05-09T16:32:00.003-07:002023-05-09T16:32:42.384-07:00Can Congestive Heart Failure Be Cured By Walking With Friends?<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglsfqaD-LDqANjEUD1xFAUF7AXN4yAYEThDM3L3pnhqxBMZae5fLLcmQ28KslUQol2vn_V0L23k6Y3Z6McyK3JoEp2a1he0c5IvBLEG0tZ6KK6XyGk7RKLDMg5FM3B_rtRSprtw44yFW6K0sCr92E-OdpFpxg2jjmxEU_eIndhmwg6ounZkmjO_3Kg/s1087/thumb_DSC07346_1024.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1087" data-original-width="723" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglsfqaD-LDqANjEUD1xFAUF7AXN4yAYEThDM3L3pnhqxBMZae5fLLcmQ28KslUQol2vn_V0L23k6Y3Z6McyK3JoEp2a1he0c5IvBLEG0tZ6KK6XyGk7RKLDMg5FM3B_rtRSprtw44yFW6K0sCr92E-OdpFpxg2jjmxEU_eIndhmwg6ounZkmjO_3Kg/s320/thumb_DSC07346_1024.jpg" width="213" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Congestive heart failure (CHF) is the inability of the heart to pump blood to meet the requirements of the body. CHF is classified into two groups based on ejection fraction. Ejection fraction (EF) is the percentage of blood ejected by the heart with each heartbeat. Normal EF is greater than 55%. CHF with reduced EF includes patients with EF less than 40% while patients with CHF with preserved EF have EF greater than 50%. CHF is an enormous global problem affecting more than 60 million people worldwide. CHF is the number one reason for hospitalization in the US and associated with frequent hospitalization, high healthcare use and cost. Symptoms of CHF include shortness of breath, trouble breathing with exertion or laying flat in bed, severe exercise intolerance, easy fatigability, and swelling. In 2021, a universal definition of CHF stated that CHF is a clinical syndrome with symptoms caused by a structural heart problem plus either an elevation in the blood of natriuretic peptides or objective evidence of congestion (by physical examination or chest X-ray). Natriuretic peptides are released when the heart is stretched or stressed, as in CHF. There are two natriuretic peptides; BNP and pro-BNP. CHF is present when BNP is greater than 35pg/ml or pro-BNP is greater than 125 pg/ml.<o:p></o:p></p><div class="separator" style="clear: both;"><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">CHF with preserved EF affects half of all CHF patients. It affects women more than men and it is increasing in prevalence compared to CHF with reduced EF. CHF with preserved EF is associated with and may be caused by hypertension, obesity, diabetes, heart artery disease, sleep apnea, kidney dysfunction and advanced age. Treating CHF preserved EF is difficult and frequent hospitalizations often result. A recent guideline recommends SGLT2 inhibitors as first line therapy. These medications, Jardiance and Farxiga, relieve congestion and promote weight loss. In addition, diuretics such as furosemide (Lasix) and spironolactone help in the treatment of fluid overload. The next line of recommended medications include Entresto, valsartan or losartan. Beyond medication, what else can be done? Recent information postulates that CHF preserved EF is an exercise deficiency and a social isolation problem. Addressing those issues could go a long way to treating the disease.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><b>CHF preserved EF is a syndrome of exercise deficiency</b>.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">An intriguing article hypothesizes a spectrum of shortness of breath with exertion. At one end is the patient with CHF preserved EF. With exercise, such as climbing the stairs, there is insufficient cardiac output to meet the demands of the muscles, pressure goes up in the heart, and breathlessness ensues. The same series of events happens with an elite athlete. The difference is the workload; the CHF patient just walks up the stairs, the athlete has run 26 miles. The athlete has larger cardiac chambers, more heart muscle mass and a compliant heart that can handle high volumes and work loads. The patient with CHF preserved EF has a small, stiff, less compliant heart that cannot handle increased volumes with exertion. Normal aging results in a smaller heart size, higher filling pressures during exertion and a greater potential for CHF. Being sedentary over the course of a lifetime exacerbates the effects of aging. For adults who sit many hours each day the cumulative effects of a sedentary lifestyle plus the effects of aging plus other factors (for example, high blood pressure, smoking, diabetes) combine to cause CHF preserved EF. On the other hand, adults who have spent a lifetime exercising regularly can stave off the cardiac stiffness that occurs with age and can avoid CHF. Fortunately, for patients with CHF preserved EF the adverse cardiac effects can be reversed with physical training. For this reason, the American Heart Association recommends structured exercise for patients with CHF preserved EF. Structured exercise, or cardiac rehab, has been shown to reduce hospitalizations and reduce cardiac events. Not all those with CHF preserved EF fall into the category of exercise deficiency; it is reserved for the subset of patients with habitually low levels of physical exertion.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><b>CHF preserved EF is a syndrome of social isolation and loneliness</b>.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Social factors are a well-known contributor to heart disease. A recent study followed more than 400,000 people for more than 12 years to see if social isolation or loneliness were associated with CHF. Social isolation was defined as objectively being alone or having few social connections. Loneliness was defined as a painful feeling resulting from a desire for more social connections. Those with social isolation or loneliness were more likely to be men and to have unhealthy lifestyles (smoking, diabetes, obesity, physical inactivity). The study found that both social isolation and loneliness increased the risk for CHF by 15-20%. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">So, if you have CHF, or are at risk for CHF, grab a friend, talk a walk, eat, sleep, repeat.<o:p></o:p></p></div><p> </p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-59084242677258860282023-04-11T15:44:00.000-07:002023-04-11T15:44:45.224-07:00The Taxing Pain Of Statin Intolerance<p> </p><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhj10Mzb3aVKpxMEJty4lceNiqVTiqnYPpLeMTjmcH62HAjNsGjy8BUTKfjiUwOaeu5m_AmAT-43DzXXW2G87jOG3VB7lGIflT3bUSvN6HWQ-IUE3xQxt70v0u6eOw2gUOC6Dr2fIHOBDU5Fe43NHyhrUXRRhB00PKOza0QYFHiu85NHK5bfkFkyM61/s1571/f1040_Page_1-cropped.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="594" data-original-width="1571" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhj10Mzb3aVKpxMEJty4lceNiqVTiqnYPpLeMTjmcH62HAjNsGjy8BUTKfjiUwOaeu5m_AmAT-43DzXXW2G87jOG3VB7lGIflT3bUSvN6HWQ-IUE3xQxt70v0u6eOw2gUOC6Dr2fIHOBDU5Fe43NHyhrUXRRhB00PKOza0QYFHiu85NHK5bfkFkyM61/w531-h200/f1040_Page_1-cropped.jpg" width="531" /></a></div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: center;"><br /></div><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">There are certain things in life that are inevitable; death, taxes and, for the physician, patient intolerance of their medication. Statins are wonderful drugs which have revolutionized medicine and almost single handedly reduced the global burden of heart disease. Statins lower “bad cholesterol” (LDL, low density lipoprotein) and raise the “good cholesterol” (HDL, high density lipoprotein). In addition, statins have anti-inflammatory effects that contribute to their ability to lower heart disease. Unfortunately, statins have side effects including raising liver enzymes and causing muscle pains. Many patients cannot tolerate statins due to muscle symptoms.. What is statin intolerance? What new medications are available for patients with statin intolerance?<o:p></o:p></p><div class="separator" style="clear: both; text-align: center;"><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;">There are many medications available to treat high cholesterol. However, to be deemed beneficial a medication must meet two requirements. Number one, it must lower LDL substantially. Number two, it must reduce major adverse cardiac outcomes (heart attack, stroke, cardiac death). Medications such as welchol, niacin, fenofibrate, fish oil (omega 3 fatty acids) lower LDL cholesterol, but do not reduce cardiac risk and are therefore not part of the modern cardiac armamentarium. Statins fulfill the criteria by lowering cholesterol and reducing cardiac events. For every 2 mg/dl reduction in LDL, there is a 1% reduction in cardiac outcomes. For example lowering LDL from 140 mg/dl to 100 mg/dl (a reduction of 40 mg/dl) not only reduces cardiac events by 20%, but also lowers mortality by 10%. <span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">The most common reason patients cite for stopping their statin is muscle pain. Muscle symptoms include soreness, aching, weakness or cramping and affect large muscle groups (such as the thigh). Muscle pain causing statin intolerance has been reported between 5% and 50% of patients. A recent large study (including 4 million patients) determined that true statin intolerance occurred in about 9% of patients taking a statin. Statin intolerance has been defined by the FDA as " the inability to tolerate at least two statins at the lowest approved doses due to muscle symptoms". Risk factors for statin intolerance include female sex, obesity, underactive thyroid, diabetes, alcohol use, chronic liver or kidney disease, use of calcium channel blocker, and the use of high doses of statin. Factors not associated include smoking and high blood pressure. Statin induced muscle pain usually occurs early in treatment (the first few weeks up to two months). However, the enormous benefit of statins is such that treatment should not be abandoned if a patient reacts to a single agent. Other statins should be tried and dosing altered to try to keep them on the medication. If a patient is truly statin intolerant after several tries, then there are new, nonstatin alternatives.</span><o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;">The first alternative medication for the statin intolerant patient is ezetimbe (Zetia). Ezetimbe alone reduces LDL by 18% and in combination with simvastatin 25%. The combination medication lowers the risk for cardiac events by 8%. Ezetimbe is rarely used by itself, rather it is used to lower the statin dose while still providing cardiac protection. The next class of agents are the PCSK9 inhibitors alirocumab (Praluent) and evolucumab (Repatha) which were approved for use by the FDA in 2015. These medications are given by a self-administered injection under the skin (much like an insulin shot) every two weeks. They lower the LDL by a whopping 58% (Praluent) and 64% (Repatha) and lower cardiac event rates by 15%. The next agent is inclisiran (Leqvio) which was approved for use by the FDA in December 2021. It too is an injectable medication but this is given every six months. Inclisiran has been tested in patients with familial hypercholesterolemia who still have high levels of LDL despite taking a statin. In these patients, inclisiran lowers LDL by 50% on top of statin treatment. Trials are ongoing evaluating inclisiran’s ability to lower cardiac events. In addition, it has not been tested in statin intolerant patients. However, it may prove very useful in this population. Side effects include only injection site reactions and no muscle pain. The last medication is bempedoic acid (Nexletol) which the FDA approved in February 2020. Bempedoic acid has been tested in patients with statin intolerance. Alone it lowers LDL by 21% and in combination with ezetimbe LDL is lowered 38%. Importantly, bempedoic acid was recently shown to lower the cardiac event rate by 13%. In addition, it seems to have anti-inflammatory properties (like statins) whereas ezetimbe and PCSK9 inhibitors do not. Side effects include gout and gallstones but no muscle symptoms. All of these characteristics make it a good alternative for statin intolerant patients.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><span style="font-size: 12pt;">Despite a plethora of good alternatives, the principal is to have patients take a statin. Fortunately, there are other medications if they cannot continue on statins. In terms of life’s inevitabilities, physicians can’t reduce the tax burden. However, there are now viable options for patients with statin intolerance that also reduce the risk for cardiac death. Two out of three ain’t bad.</span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><span style="font-size: 12pt;"><br /></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><span style="font-size: 12pt;"><br /></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><o:p> </o:p></p><span style="text-align: start;"></span></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-5711095683157009672023-03-07T16:01:00.000-08:002023-03-07T16:01:16.528-08:00AED Density<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjyz4KILeCSOn_UarqN8lVcfzhwglyMlOGKIScBfLQan9SmFR_cPsB5kPJLRri01qS2nPJzdF71SM6bTmSRp2eKD19RSrcgVt6JekUQwpi5IUaNld5wBA_TFOn3khnyPUuWd1IIXvS1UDMbyHdDz0_sra5d_85Bqg0uIPIEqoHRv2A1gh5s2jqxVCvL/s576/AED.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="432" data-original-width="576" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjyz4KILeCSOn_UarqN8lVcfzhwglyMlOGKIScBfLQan9SmFR_cPsB5kPJLRri01qS2nPJzdF71SM6bTmSRp2eKD19RSrcgVt6JekUQwpi5IUaNld5wBA_TFOn3khnyPUuWd1IIXvS1UDMbyHdDz0_sra5d_85Bqg0uIPIEqoHRv2A1gh5s2jqxVCvL/s320/AED.jpg" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Sudden cardiac arrest is an abnormal heart rhythm most often caused by ventricular fibrillation (an irregular heart rhythm from the lower chambers of the heart). When the heart’s ventricles are fibrillating, they cannot pump blood to the brain and vital organs. If not treated promptly, this leads to death. Sudden cardiac arrest is common and affects 350,00 people in the US each year. Surviving sudden cardiac arrest requires prompt cardiopulmonary resuscitation (CPR) and defibrillation with an Automatic External Defibrillator (AED). Timing is everything; if an AED shock is provided within one to two minutes of going into sudden cardiac arrest about 50% of victims will live. However after 10 minutes, less than 10% will survive. We have all seen this in real time recently. Due to the quick response and the coordinated efforts of a team who practiced for just this type of situation, Damar Hamlin is alive today. However, most sudden cardiac arrests do not happen in a controlled environment such as a cardiac care unit. The big question then is how to get responders and AEDs to sudden cardiac arrest victims as fast as possible.<o:p></o:p></p><div class="separator" style="clear: both;"><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="color: #222222;">If a patient has cardiac arrest in the hospital, doctors and nurses with advanced cardiac training can often successfully resuscitate the patient. If someone suffers sudden cardiac arrest outside of the hospital, it is a different story. In studies it has been shown that 8% of cardiac arrests occur in a public setting and witnessed by bystanders, but the vast majority of out of hospital cardiac arrests occur in the home (75%). The overall survival rate for out of hospital cardiac arrest is only between 2% and 14%. One of the biggest barriers to successfully resuscitating a patient out of the hospital is getting trained responders to the victim. Once a cardiac arrest has been called to 911 or emergency services, a dispatch is placed to first responders; police, fire and ambulance corps. However, if it takes emergency responders more than ten minutes to locate and get to the victim, the outcome is usually not good. If bystanders near a victim are able to start CPR and, even better, use an AED, the chance of survival increases dramatically. Resuscitation by bystanders is associated with survival rates between 53% and 66%. For comparison, survival rates for emergency medical personnel is between 28% and 43%. Most studies show a 2 fold better chance of living if the patient is treated immediately by a bystander. There are a number of volunteer responder programs around the world, including Denmark, Netherlands, United Kingdom, Australia, US and Canada. The idea is to alert volunteer trained responders about a cardiac arrest and direct them to the victim so that prompt CPR can be initiated. The programs work in the following way. Once a cardiac arrest has been called in to a central dispatching agency, registered volunteers in the vicinity of the arrest are contacted via text message. Some responders are directed to the nearest available AED, while others are sent straight to the patient to start CPR. The system keeps notifying volunteers until a critical mass have responded and are on their way. How many responders are needed to optimally manage a sudden cardiac arrest? <b> </b>When 3 or more<b></b>volunteers<b></b>responded before emergency medical services, there was a greater chance for bystander defibrillation with an AED.<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="color: #222222;"> </span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="color: #222222;">The other huge barrier to successful resuscitation is getting an AED to the victim as soon as possible. AEDs have become ubiquitous. About 500,000 to 1 million were sold in the US last year and there are about 3.2 million AEDs in public settings. Yet, there is still a shortage. AEDs in public places (for example gyms, casinos, airports, arenas, shopping malls) should be prominently mounted with easy to see signs. In addition, emergency services and security personnel should know the exact locations of AEDs. What is the optimal density of AEDs? In a large public space how close together should AEDs be placed? In 1999 AEDs were installed in O’Hare airport in Chicago. AEDs were placed a “brisk 60-to-90 second walk apart”. The survival rate for cardiac arrest at the airport is 56%. The American Heart Association recommends an AED within a 3-to-5 minute round trip walk from anywhere in a public place. This translates to each AED covering about 100 yards in each direction. <o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="color: #222222;"> </span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="color: #222222;">In case of sudden cardiac arrest in the home, getting an AED to the person is very problematic. As described above, formal programs will send out texts to responders and direct them to the location of a known AED. What is the optimal density of AEDs in residential areas? <span style="background-color: white; background-position: initial initial; background-repeat: initial initial;">One study from the Netherlands found that approximately 2 AEDs per square kilometer (5 AEDs per square mile) in residential areas was optimal coverage. However, in Holland there is a national registry for all public and private AEDs, including location. When emergency services are called, responders are directed to the nearest AED. Another study from Copenhagen concluded that the optimal coverage was 16 AEDs per square kilometer (41 AEDs per square mile) in residential areas. Keeping in mind that the Netherlands and Denmark are each about 16,000 square miles, that is not an insurmountable number of AEDs to provide residential coverage. The United States is 3,531,905 square miles.</span></span><span style="color: #222222;">Novel ideas that are being piloted include delivering an AED via a drone to the victim and having ultraportable AEDs carried by volunteer responders.<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">You may ask, “How does this information help me? I can’t afford to outfit the US with millions of AEDs.” This is a valid question, but there are still lessons for the general public. The first is to get trained in CPR. The local hospitals have CPR classes for the community. You never know when you might need these skills. Next, even if you lack formal training, this should not deter you from attempting to save a life. AEDs are easy to use and they help guide the responder through the process of deploying them. Next, if you see a resuscitation in progress, go and help. Remember, the more hands, the greater the chance to save a life. Lastly, advocate in your community for greater AED density.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-85902348866555933412023-02-07T15:50:00.000-08:002023-02-07T15:50:21.617-08:00The Hibernating Heart<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiNiCcjiGl-WEz14yy7f_kzFENoBjmb9k_pnAhSQMlNUqyn1FF2XjEn3IM0OxZgP6QstW0N7pq1jbJvhv8YaubJ6HFSDB1uMRu09Dh4BreWthTL-hbpeZ91VGVZQshYfPewqzyqxevqo7gWkzMJy6tjy-DCrTbrg96zNs9IH7EO_SxoQyXnx-kAVE8m/s980/P7091327.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="735" data-original-width="980" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiNiCcjiGl-WEz14yy7f_kzFENoBjmb9k_pnAhSQMlNUqyn1FF2XjEn3IM0OxZgP6QstW0N7pq1jbJvhv8YaubJ6HFSDB1uMRu09Dh4BreWthTL-hbpeZ91VGVZQshYfPewqzyqxevqo7gWkzMJy6tjy-DCrTbrg96zNs9IH7EO_SxoQyXnx-kAVE8m/s320/P7091327.JPG" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">It’s February and if you are a bear, it’s the middle of hibernation season. During hibernation, the bear does not merely fall asleep; there are a complex series of changes that occur throughout its body and the heart is no exception. First, the heart rate slows dramatically. When active, a bear’s heart rate is around 70 to 80 beats per minute. During hibernation, the heart rate slows to 14 beats per minute. There are also a series of changes within the heart. The left ventricle stiffens, preventing stretching due to the low heart rate. In addition, there is a change in the biochemistry of the heart muscle itself. A protein called myosin controls heart muscle contractions. During hibernation, there is a switch from the usual myosin to a different variety which produces a weaker contraction. What can we learn from the study of animals to help us understand the human heart better? What happens when our heart beat is very low? Can human hearts hibernate?<o:p></o:p></p><div class="separator" style="clear: both;"><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">The normal human heart beat ranges from 60 to 100 beats per minute. Very slow heart rates, 20 to 40 beats per minute, do occur and can be present in normal hearts as well as various disease states. The heart beat normally slows while sleeping. Athletes often have very slow rates as a result of training. In fact, athletes usually have a heart rate in the 40’s and are symptomatic. It is not considered abnormal until an athlete’s rate is below 30 beats per minute. The most common abnormality causing a slow heart beat is sick sinus syndrome. This occurs in older individuals and is a result of the electric system of the heart “wearing down” over the years. A heart attack can slow the heart rate, especially if it affects the blood flow to the electric system. Low heart rates are also seen in an under active thyroid (hypothyroidism), sleep apnea, and Lyme disease. There are many medications that can slow the heart beat. These include beta blockers (for example, metoprolol), calcium channel blockers (ex, diltiazem), digoxin, rhythm agents (ex, amiodarone, sotalol), eye drops (especially ones containing timolol, a beta blocker) and Alzheimer medications (donepezil and memantine). Patients with very slow heart rates may have no symptoms or they may feel lightheaded, dizzy, sweaty or pass out. If left untreated, a slow heart rate will lead to congestive heart failure or death. The diagnosis of a slow heart rate is made by capturing the event on an EKG strip. A variety of methods can be used. A Holter monitor is an EKG that is attached to patient and worn all day and night for one to three days. An event monitor is a patch that is applied to the chest. A constant signal is sent to monitoring center and if a significant rhythm change occurs, the doctor is notified. The patch is worn for two to four weeks. These monitors are good if the patient has frequent events. Sometimes, events occur weeks or months apart. In that case, an implantable loop recorder is placed. This is a small metal device that is placed under the skin and can monitor a patient for months or years at a time. In the case of an event, the EKG can be downloaded on a computer. For patient centric devices, there is the Apple watch and Kardia mobile. Kardia mobile provides a single lead EKG when the patient places two fingers on the device and an EKG is stored on a cell phone. It is commercially available on Amazon and can be bought without a prescription. The treatment for a slow heart is to correct the underlying cause or stop the offending medication. If that does not improve the heart rate or symptoms, then a pacemaker is placed. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">The human heart can hibernate, but for a different reason compared to the hibernating bear’s heart. In humans, the whole heart doesn’t hibernate, like the bear, but only a portion of the heart muscle. If there is a region of the heart muscle that is supplied by a blocked artery for many months or years, the region will hibernate. Normally if there is lack of blood flow to the heart muscle, there is a heart attack and the affected muscle dies (it stops working, contracting). In an area of hibernation, there is enough blood flow to keep the muscle alive, but it doesn’t contract normally. In effect, the area of heart muscle adapts by downregulating- reducing or ceasing contraction and changing metabolism to try to keep the area alive. Similar to the bear’s hibernating heart, there is a change in the biochemistry. Biopsies of hibernating heart muscle in humans has shown a reduction in and disorganization of the contracting proteins, including myosin. If the blocked artery supplying the area is opened (with a stent or bypass surgery) and blood flow restored, the affected hibernating heart muscle returns to normal function. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">In the animal kingdom, the adaptations made by the heart are beneficial, helping the animal to survive cold winters and to ultimately thrive. In humans, the hibernating heart can keep us alive, but in the long run the changes are detrimental. Hibernating areas of heart muscle weaken the overall contraction of the heart resulting in congestive heart failure and ultimately death. Similarly, a slow heart rate seems to confer a survival advantage in the animal kingdom while not a factor in man. Animals with fast heart rates such as the shrew with a heart rate of 220 beats per minute tend to have short lifespans, a few years at most. On the other hand, the Galapagos giant tortoise, whose average heart rate is six, can live for more than 100 years. If the human heart were to slow down to that level blood would pool in the four chambers, the heart would start to enlarge, the muscle would weaken leading to congestive heart failure and death. Aside from interesting physiology, the study of animal adaptations may lead to advances in human heart disease. The research has already borne fruit by producing new medications that target myosin. Omecamtiv activates myosin, improving the heart’s contractility and helping with heart failure due to a weakened heart muscle. Mavacamten inhibits myosin, decreasing the force of contraction in patients with a thickened heart muscle who need less vigorous heart pumping. Let sleeping bears lie, we can learn a lot from them.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-70279830950425130352023-01-10T15:58:00.000-08:002023-01-10T15:58:06.737-08:00Sudden Cardiac Arrest<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjkJfKjWBrk7Nx_9a6KD_J2zo1INYM57FmaX7LOQyoCvUiI4an_ZCnif2hnGm2vlV8IHsHmYYWLG_PNAQSK6TlD0ymE826JqjGlvwPpdQGjln978d7KRrqXViCsBUFEkEJpjq8y8xb-LADjoL9nLr9ndfPtQHWj47sRxCUJBCov8HHvD5-j_oKWhl_L/s4032/IMG_2203.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="3024" data-original-width="4032" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjkJfKjWBrk7Nx_9a6KD_J2zo1INYM57FmaX7LOQyoCvUiI4an_ZCnif2hnGm2vlV8IHsHmYYWLG_PNAQSK6TlD0ymE826JqjGlvwPpdQGjln978d7KRrqXViCsBUFEkEJpjq8y8xb-LADjoL9nLr9ndfPtQHWj47sRxCUJBCov8HHvD5-j_oKWhl_L/s320/IMG_2203.JPG" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">On January 2 2023 in front of thousands of people at the stadium and millions on a national television broadcast, a Buffalo Bills player made a routine football play, stood up and then collapsed with sudden cardiac arrest. What is sudden cardiac arrest? What causes it? How is it treated? Can it be prevented?<o:p></o:p></span></p><div class="separator" style="clear: both;"><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;"><o:p> </o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Sudden cardiac arrest is an abnormal heart rhythm most often caused by ventricular fibrillation (an irregular heart rhythm from the lower chambers of the heart). When the heart’s ventricles are fibrillating, they cannot pump blood to the brain and vital organs. If not treated promptly, this leads to death. Sudden cardiac arrest affects 150,000 to 250,00 people in the US each year. Less than 20% of sudden cardiac arrest victims have their rhythm restored to normal and only 10% survive to ultimately leave the hospital. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">The cause of sudden cardiac arrest depends on the age of the victim and the type of underlying heart disease. In patients over the age of 35, the overwhelming cause of sudden cardiac arrest is a heart attack. A heart attack occurs when the blood flow to the heart muscle is stopped completely. Usually there is a pre-existing plaque or blockage in a heart artery, the plaque breaks open, a blood clot forms and the blood flow is halted. It is important to realize that a heart attack and sudden cardiac arrest are not the same thing. A heart attack is one of the causes of sudden cardiac arrest and primarily a plumbing problem (the artery and the blood flow) while sudden cardiac arrest is an electrical problem (an abnormal rhythm). In those under age 35 and less likely in older victims cardiomyopathy (a primary heart muscle problem) can cause sudden cardiac arrest. This includes dilated cardiomyopathy (a weak, flabby heart), hypertrophic cardiomyopathy (an abnormally thickened heart muscle) and arrhythmogenic right ventricular dysplasia (fatty infiltration of the wall of the right ventricle). Primary rhythm problems such as Wolf-Parkinson-White syndrome (a bypass which circumvents the usual electrical pathway), Long QT syndrome and Brugada syndrome must also be considered. In young patients, especially young athletes, an anomalous origin of a heart artery can be seen in 12 to 19% of victims. The artery follows an abnormal course between the main artery (the aorta) and the lung artery (pulmonary artery). With exercise, the pressure in these arteries goes up, compressing the heart artery and interrupting blood flow to the heart. Another cause that has come to the forefront in recent years is myocarditis (inflammation of the heart muscle). Myocarditis can be due to infection (from various viruses including COVID), cancer chemotherapy agents (check point inhibitors) or idiopathic. All of these causes are due to an underlying heart issue but sudden cardiac arrest may occur in a normal heart as well. Commotio cordis occurs after a blunt impact to the chest (with a projectile such as a baseball). The energy of the impact is transmitted to the heart, disrupting the normal heart rhythm. The vulnerable period for a projectile striking the heart is only about 10 to 15 milliseconds long and represents one percent of the total heart cycle. It is a rare but not uncommon occurrence. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">The successful treatment of sudden cardiac arrest demands prompt recognition, cardiopulmonary resuscitation (CPR) and defibrillation. Recognizing sudden cardiac arrest may not be easy. The patient cannot explain what is wrong and they are often first evaluated by nonmedical personnel. In addition, it may look like another process is occurring, such as a seizure. If sudden cardiac arrest is suspected, the initiation of prompt CPR has been shown to save lives. The American Heart Association now recommends hands only chest compression (no mouth-to-mouth) and pressing hard and fast. Sudden cardiac arrest need not be 100% confirmed to start CPR; if suspected start chest compressions. If the victim doesn’t have cardiac arrest they will ask not to have their chest pumped. Definitive treatment of sudden cardiac arrest is defibrillation, an electric shock to the heart that restores the heart to normal rhythm. The shock is usually provided by an Automatic External Defibrillator (AED), a small portable device that is brought to the victim’s side. The sooner the patient is shocked, the greater the chance of surviving. Fifty percent of victims of sudden cardiac arrest survive if shocked within two to three minutes, but only ten percent will live if the shock is more than ten minutes from the time of collapse. Timing is everything and having an AED as close as possible to potential victims is life saving. As such, there is a push to have AEDs placed in areas where there are large public gatherings (such as airports, schools, stadiums, sports complexes). AEDs have been successfully deployed by police, firemen, sports trainers, and bystanders. There is even a study exploring delivering AEDs by drones.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Sudden cardiac arrest is often the first sign that a person has heart disease, but there are steps that can be taken to prevent it. For those over 35 years old, following a heart healthy lifestyle is the first step (staying active, watching a good diet, not smoking, keeping weight under control, treating high blood pressure and/or high cholesterol). For those at higher risk (for example a family history of heart disease at a young age), speak to your doctor about additional testing. Lastly, don’t ignore symptoms such as chest pain, shortness of breath, nausea/vomiting or passing out. Studies have shown that 50% to 75% of sudden cardiac arrest patients had warning symptoms. Many of the symptoms are nondescript; when should you be concerned? If symptoms are new or unusually severe, then seek care immediately. For those under age 35 and who have high-risk characteristics, cardiac testing (EKG, echo, cardiac MRI) as well as genetic testing may be indicated. For people under age 35 not at high risk, screening for sudden cardiac arrest is controversial. Many professional athletes (especially football, basketball and soccer players) are screened before a contract is signed. In addition, Division 1 college athletes are screened. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">The NFL routinely screens players for their risk of sudden cardiac arrest. In addition, NFL sideline training staff routinely practices responses to sudden cardiac arrest. Due to the prompt response, CPR, the use of an AED, and expert team work by the training staff and medical personnel the player was resuscitated on the field and was able to survive a near death experience.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="color: #222222;">The Cardiology Department at RWJ Somerset is conducting its annual screening of high school athletes on Saturday February 4 2023. The screening is free and open to athletes from 14 to 18 years of age.<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="color: #222222;">For more information please check the website (rwjbh.org/cardiacathleticscreening) or call 908-685-1414 to reserve a time slot.<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p></div><p></p><div class="separator" style="clear: both; text-align: center;"><br /></div><br /> <p></p>Unknownnoreply@blogger.com1tag:blogger.com,1999:blog-6619506163557319420.post-88945476876066126062022-12-13T15:11:00.001-08:002022-12-13T15:11:24.235-08:00Resistance is Futile<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiRWSwHviX8sJBGS7zgOFbaa_47rZXucvYX3nAjJTv_Vj5dmZwqQwM4DCasL03CrOK20sG1KNQqqdf6rFtzjkiKEjmGHTJsHe4NR1tn3kjlp-iesBSi65ZJcYcckMJAZhGDwmKTzOQPN6Vg15wDtg34b03JXSCeWgZVWvU_721hCU3_H4WpsUsyGv6N/s1758/Omega-Symbol-and-Its-Meaning.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1758" data-original-width="1359" height="249" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiRWSwHviX8sJBGS7zgOFbaa_47rZXucvYX3nAjJTv_Vj5dmZwqQwM4DCasL03CrOK20sG1KNQqqdf6rFtzjkiKEjmGHTJsHe4NR1tn3kjlp-iesBSi65ZJcYcckMJAZhGDwmKTzOQPN6Vg15wDtg34b03JXSCeWgZVWvU_721hCU3_H4WpsUsyGv6N/w192-h249/Omega-Symbol-and-Its-Meaning.jpg" width="192" /></a></div><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222; font-family: Arial;">The letter omega (Ω) is the last letter in the Greek alphabet. As such, omega is often used to denote the last, or the ultimate end, of a list. Therefore, it is a fitting topic for December, the final month of the year. In addition, omega symbolizes the ohm, the unit of electrical resistance. The ohm is named after the German scientist George Ohm who described the mathematical formula of electrical resistance. There is a further connection between electrical resistance and resistant hypertension, since external energy can potentially be used to bring down the blood pressure. What is resistant hypertension and how is it treated? Can new treatments be the omega of high blood pressure?<o:p></o:p></span></p><div class="separator" style="clear: both;"><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222; font-family: Arial;"><o:p> </o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222; font-family: Arial;">Elevated blood pressure (hypertension) is the leading risk factor for cardiovascular disease, stroke and death. It affects about 1.4 billion people worldwide. In the US, approximately 10 to 30% of patients with high blood pressure have treatment resistant hypertension (10-12 million people). Resistant hypertension is defined as blood pressure above goal despite taking the maximally tolerated doses of three different classes of blood pressure medications. In the past, the goal was a blood pressure under 140/90, but a new definition now moves the goal to under 130/80. The three medications should include a diuretic (a “water pill”), an ACE or ARB (for example, lisinopril, ramipril, losartan or olmesartan) and a calcium channel blocker (usually amlodipine). A structured approach to resistant hypertension has been developed by the American Heart Association. The first step is to make sure the blood pressure is truly high (not white coat hypertension; high blood pressure in office, but normal at home). The next step is to ensure the patient is taking his or her medications (and correctly). After that, lifestyle modifications may be necessary if the patient is not following a low sodium diet, not exercising, or drinking excess alcohol. In addition, many medications can raise blood pressure. These should be eliminated or reduced. Medications that can raise blood pressure include non-steroidal anti-inflammatory agents (such as ibuprofen or naproxen), over the counter cold medications, oral contraceptives, corticosteroids (for example prednisone), some cancer chemotherapy agents and many supplements (ephedra, ginseng, saw palmetto). Lastly in the lifestyle category is obstructive sleep apnea. </span><span style="font-family: Arial;">Obstructive sleep apnea occurs when the upper airway collapses, air movement into the lungs ceases causing the oxygen level in the body to fall. This prompts the person to wake up and take deep breaths. These periods of low oxygen disrupt the sleep cycle and prevent the person from getting enough time in the deep sleep, restorative stages of sleep. Because the body does not get enough rest, the person feels “revved up” all the time. Over time, this causes hypertension. Treating sleep apnea can reduce blood pressure. <o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222; font-family: Arial;"><o:p> </o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222; font-family: Arial;">The next step in managing resistant hypertension is to evaluate for secondary causes of high blood pressure. A variety of disease processes can raise blood pressure (including kidney, adrenal, and aortic diseases). Identifying such a process and treating it will bring down the blood pressure. One such entity is renal artery stenosis (a severe blockage in the artery supplying blood to a kidney). The most common cause of renal artery stenosis is atherosclerosis of the kidney artery (the same process that causes blockage in a heart artery). It is characterized by a sudden increase in blood pressure, low potassium levels in the blood and an extra “whooshing” sound (bruit) heard over the abdomen. The diagnosis is made by ultrasound, CT scan or angiogram of the blood flow to the kidneys. In the appropriate patient, opening up the blockage, placing a stent and restoring blood flow to the kidney can reduce blood pressure.<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222; font-family: Arial;"><o:p> </o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222; font-family: Arial;">If the blood pressure is still elevated after all of these evaluations, the next step is to add further medications. The next medication that is recommended is spironolactone, which blocks the synthesis of aldosterone, a hormone that promotes salt retention and increases blood pressure. Spironolactone has been used for many, many years and is quite effective at lowering blood pressure. However it does have side effects including raising the potassium level in the blood (a potentially dangerous situation). If the potassium goes above a certain level, the medication has to be discontinued. <o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222; font-family: Arial;"><o:p> </o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222; font-family: Arial;">Even though resistant hypertension affects millions of people, no new blood pressure lowering agent has been approved since 2007. A couple of new strategies for lowering blood pressure are on the horizon and look promising. The data for a new medication, baxdrostat, was just published this past month. Baxdrostat lowers aldosterone levels by a different mechanism from spironolactone. In the trial just reported, baxdrostat lowered blood pressure in resistant hypertensive patients 11 mmHg more than placebo, a statistically significant amount. There was no significant increase in potassium.<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222; font-family: Arial;"><o:p> </o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222; font-family: Arial;">Are there any other therapies besides medication to treat resistant hypertension? A new procedure called renal denervation has been extensively studied recently. Renal relates to the kidneys and denervation means to deaden the signal the nerves give off. One of the ways in which blood pressure is controlled is via the nerves to the kidney arteries. The nerves send a signal to the kidneys, prompting the kidney to start retaining more salt (sodium) and increase blood pressure. In addition the nerves from the kidneys send signals back to the brain. This causes the brain to send signals to the arteries throughout the body, making them contract and stiffen, also raising blood pressure. These are normal mechanisms the body uses to regulate blood pressure, but in some people the nerves are overactive resulting in continuously high blood pressure and resistant hypertension. Renal denervation is a procedure where a catheter is placed in the kidney arteries. The nerves are then deadened using radiofrequency or ultrasound. Many trials have been conducted comparing renal denervation with a sham procedure (the catheter is placed but no energy is given). In patients with resistant hypertension, renal denervation lowered blood pressure by 7 to 11 mmHg. These reductions were sustained at 6 months and 3 years. In addition, renal denervation increased the time in therapeutic range (< 140 in office blood pressure, < 130 in home readings) as well as decreased major cardiac events. One of the advantages to renal denervation is that it is always “on”; the blood pressure effect is there, night or day and is not dependent on whether medication is taken or whether medication has worn off during the course of the day. Taking multiple medications every day, often with several doses spaced across the day, 365 days of the year is a difficult task. If approved, renal denervation may be a reasonable option for people with resistant hypertension. <o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222; font-family: Arial;"><o:p> </o:p></span></p><span style="background-color: white; color: #222222; font-family: Arial; font-size: 12pt;"><br clear="all" style="break-before: page;" /></span><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222; font-family: Arial;"><o:p> </o:p></span></p></div><p> </p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-70252630921564071202022-11-15T17:05:00.003-08:002022-11-15T17:05:29.015-08:00The Radio Blood Pressure Show<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgul-rJpstdbIMwY5dr2hx4lpU-qU-b6XmQyTF2XlK6CulJGgi5WoplOtYQQ0L5E_rPITLoWOLyR1QasmMHBhrM45RU1dTfgkV2chcvVAY6FPElHBI_wKCRwv-LtVTgUQfvI_WUJzPORTkZ6Tz_AU-45Aa7Z8hF_l20Tom_olIxf26CqS4anPO3DzVh/s4032/IMG_4119.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgul-rJpstdbIMwY5dr2hx4lpU-qU-b6XmQyTF2XlK6CulJGgi5WoplOtYQQ0L5E_rPITLoWOLyR1QasmMHBhrM45RU1dTfgkV2chcvVAY6FPElHBI_wKCRwv-LtVTgUQfvI_WUJzPORTkZ6Tz_AU-45Aa7Z8hF_l20Tom_olIxf26CqS4anPO3DzVh/s320/IMG_4119.jpg" width="240" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;">Hi everyone and welcome to WWAD in New Jersey, number 807 on your AM dial. I’m your host, Brother Brucie from Asbury Park. Today on the Blood Pressure Show we answer all of your burning questions about hypertension. So email me, text me or hire an airplane to pull a banner over the shore with your question. Lets get started.<o:p></o:p></span></p><div class="separator" style="clear: both;"><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;"> </span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;">Meryl S from Summit asks, “How common is high blood pressure? Is high blood pressure a bad actor?”<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;">High blood pressure (hypertension) affects nearly 1 in 2 people worldwide between the ages of 35 and 70 years old. Hypertension is a leading risk factor for stroke, heart attack, death and disability. Hypertension is often called the silent killer, as there usually aren’t any symptoms until an adverse event occurs. In addition to affecting the individual, hypertension impacts the health care system. It was recently shown that about one third of emergency room visits in heart patients were for high blood pressure. This represents about 2.7 million people. In addition, hospitalization for uncontrolled hypertension has increased in recent years. <o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;"> </span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;">Jon B from Perth Amboy queries, “How high is too high? What is the optimal blood pressure?”<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;">Blood pressure is considered normal if less than 120 and less than 80. Elevated blood pressure is defined as a systolic pressure between 120 and 129 with diastolic less than 80. </span><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222; font-family: Arial;">Stage 1 hypertension occurs with blood pressure over 130/80. Stage 2 hypertension is defined as a blood pressure of 140/90 or greater. Hypertension should be diagnosed if blood pressure readings are elevated on three separate occasions, several weeks apart. Once hypertension has been established, what is the target blood pressure? </span><span style="font-family: Arial;">The landmark SPRINT study is the current gold standard answer to the question. The SPRINT trial compared two blood pressure goals, treating to under 140 and treating to under 120. The study showed that patients who were treated to under 120 had a significantly lower risk for cardiac outcomes. However, those treated to under 120 were taking more medications and had a higher risk for side effects from the medications. Therefore treating to a blood pressure under 120 is recommended for heart patients or those at high risk for cardiac disease. Other populations, such as diabetics and the elderly, should be treated to under 140.<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;"> </span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222; font-family: Arial;">Francis S. from Hoboken wonders, “Is it best to measure blood pressure in the doctor’s office or should I do it my way?”<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222; font-family: Arial;">The doctor’s office is not the ideal location for blood pressure checks. More accurate readings occur when patients take their blood pressure at home. Home blood pressure reading can be obtained either by the patient checking their own blood pressure or 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 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). In addition, ambulatory blood pressure monitoring is a stronger predictor of cardiac disease and mortality than office blood pressure values. <o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;"> </span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;">Vincent L. from Ridgefield demands, “What is a winning game plan for blood pressure?”<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;">The amount of time patients spend in a target blood pressure range is emerging as a therapeutic goal. More and more research is focusing on time in therapeutic range. The more time in range, the lower the risk for cardiac events. For example, studies have shown that increased time in the blood pressure range of 110 to 130 lowered the risk for cardiovascular death, heart attack, stroke and heart failure. Therefore, a winning strategy is to try to keep the pressure in range for the longest time. This has implications for office visits as well. If a patient comes in with an elevated blood pressure, it has to be placed in context and compared to home readings as well as prior office measurements. When blood pressure readings are taken also help describe the bigger picture. If blood pressure is 120 while sitting but is 160 after walking, or when under stress, or when in pain, then the higher reading again has to be placed in context and likely discounted.<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;"> </span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;">Thomas E from Menlo Park, “If blood pressure readings at home and time in target blood range are keys, would wearable devices help achieve these goals?”<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;">The blood pressure cuff was first introduced in 1896. Today, more than 120 years later, there is no significant difference in blood pressure cuff technology. This may be changing. Home blood pressure monitors and ambulatory devices all use a cuff that must be inflated to provide a reading. This limits the usefulness of these devices. There are now several cuffless wearable blood pressure devices on the market. These monitors hold lots of promise: the ability to record blood pressure comfortably, continuously, during the day and at night and provide good unbiased data on blood pressure variation. Several different technologies have been incorporated including photoplethysmography (the green light on the back of the watch). Unfortunately, the cuffless devices currently available on the market have not been shown to be accurate. For example, one smartwatch had a difference of 17 points compared to the standard cuff. Because of this, no device is recommended for use by any medical society. On the other hand, traditional home blood pressure monitors have been independently validated as accurate and a list of these validated devices is available at ValidateBP.org<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;">One cuffless technology may prove to be both accurate and useful. The mechanism is a thin sticker that is worn on the skin and uses bioelectrical impedance, a method that has been used for years in medicine for other reasons. The sticker can be worn on the skin for a week at a time and in trials was very accurate (within 0.2 points of a standard measurement). While not currently available, it may be the future.<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;"> </span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;">Joe P from Passaic asks, “My blood pressure is high when I am working on Saturday night. When should I take my blood pressure meds?”<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;">There is an old debate regarding when to take blood pressure medications- morning or evening. There is logic to taking medications at night. Blood pressure usually drops at night. Patients who do not have the traditional nighttime blood pressure dip are at higher risk for cardiovascular problems. In addition, taking meds at night may lead to fewer side effects. So, taking meds at night makes sense. Does the data support this approach? Over the years, most studies supported taking medications at night. Recently a large, well-run trial showed no difference; morning or evening there was no difference in cardiovascular events at 5 years. When is the best time to take meds? The answer is to tailor to each patient’s individual needs, balancing efficacy (remembering to take the meds) versus tolerability (the time with the lowest side effects).<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;"> </span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;">Lawrence B from Montclair asks, “Is one blood pressure medication sufficient? Or should I go for a four bagger?”<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;">Doctors traditionally have been trained to use a step wise approach when treating hypertension. One medication is started and the dosage is increased if the blood pressure is not controlled. If one medication is maxed out and the number is still not good, a second or third medication is added. Is this the best approach? Recent trials have compared a single blood pressure pill to a “quadpill”, a tablet containing small doses of four different blood pressure medications. The quadpill dropped the blood pressure 7 points lower than the single agent. The appeal of the quadpill is that it offers better blood pressure control while providing ease of use (only one pill to remember) and lower side effects.<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;"> </span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;">Robert J. from New Brunswick asks, “I have arthritis. Can I take Tylenol with my blood pressure medications?”<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;">It is well known that nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided for patients with hypertension. NSAIDs include ibuprofen (Motrin, Advil), naproxen (Naprosyn, Aleve), indomethacin (Indocin), diclofenac (Voltaren) and celecoxib (Celebrex). These medications can raise the blood pressure and can interfere with some blood pressure drugs. Tylenol (acetaminophen) is often prescribed instead. However, recent data shows that Tylenol may not be innocuous. Patients who took Tylenol for two weeks saw their blood pressure increase nearly 5 points above patients who took placebo. Therefore, long-term use of Tylenol may not be safe for patients with hypertension. Short-term (few days) use may still be fine.<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;"> </span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;">That’s it for our show. Thanks for joining me and hope to see you next week. This is Brother Brucie signing off (fade to music): <o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;">“This is Radio Blood Pressure<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;"> Is there anybody normotensive out there?<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;"> I was staring at a dumb dial<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;"> Just another lost number in a file<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;"> This is Radio Blood Pressure”<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="font-family: Arial;"> </span></p><span style="font-family: Cambria; font-size: 12pt;"><br clear="all" style="break-before: page;" /></span><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-47364186232366627432022-10-10T15:51:00.001-07:002022-10-10T15:51:45.543-07:00How High Is Too High?<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiFzaVy_t6JyIeP6UFQellLhhPkQC6cBt6xMphcO7_rs9dvcEfq7jzYME0kOPlPYylbF0uOpgrAaYrJ9gBOHrdKKEMd-Yhi4ShTUEsJeAFIfWTNpIS8ei53AjUPPiY6eFxmXbfW7OZAH6hiiFjLvIOyaPa3jHO2DPdyE1suDN4xIkC7UgdfNiSQiDkd/s4032/IMG_1519.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiFzaVy_t6JyIeP6UFQellLhhPkQC6cBt6xMphcO7_rs9dvcEfq7jzYME0kOPlPYylbF0uOpgrAaYrJ9gBOHrdKKEMd-Yhi4ShTUEsJeAFIfWTNpIS8ei53AjUPPiY6eFxmXbfW7OZAH6hiiFjLvIOyaPa3jHO2DPdyE1suDN4xIkC7UgdfNiSQiDkd/s320/IMG_1519.jpg" width="240" /></a></div><br /><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Come and listen to a story about a blood test named HDL (High Density Lipoprotein, the “good cholesterol”). It is an epic saga full of lows and highs. It is a story that spans the globe, from Massachusetts to the Italian Alps. What is HDL and how is it associated with heart disease?<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">The story begins in a town outside of Boston, Massachusetts. In 1977, the famous Framingham Heart Study first identified low levels of HDL in the blood as a risk factor for heart artery disease. In patients with HDL levels less than 40 mg/dl, there is an increased risk for blockage in the heart arteries and cardiac death. On the other hand, in patients with elevated LDL (the “bad cholesterol”) normal or high levels of HDL protect against heart disease. The prevalence of low HDL in North America is about 7% in men and 2% in women. How does HDL protect against plaque build up in arteries? There are several mechanisms. HDL transports excess cholesterol from arteries back to the liver, where it is metabolized and excreted. This process is called reverse cholesterol transfer. In effect, HDL “cleans” the arterial wall, sweeping away cholesterol and stopping plaque in its track. In addition, HDL is anti-inflammatory (plaque formation is an inflammatory disease) and has anti-oxidant and anti-blood clotting properties. Are there ways to treat low HDL? Aerobic exercise, weight loss and smoking cessation all increase HDL levels. Diet plays a role as well. Low fat diets lower both LDL and HDL levels but diets high in monounsaturated fats (including olive oil) reduce LDL without adversely affecting HDL. Statins will increase HDL levels. They raise HDL between 5% and 15% with an average increase of 9%. Many, many other pharmacologic agents have been tried to see if they can raise HDL levels and improve outcomes. Niacin and fenofibrate both raise HDL (by concomitantly lowering triglycerides). However, despite the positive impact on HDL levels, both drugs failed to reduce heart attacks, strokes and cardiac deaths. Several other medications have been tried, but in clinical trials they all failed to improve cardiac events, some agents even raised mortality. There are several reasons for the failure of theses medications. The biology of HDL appears to be much more complex than that of LDL. There are several different subclasses of HDL; we don’t know which ones are the keys to the success of HDL. In addition, the function of the HDL molecule is more important than the level. Increasing the amount of HDL doesn’t mean it works better at preventing artery blockage. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">At this point, the story of HDL heads overseas to two small towns in Italy. In 1980, a genetic mutation in HDL was discovered in families in a town outside of Milan. People with this mutation were smokers, did not follow a heart healthy diet, and had low levels of HDL (10 to 30 mg/dl). Yet they had low levels of blockage in the heart arteries and lived well into their 90’s. Researchers discovered that their genetic mutation (called apolipoprotein A-1 Milano) was protective against heart disease. Subsequent trials tested whether IV infusions of this apolipoprotein could help patients with established heart disease, but again the trials failed. In another town, this one located in the Italian Alps, there is a cohort of people who have longevity and virtually no heart disease. Like their countrymen, their diet is not heart healthy but they have higher levels of HDL than the average Italian. The genetic variant in this healthy town has not yet been identified.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">The guidelines for lipid management recommend a threshold value for HDL of 40 mg/dl; below that level there is an increased risk for heart disease while levels above provide protection. If an HDL value of 40 mg/dl is good, is 100 mg/dl better? Does the risk for heart disease continue to fall as HDL levels rise? How high is too high? To answer the question researchers pooled multiple studies of HDL (all told more than a million patients were evaluated). They found a U shaped relationship between HDL levels and death. Levels below 40 mg/dl were associated with increased risk of death. Surprisingly, levels over 80 mg/dl also were associated with increased deaths. They found the optimal range of HDL to be between 40 and 80 mg/dl.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">The final chapter to the HDL saga has not yet been written. If you are not genetically gifted and have a low HDL level, do what you can to raise HDL. Stay active, exercise, keep weight down, don’t smoke and take your statin. If you have a very high HDL level, don’t assume that you are protected against heart disease. A healthy lifestyle and a statin may still be necessary if the LDL level is also elevated. Only time and further research will tell whether there is a better approach to HDL and a happy ending to the story. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-29686186602265098102022-09-13T16:08:00.002-07:002022-09-13T16:08:43.368-07:00It Was A Swell Summer<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEice4n_w0aqXslv7LixPRfSZH2A0jZiVo3rY3fxpVhbdW7oAX0oRGLknJyDC4TdGkmihWrJGYgu5S3AgyG5-hbS0HjO8MCiZt8-ixjqWUrwpfIZy9TxMU5Da_BJV9g4arlaNN0dhjRdy9XXWH_cCxV-_mnb3e9T5cDUa_PkMC-eIL43TdkVpVJYdU_L/s4032/IMG_4046.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEice4n_w0aqXslv7LixPRfSZH2A0jZiVo3rY3fxpVhbdW7oAX0oRGLknJyDC4TdGkmihWrJGYgu5S3AgyG5-hbS0HjO8MCiZt8-ixjqWUrwpfIZy9TxMU5Da_BJV9g4arlaNN0dhjRdy9XXWH_cCxV-_mnb3e9T5cDUa_PkMC-eIL43TdkVpVJYdU_L/s320/IMG_4046.JPG" width="240" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">As we say goodbye to the scorching summer of 2022, it is worth noting that heat records have been broken across the globe. Unprecedented heat waves have hit the US, Europe, England and China. According to the National Oceanic and Atmospheric Administration July 2022 was the third hottest July on record, June was the sixth warmest and overall the year 2022 is trending as the third warmest year in history. In the midst of all of this hot humid weather, patients flocked to their doctors with lower leg swelling. What are the causes of leg swelling? Why does it occur with greater frequency in the hot summer months?<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">To understand why the legs swell, we have to review the blood flow to and the drainage from the lower extremities. The arteries bring blood to the legs from heart. The veins drain the blood back to the heart. There are two venous systems in the legs: the deep veins and the superficial veins. How does blood defy gravity and flow back to the heart? As we walk, the contraction of the muscles in the legs causes the blood to be pumped upward and back to the heart. To facilitate the flow, the veins have valves to prevent blood from leaking back. Another conduit is the lymphatic system. This consists of thin tubes and nodes that drain lymph back to the heart. Lymph is a fluid that includes excess fluid, proteins, cells, fats and nutrients. About 20 liters of blood flow to the legs every day. The veins drain about 17 liters back to the heart. The lymph system drains the extra 3 liters. Leg swelling occurs if fluid leaks from the veins or the lymph system because of blockage to the flow or excess pressure within the vessels or the vessels become damaged or dilated. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Leg swelling can be categorized as acute (recent) or chronic. One leg can be affected (unilateral) or both legs (bilateral). There are many causes of leg swelling including deep venous thrombosis (a blood clot in the leg, DVT), chronic venous insufficiency, lymphedema, heart failure, kidney failure, liver failure, infection (cellulitis), cancer, thyroid disease, medications, and pregnancy. Medications include calcium channel blockers (especially amlodipine), prednisone, and non-steroidal anti-inflammatory drugs (such as ibuprofen and naproxen). Leg swelling may be asymptomatic or cause pain, aching, heaviness or fatigue of the leg, skin changes or ulceration of the skin. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">DVT may cause leg swelling in the acute phase as a blood clot could block the flow in the deep venous system. Many patients have swelling years after an acute DVT, likely because the blood clot has caused damage to the venous valves. Treatment of DVT is blood thinners such as warfarin, Eliquis, or Xarelto.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Chronic venous insufficiency is a very common clinical problem. In this condition, the venous valves become incompetent, blood refluxes back into an already congested venous chamber, this increases the pressure in the chamber and fluid leaks from the veins into the surrounding tissue. Risk factors include older age (peak incidence in women is 40-49 years and men 70-79 years), smoking, pregnancy, hypertension and varicose veins. Prolonged standing or sitting with the legs in a dependent position also can cause swelling. In this case, the veins are completely filled, the valves float open and fluid leaks out. In addition, warm conditions (such as the hot humid summer weather) tend to aggravate symptoms as the warmth can dilate the veins, causing further venous valvular incompetence. Conversely, cold conditions relieve symptoms. The best test to diagnose the cause of leg swelling is a venous ultrasound. The ultrasound can demonstrate a DVT and can show if there is venous reflux/insufficiency. Chronic venous insufficiency is treated by avoiding prolonged sitting or standing, leg elevation, exercise (walking or calf muscle exercises to help increase the flow) and compression stockings. If swelling persists despite these measures, venous ablation can be performed. Ablation shrinks the refluxing vein, allowing the valves to do their job and decrease or eliminate leaking. Varicose veins are enlarged twisted veins near the surface of the skin. They are usually branches off the superficial or deep vein system. They are quite common (25% of adults have them). Treatment is the same as chronic venous insufficiency but varicose veins can also be surgically stripped or injected with a sclerosing agent to shrivel the vein up. These treatments are more cosmetic than medically necessary. Spider veins are similar to varicose veins, but occur in even smaller surface veins. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Lymphedema may be primary or secondary to another condition. Primary lymphedema occurs with congenital absence or damage to the lymph system. Secondary lymphedema occurs with blockage of the lymph system due to cancer, prior pelvic surgery, radiation, or trauma. Lymphedema can be differentiated from chronic venous insufficiency by physical exam. In lymphedema there is no pitting of the edema, swelling affects the back of the foot, the toes are involved and there is skin thickening. Lymphedema is usually painless. Treatment includes compression stockings and pneumatic pump compression. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">So don’t get pumped up over lower leg swelling. See your doctor and get a diagnosis. Then follow the treatment plan to avoid any long-term complications. Keep in mind that cooler weather and relief is coming.<o:p></o:p></p><p><span style="font-family: Cambria;"> </span> </p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-74092884178479003162022-08-09T16:18:00.000-07:002022-08-09T16:18:29.889-07:00What is Optimal Heart Health?<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi0C9fGtDwdeFBt2d6OQ5tUYWOjHFKN9CqzAENjEhs2nJe2jsnqFpJfRBaiLQug-QVCbDNc2i0NvQaKvw_jBQB70NVGT3JbgW8JwiDeK0rJnwQGIyI8M-zQPSkRf_A4Ez_EBX_Nx4fsHmdMeoeIqZLgOeX3tO7RoSA2PPeMcGoRIbdPMtwf0VSRTrkb/s4032/IMG_3987.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi0C9fGtDwdeFBt2d6OQ5tUYWOjHFKN9CqzAENjEhs2nJe2jsnqFpJfRBaiLQug-QVCbDNc2i0NvQaKvw_jBQB70NVGT3JbgW8JwiDeK0rJnwQGIyI8M-zQPSkRf_A4Ez_EBX_Nx4fsHmdMeoeIqZLgOeX3tO7RoSA2PPeMcGoRIbdPMtwf0VSRTrkb/s320/IMG_3987.JPG" width="240" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">What is optimal heart health? Is it normal heart arteries on cardiac catheterization? Is it the ability to run a marathon? Is it playing a round of golf and walking the course? Is it being able to do moderate exercise without shortness of breath? </span>There are many different and unique perspectives on this question. <span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">The American Heart Association’s (AHA) perspective defines optimal heart health using eight variables dubbed “Life’s Essential Eight”.<o:p></o:p></span></p><div class="separator" style="clear: both;"><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;"><o:p> </o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">The AHA initially defined seven variables for optimal heart health in 2010. After 12 years and lots of subsequent research, the AHA updated these seven parameters and added a new one this summer. Here is an update to the original seven with a deep dive into the eighth.<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><b><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">Diet</span></b><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">- this was updated to encourage everyone to follow one of the known heart healthy diets; DASH (Dietary Approach to Stop Hypertension) or a Mediterranean Diet.<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><b><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">Physical Activity</span></b><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">- no change was made. The optimal level of activity is still 150 minutes per week of moderate physical activity or 75 minutes per week of vigorous exercise.<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><b><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">Nicotine exposure</span></b><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">- updated to discourage the use of e-cigarettes (vaping) and to reduce exposure to second hand smoke.<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><b><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">Body Mass Index</span></b><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">(BMI) – BMI is body weight divided by height and is a measure of overweight or obesity (A BMI calculator may be found here: https://www.calculator.net/bmi-calculator.html). There was no change to the ideal BMI: between 18 and 25 kg/m2. <o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><b><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">Lipids</span></b><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">- the updated metric for blood lipids is non-HDL cholesterol (total cholesterol minus HDL). The ideal non-HDL cholesterol for optimal heart health is < 130 mg/dl.<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><b>Blood sugar</b>- optimal levels for non-diabetic patients are a fasting blood sugar < 100 mg/dl or Hemoglobin A1C < 5.7%.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><b>Blood pressure</b>- the optimal blood pressure is less than 120/80 mmHg; 130/80 and above is considered hypertension.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">The new variable is sleep duration. According the AHA, the ideal duration of sleep for optimal heart health is between seven and nine hours per night. The importance of sleep on overall health has been well documented and known for years. Poor sleep can lead to irritability, anxiety, reduced cognitive performance (including loss of concentration and poor decision making), Alzheimer’s disease and increased risk for obesity, diabetes, heart attack, stroke, hypertension, atrial fibrillation and cancer. Several recent studies outline the risks of not getting a good night’s sleep. A study from the US (6,820 people, mean age 53) looked at various measures of sleep health. Those with poor sleep health had a 54% increased risk for cardiovascular disease. In another study of young healthy people, sleeping only four hours per night added extra weight and specifically added “belly fat”, which has an increased risk for heart disease. The association between sleep and metabolic disease was shown again in a study in women. Sleeping less than 7 hours per night altered glucose (blood sugar) metabolism, leading to diabetes and hypertension. Since sleep is so important, let’s tackle some pressing questions about sleep such as the optimal sleep duration, the best time to go to bed, melatonin and sleep trackers.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">What is the optimal amount of sleep? There seems to be a “right” amount of sleep, at least as far as cognitive function is concerned as demonstrated in two recent studies. One study of elderly patients showed dramatic decline in brain function for those who slept less than 4.5 hours or more than 6.5 hours per night. In patients who slept less than 6 hours per night, there was a greater burden of amyloid in the nervous system, a marker for Alzheimer’s disease. Another study from the United Kingdom (500,00 patients, 38-73 years) showed that seven hours of sleep per night was optimal for cognitive performance. Therefore, seven hours of sleep seems to be the sweet spot for optimal health for middle aged and elderly people (children and adolescents need more sleep). Now that we know the optimal amount of sleep, is there an optimal time for bed? An interesting study (88,000 patients, average age 61) answers the question. Researchers found that going to sleep before 10 PM or after midnight increased the risk for heart disease. Those who went to sleep between 11 and 11:59 PM had a 12% higher risk for heart disease and those who hit the sack before 10 PM or after 12 AM had a 24% higher risk. The people who went to bed between 10 PM and 10:59 PM had the lowest risk for heart disease in the study; thus defining the optimal time for bed. In this study, timing of sleep was actually more important then duration of sleep. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">If there is difficulty falling asleep and getting the recommended amount of sleep, does melatonin help? Melatonin is a hormone produced by the brain. As darkness falls, the brain senses that it is nighttime and releases melatonin. The elevated levels of melatonin help us fall asleep and stay asleep. As dawn breaks, melatonin levels go down and we wake up. Can over the counter melatonin help people who have trouble falling asleep (insomnia)? Melatonin has been available for quite some time and is felt to be safe, but no formal studies have been done. Over the counter melatonin is not benign. It has effects on body temperature, blood sugar and blood vessel tone. In addition, since it is not regulated by the FDA, melatonin doses vary widely. The American Academy of Sleep Medicine is currently reviewing the safety and efficacy data of melatonin. Until the review is complete, they recommend that it not be used for insomnia.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Are there devices that can help track sleep? There are a variety of sleep tracking devices that fall into two broad categories: devices put under a mattress or pillow and wearable devices. The devices may help to tell you when you went to sleep and your total sleep time. However, no device can diagnose sleep apnea (stopping breathing). In addition, when compared to a formal sleep study (the gold standard for sleep), no device can accurately measure sleep quality. In addition, no sleep tracker or sleep app is endorsed for use by national sleep academies or sleep specialists.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><span style="font-family: Cambria; font-size: 12pt;">So for optimal heart and brain health, go to sleep between 10 PM and 10:59 PM and try to get, on average, seven hours of sleep. Skip the melatonin and the sleep tracker. How many people get enough sleep and score highly on Life’s Essential Eight? It turns out that only one in five US adults (20% of people) have optimal heart health according to the AHA checklist. That certainly is not good; let’s start to improve those numbers. </span></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-79226221752434563312022-07-05T15:57:00.000-07:002022-07-05T15:57:28.988-07:00It's Summer Time!<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiGvKrI11byfSNgTKJvuZhLW6lA79IWSH_GBtVjYtPRaDuBEhq0uzFakrRTuYll57RPOFkmAgsbmxkX0M2Tt9191fl6Uxl3sr5aFpqFmVphQlXaF6w8jrHCSIgUpEp6EnMwNuKkS1e9rLVKr80ci-7T0Zt1sK39Bqp0vmNPyJlU8aVbdPFsZPL5_Vi_/s1024/thumb_IMG_3942_1024.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1024" data-original-width="768" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiGvKrI11byfSNgTKJvuZhLW6lA79IWSH_GBtVjYtPRaDuBEhq0uzFakrRTuYll57RPOFkmAgsbmxkX0M2Tt9191fl6Uxl3sr5aFpqFmVphQlXaF6w8jrHCSIgUpEp6EnMwNuKkS1e9rLVKr80ci-7T0Zt1sK39Bqp0vmNPyJlU8aVbdPFsZPL5_Vi_/s320/thumb_IMG_3942_1024.jpg" width="240" /></a></div><br /><p></p><p class="MsoNormal" style="font-family: Calibri; font-size: 11pt; line-height: 15.693333625793457px; margin: 0in 0in 8pt;">Summer has arrived. It is time for all of those fun summer activities: golf, tennis, hiking, swimming, kayaking and sitting on the beach. Unfortunately, summer poses some unique risks for the heart patient. How does the heat affect the heart? Is vacationing good for cardiac health? If so, what type of vacation is beneficial? These questions and more will be answered!<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri; font-size: 11pt; line-height: 15.693333625793457px; margin: 0in 0in 8pt;">The extremes of temperature, either very hot or very cold, are known to cause additional stress to the heart patient. It is well known that heat waves cause a surge in deaths and hospitalizations for heart disease. Elderly patients are more prone to dehydration which can lead to low blood pressure and increased blood clotting. In addition, very hot temperatures increase the work load of the heart. These effects can lead to a subsequent heart attack or passing out or congestive heart failure. A recent study showed that for each additional extreme heat day (defined as heat index over 90 degrees) there is a 0.13% increase in deaths from heart disease. This translates to an additional 600 to 700 deaths per year in the US due to the heat. With three times as many heat waves per year now compared to the 1960’s, heat related illness must be taken seriously. <o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri; font-size: 11pt; line-height: 15.693333625793457px; margin: 0in 0in 8pt;">In the absence of a heat wave can a warm summer night be just as risky? Recent research showed that a rise of just 1.8 degrees Fahrenheit in the usual summer-time temperature caused a 3-5% increase in heart related deaths in men aged 60 to 64, but not in men over 65 or in women. It seems that nighttime temperature had a more potent effect than daytime warmth on death and heart disease. The reason for this is not clear. Socio-economic factors are an issue; those without air conditioning would be more vulnerable to warm temperatures. An intriguing theory involves sleep deprivation. Hot summer nights, especially without air conditioning, could lead to more tossing and turning, interrupting sleep patterns with subsequent increase in blood pressure, heart rate and risk for cardiac events. <o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri; font-size: 11pt; line-height: 15.693333625793457px; margin: 0in 0in 8pt;">One way to escape the heat is to go on vacation. Can taking a vacation reduce the risk for cardiac events? The Framingham Heart Study showed that men who didn’t take a vacation for many years were 30% more likely to have a heart attack than men who took a yearly vacation. The same study concluded that women who took vacations once every 6 years were 8 times as likely to have heart disease as those who took more frequent time off. The MRFIT trial followed 12,000 men for nine years. It showed that men who took annual vacations were 21% less likely to die and 32% less likely to die from heart disease. Vacationing may have a direct protective effect on heart health for the following reasons. First, vacationing reduces stress and releases one from job demands. Next vacationing may have restorative effects by promoting social contact with family and friends (“reconnecting”). Lastly, certain types of vacations increase physical activity.<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri; font-size: 11pt; line-height: 15.693333625793457px; margin: 0in 0in 8pt;">So vacations are good for cardiac health. What type of vacation is beneficial; an active vacation or relaxing on the beach? One study from Austria helps answer the question. It showed that an active vacation involving walking, biking or golfing reduced blood pressure and heart rate and helped improve cardiac function. Therefore, an active vacation may improve cardiac health more than lying in the sun. It seems that physical activity during leisure time (including vacations) is beneficial. How does physical activity during leisure time compare to physical activity at work? The Copenhagen General Population Study followed 104,000 people over 10 years and had an interesting answer to the question. The study found that physical activity during leisure time reduced the risk for cardiac events by 15% and the risk for death by 40% but physical activity at work <b>increased</b>the risk for cardiac events and death. They called this the “physical activity paradox”. Why is this? They theorized that leisure time activity was more dynamic, more likely to improve cardiorespiratory fitness and allows sufficient recovery time. Physical activity at work, on the other hand, is more static, monotonous, often occurring with awkward positioning and did not allow for meaningful recovery time. <o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri; font-size: 11pt; line-height: 15.693333625793457px; margin: 0in 0in 8pt;">So as we head into summer, make those vacation plans. Then dust off the golf clubs or hiking boots. Lastly, crank up the air conditioning at night and get a good night’s sleep.<o:p></o:p></p><p class="MsoNormal" style="font-family: Calibri; font-size: 11pt; line-height: 15.693333625793457px; margin: 0in 0in 8pt;"><o:p> </o:p></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-66288026796543876342022-06-06T16:11:00.000-07:002022-06-06T16:11:22.491-07:00The Calcified Aortic Valve<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOF4_ezeH7iaCAYpqteWNyoc9snNFWOBqGqjuGkhUglj2pDAbTWxoUXvT_CxymZC1LNYoLepmxSyc4SCZxo1Ss2i6ALtaANm9n9uS4865JgjAC8D5zUC8iPEBNi1AZQwAVGWf3hSnAyYGoHYzfa7NoJCU8HKTdRCwlW2KltyyWa3kQ3FzXTln5OfWL/s4032/IMG_3823.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgOF4_ezeH7iaCAYpqteWNyoc9snNFWOBqGqjuGkhUglj2pDAbTWxoUXvT_CxymZC1LNYoLepmxSyc4SCZxo1Ss2i6ALtaANm9n9uS4865JgjAC8D5zUC8iPEBNi1AZQwAVGWf3hSnAyYGoHYzfa7NoJCU8HKTdRCwlW2KltyyWa3kQ3FzXTln5OfWL/s320/IMG_3823.JPG" width="240" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">The aortic valve is a three-leaflet valve situated between the left ventricle (the main pumping chamber of the heart) and the aorta (the main artery leading from the heart). When the left ventricle contracts to send blood to the body, the aortic valve opens to allow the blood to flow out. After the blood is ejected, the valve closes to prevent blood from leaking back in to the heart. The aortic valve opens and closes, under a tremendous amount of pressure, with each heartbeat, for our entire lives. Because of this, the aortic valve is subject to “wear and tear” over time. As the valve wears down, the leaflets become thickened and calcium is deposited to repair microtears in the valve. As the valve becomes more thickened and calcified, it doesn’t open fully, restricting the blood flow from the heart. This pathologic condition is called calcific aortic stenosis. When there is significant restriction of the blood flow, it is called severe aortic stenosis. Severe aortic stenosis may cause chest pain, passing out, congestive heart failure or sudden cardiac death. Unfortunately, once severe symptomatic aortic stenosis occurs, there is no medication to treat it. The only way to restore blood flow is to replace the valve. This is done by surgically removing and replacing the aortic valve or, more recently, the valve can be replaced without surgery by inserting a new valve through the artery in the groin (TAVR). Currently there are no medications that can prevent calcific aortic stenosis or slow its progression once it occurs. Or is there?<o:p></o:p></p><div class="separator" style="clear: both;"><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Calcific aortic stenosis is very common occurring in 2% of people over the age of 65 and 4% over 85 years old. It is associated with older age and shares other risk factors for atherosclerosis (blockage in the heart arteries). It has been known for some time that plasma lipids (cholesterol) are involved in the process of thickening and calcification of the aortic valve. It seems reasonable to presume that if elevated cholesterol is a risk factor that lowering cholesterol with a statin would halt the process. Many studies with statins have been performed. Unfortunately, statins do not halt the progression of severe calcific aortic stenosis. What if a statin is started before the disease is far advanced? Again, statins did not slow the progression in patients with mild aortic stenosis. So, lowering cholesterol doesn’t work. Are there other targets? One possibility is PCSK9. PCKS9 is a protein involved in the production of LDL cholesterol. In patients with heart artery disease PCSK9 inhibitors (such as Praluent or Repatha) dramatically lower LDL cholesterol and reduce the risk for heart attack and cardiac death. Recently it has been shown that patients with calcific aortic stenosis have higher levels of PCSK9. It is felt that PCSK9 plays a role in mediating aortic stenosis through inflammation and the stress responses of the cell. Do PCSK9 inhibitors slow the progression of calcific aortic stenosis? We don’t know, but future trials may give an answer. Another possible target is lipoprotein a. Lipoprotein a is an LDL like particle that is also associated with elevated risk for heart artery disease. Elevated levels of lipoprotein a have been shown to correlate with progression of calcific aortic stenosis as well. Patients with the highest level of lipoprotein a were twice as likely to need aortic valve replacement as patients with low levels of the protein. Statins do not lower levels of lipoprotein a, but PCSK9 inhibitors do. Whether this translates to a beneficial effect for calcific aortic stenosis is not known, but it seems a trial with these agents is badly needed. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Another potential target is cardiac amyloid. What is amyloidosis? The pathogenesis of amyloid involves a protein called TTR which is produced by the liver and aids in transporting thyroid hormone. In some people (older patients, patients with genetic predisposition), TTR clumps together to form amyloid fibrils. These amyloid fibrils are deposited in many tissues in the body, but especially the brain, the nerves and the heart. Amyloid deposition in the heart can cause a variety of problems including congestive heart failure as well as calcific aortic stenosis. In patients older than 75 years old with aortic stenosis, 14% have cardiac amyloid. Cardiac amyloid is treated with a medication called Tafamidis, which stabilizes TTR and prevents the formation of amyloid fibrils. Tafamidis slows the progression of cardiac amyloid in patients with congestive heart failure, but it is not known whether it does the same for calcific aortic stenosis. This too may be a promising area and ripe for future research. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Another potential target is calcium. Since calcium is deposited in the aortic valve do calcium supplements increase the risk? A study of 2600 patients with mild to moderate aortic stenosis found the following. Aortic valve replacement was ultimately needed in 50% of patients taking calcium supplements versus only 11% in patients not taking supplements. It was concluded that long-term calcium supplementation should be avoided in calcific aortic stenosis. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">If you have calcific aortic stenosis, don’t despair. A newer and better treatment (TAVR) has already dramatically changed the life for many a patient with this disease. Although we currently cannot stop calcific aortic stenosis or alter its progression, newer targets and newer treatments may be on the horizon offering similar dramatic medical options to improve the lives of patients. In the meantime, hold those calcium supplements. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-31766473256735037372022-05-10T13:29:00.000-07:002022-05-10T13:29:36.935-07:00April Showers Bring May Green Prescriptions<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhWakrLK0nWY99FuFSgnDDrObaL5eO27QpfgfXpYsGbRmM4GTpHeWxMD-LxI6Oa9GpFfAdzDS9RzqawxmoKdOxsZ69IENr16K5g-U8TLkNUwFNEQidV7sga2-Py_m8GNqibWhbGRydT0cKsb7VdYeRFIDnk6zKwTOZBpC-2rNfUvPti-Qv9SFvMG6b7/s4032/IMG_2052.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhWakrLK0nWY99FuFSgnDDrObaL5eO27QpfgfXpYsGbRmM4GTpHeWxMD-LxI6Oa9GpFfAdzDS9RzqawxmoKdOxsZ69IENr16K5g-U8TLkNUwFNEQidV7sga2-Py_m8GNqibWhbGRydT0cKsb7VdYeRFIDnk6zKwTOZBpC-2rNfUvPti-Qv9SFvMG6b7/s320/IMG_2052.JPG" width="240" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">As the rain in April turns into the beautiful trees, shrubs, grass and flowers of May, we can see that green is good! As we sit gazing out of our window at the marvelous greenery, we wonder, “Is it better to exercise indoors in a gym or outdoors in nature? How else is green good for health?” The US Environmental Protection Agency has estimated that Americans spend 90% of their time indoors. Is this healthy? Should we heed our mothers’ advice and “Go outside and get some fresh air”?<o:p></o:p></p><div class="separator" style="clear: both;"><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">It has been felt for a long time that getting back to nature, spending time in natural environments, had positive mental and physical effects. Being outside supposedly lowered blood pressure, decreased obesity, helped with diabetes, reduced anxiety and depression, lessened stress, and promoted physical activity while combating sedentary leisure time. Because of these effects, doctors have given out nature prescriptions, essentially encouraging patients to get outside. There is even a Japanese practice called “forest bathing” (shinrin-yoku) whereby health benefits are obtained just by sitting in nature. Is there any data to support these health claims? One study of forest bathing showed that the practice increased natural killer cells and other cancer fighting proteins. Researchers theorize that the trees emit compounds that help plants fight disease, but apparently also help humans fight cancer as well. Another study showed that exercising in natural environments reduced stress, decreased anger, lessened depression and improved energy compared to exercising indoors. A different study compared a three-hour mountain hike with walking on treadmill indoors and with sedentary activities. Mountain hiking improved a variety of psychological parameters compared to the treadmill and sitting indoors. A 2019 study looked at nearly 20,000 people in England and found that spending two hours per week in green spaces (parks or other natural environments) improved people’s health and psychological well-being. The two hours could be all at once or spread over the week. The two hours also held for those who were ill or disabled, suggesting the time in nature was the key rather the effect of healthier people outside exercising more often. It seems that exercising outside, in a natural green space, is better than indoors. Even if the data isn’t entirely true, there is no downside risk to being outside except for encountering a few raindrops now and then.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">How about living near green spaces? Is there a health benefit? One study looked at the green space of Toronto. They found that people who live in areas with more trees had less hypertension, diabetes, heart attacks and stroke. They found that having 11 or more trees in a city block reduced the risk for cardiac disease. In addition, researchers looked at NASA images of the United States and categorized each county’s greenness (a measure of trees, shrubs and grass). For every 0.1 unit increase in greenness, deaths from heart disease fell by 13 deaths per 100,00 people. This was confirmed in a study from Spain. People who live near green spaces had a 16% reduction in their risk for stroke. The mechanism of benefit of green spaces may be the lower amount of air pollution and better air quality in general in these areas. Green is good!<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Another type of green is good for overall health. Green leafy vegetables (for example, arugula, green beans, kale, spinach, asparagus, broccoli, zucchini) have significant health benefits. Three servings a day reduced the risk of diabetes by 13% and lowered the risk for heart disease by 24%. Now there is new information about a different green. Add avocado to the list of healthy greens. People who ate two avocados per week had a 22% lower risk for developing cardiovascular events.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="color: #222222;">How can we put all this greenness to work for us? With a Green Prescription. The prescription itself is more than just a ticket to get medication at the pharmacy. It is a contract between the doctor and the patient. With that in mind, here is your contract with your doctor and with nature, the Green Prescription: <o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="color: #222222;">1) Spend 120 minutes per week outdoors in nature<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="color: #222222;">2) Eat 3-4 servings of green leafy vegetables per day<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="color: #222222;">3) Have 2 avocados per week<o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="background-color: white; background-position: initial initial; background-repeat: initial initial; color: #222222;">Munching on an avocado and some celery sticks while hiking through the forest is optional.</span><span style="font-size: 10pt;"><o:p></o:p></span></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><span style="color: #222222; font-family: Arial; font-size: 10pt;"> </span></p></div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-65016481507873674682022-04-05T16:03:00.003-07:002022-04-05T16:03:55.110-07:00The Intersection of Breast Cancer and Heart Disease <p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-MymVId7R0ckLWODM0jS89wiRRzVhOGqzNVpf9z6R8jfMWsHWL3ZcHBZOEDYJhw4bRc0_Skk3toj5GcVSpI-WPP5vcEOqqmfleGZ2uVJhxnP8stUOo8FQ9Mu4uglzCunuXeB3H2fqzKEDGavjhkMOv6BQ5eK0ae--AwxtYHv4IcCj0bw68dTofM5s/s478/Breast%20artery%20calc.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="478" data-original-width="339" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-MymVId7R0ckLWODM0jS89wiRRzVhOGqzNVpf9z6R8jfMWsHWL3ZcHBZOEDYJhw4bRc0_Skk3toj5GcVSpI-WPP5vcEOqqmfleGZ2uVJhxnP8stUOo8FQ9Mu4uglzCunuXeB3H2fqzKEDGavjhkMOv6BQ5eK0ae--AwxtYHv4IcCj0bw68dTofM5s/s320/Breast%20artery%20calc.jpg" width="227" /></a></div><div class="separator" style="clear: both; text-align: center;">(Google Images)</div><div class="separator" style="clear: both; text-align: center;"><br /></div><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">A 69-year-old woman presents to her cardiologist with shortness of breath. She was diagnosed with congestive heart failure (CHF). An echocardiogram showed an ejection fraction (a measure of the pumping function of the heart) of 25%, representing a severe weakness of the heart muscle. Her past medical history is remarkable for left sided breast cancer diagnosed in 2000. She was treated with lumpectomy and chemotherapy. She was felt to be cancer free in 2008. What caused her CHF and her weak heart?<o:p></o:p></p><div class="separator" style="clear: both; text-align: center;"><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;">Breast cancer is the most common form of cancer in woman in the United States. Approximately 1 in 8 women will develop breast cancer. Breast cancer does occur in men as well, although it is rare, accounting for only a few cases per year. Breast cancer is treated with surgery, radiation therapy and chemotherapy. Fortunately, cancer treatments are curing more and more breast cancer. Unfortunately, those same treatments can cause heart disease, often years later. Radiation, especially to the left side, can affect all of the layers of the heart. It can affect the outer layer of the heart causing inflammation and chest pain (pericarditis). Radiation can damage the heart muscle and cause it to weaken. Lastly, radiation can cause blockage in the heart arteries. Studies have shown that patients who had radiation for left-sided breast cancer are twice as likely to have heart artery disease as patients with right-sided cancer. Radiation can accelerate blockage starting about 5 years after therapy and the effect may persist for up to 30 years. Chemotherapy agents are very good at inducing cures, but two agents in particular can cause significant heart damage. Adriamycin acts as a toxin to the heart muscle. It causes weakening and a reduction in the ejection fraction, leading to CHF, often 10 to 20 years after the chemotherapy is given. Unfortunately, Adriamycin’s effect is irreversible. Another agent, Herceptin (Trastuzumab) also causes a weak heart muscle and CHF. However, stopping the agent does allow the heart to recover function, so vigilance is needed during its administration. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;">Breast cancer and heart disease share a number of risk factors including: older age, poor diet, alcohol use, obesity, sedentary lifestyle and smoking. In a two for one deal, exercising, keeping weight down, not smoking and limiting alcohol not only reduces the risk for heart disease, but also lowers the chance of getting breast cancer. This advice is valid for both women and men (remember, men can get breast cancer as well). Two strategies in particular are worth noting for their reduction in both heart disease and breast cancer: exercise and taking a statin for cholesterol. Exercise capacity has shown to be a prognostic factor in breast cancer. Patients with higher levels of physical activity have a lower risk of developing breast cancer and dying from the disease. Patients with better cardiorespiratory reserve, developed from years of exercising, can tolerate the toxic effect of chemotherapy. These patients suffer less cardiac side effects during treatment. In addition, these patients are more likely to stay active during chemotherapy, thus lessening their risk further. Statins may be protective as well. Women who were taking a statin during chemotherapy had a lower risk for CHF. This may be because, beyond lowering cholesterol, statins decrease inflammation and stress in heart cells. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;">Screening for breast cancer may be a useful tool for screening for heart disease too. The mammogram (an X-ray of the breast) is the standard test for screening for and detecting breast cancer. If a suspicious area is seen on mammography, then a biopsy is done to confirm or rule out cancer. Breast artery calcification may also be seen on mammography. Breast artery calcification, like heart artery calcification, signifies the presence of plaque or blockage in the arterial wall. Heart artery calcification on CT scan is associated with a higher risk for heart attack and heart death and a reason to intensify preventive treatments. Does breast artery calcification have the same prognostic significance? In a study of 5000 women (all over age 60) who did not have breast cancer or heart disease, 26% were found to have breast artery calcification. Those with calcification were twice as likely to have heart disease or stroke. In another two for one deal, it looks like mammography can screen for bother breast cancer and heart disease. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt; text-align: start;">The index case and the three intersections between breast cancer and heart disease teach us the following lessons. Patients who have had breast cancer and who had radiation or certain types of chemotherapy must remain vigilant about heart symptoms and see their doctor if symptoms do occur. With common risk factors, following a healthy lifestyle reaps rewards in numerous ways. Lastly, artery calcification anywhere in the body must be taken seriously and preventive medications must be initiated. Following these measures can help avoid two deadly diseases: breast cancer and cardiovascular disease.<o:p></o:p></p></div><p></p><div class="separator" style="clear: both; text-align: left;"><br /></div><br /> <p></p>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-6619506163557319420.post-3202183033512463642022-03-08T17:16:00.000-08:002022-03-08T17:16:01.829-08:00Cholesterol-Years<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEjQMufCfrIwXVpdcbL7QOqZspctMXTzBYc02J2ddoiSQTC_21OyOubF_58rE9XSiGNyDUA6LiWxX_JoclzftYAy8YPllXaYy9PizEcHjk_bs__ffqZPZD3bMDri-52Ks5NEkqHKd95Hgz0DbIV_izLTEz2YtbBSQgqidJi2Wgq_gwYNAnkkoa53Kz7z=s274" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="184" data-original-width="274" height="184" src="https://blogger.googleusercontent.com/img/a/AVvXsEjQMufCfrIwXVpdcbL7QOqZspctMXTzBYc02J2ddoiSQTC_21OyOubF_58rE9XSiGNyDUA6LiWxX_JoclzftYAy8YPllXaYy9PizEcHjk_bs__ffqZPZD3bMDri-52Ks5NEkqHKd95Hgz0DbIV_izLTEz2YtbBSQgqidJi2Wgq_gwYNAnkkoa53Kz7z" width="274" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Let’s evaluate the cardiovascular risk for three hypothetical scenarios. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">A 50-year-old office worker who, prior to the pandemic, was not overweight and had normal cholesterol levels. He has no family history for heart disease. During the pandemic, he worked from home, stopped exercising, did not watch his diet and gained 25 pounds. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">A 50-year-old construction worker who has had high cholesterol all of his life, but has not been on medication. His father and brother both had heart attacks in their fifties. During the pandemic, he was active at work, exercised on the weekends and didn’t gain any weight. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">A 65-year-old woman who did not have high cholesterol until menopause. She has no family history of heart disease, is active and eats a Mediterranean diet. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">All three recently had blood work and the results are the same; cholesterol 250, HDL cholesterol 30, LDL cholesterol 135. All three are nonsmokers, do not have diabetes or high blood pressure and are not taking a statin. Entering their information into the American College of Cardiology (ACC) risk calculator yields similar results: they each have a 7.2% risk for a heart attack or stroke over the next ten years. Even though their cholesterol numbers and their risk levels are the same, is the risk for heart disease the same for all three people?<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">Unfortunately, the ACC risk calculator does not factor in family history of heart disease. It has been known for quite some time that having a first degree relative with heart disease at an early age is a strong risk factor for heart disease. One of the reasons for premature heart disease in families is a genetic tendency for high cholesterol, especially elevated levels at an early age (a condition known as familial hyperlipidemia). Premature heart disease is a major consequence of familial hyperlipidemia. Familial hyperlipidemia is suspected in a patient who has: 1) heart or vascular disease at a young age (for men under the age of 55, for women under 60); 2) a family history of vascular disease at a young age; 3) tendon xanthomas (cholesterol deposits on tendons - pictured above); 4) a very high LDL cholesterol (over 155 and often in the 200 to 300 range). Why do people with familial hyperlipidemia develop blockage in heart arteries earlier than those who don’t have this condition? The answer is that the plaque forming effect of LDL cholesterol is dependent on both the level of LDL and the duration of elevation. The risk for heart artery disease can be expressed in “cholesterol-years” or the average LDL level times the number of years of exposure (this is similar to a core concept in cardiology, pack years, the average number of packs of cigarettes smoked times the number of years smoked). Plaque begins to form in the heart arteries after a certain threshold of LDL exposure is reached. For example, a person can have an average LDL level of 100 mg/dl for 70 years resulting in 7 grams/dl cholesterol-years. If 7 grams/dl is the threshold for developing plaque then they will manifest heart artery disease at age 70. On the other hand, a person with familial hyperlipidemia may have an average LDL of 200 mg/dl, reach 7 grams/dl cholesterol-years and develop heart issues at 35 years old. The theoretic threshold for developing disease is lower if there is hypertension or diabetes. The threshold will be higher if a healthy lifestyle keeps LDL lower for longer.<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">The concept of cholesterol-years may explain why women manifest heart disease at later ages than their male counterparts. It is well know that women have low levels of heart disease (compared to men) until they hit menopause. After menopause, the rate of cardiac disease accelerates exponentially. This is because total cholesterol and LDL go up dramatically in the year after the onset of menopause. Due to the protection afforded women by their hormones before menopause, their cholesterol-years or their years of LDL exposure are less than men (especially in their teens, twenties and thirties) and therefore heart disease is shifted towards older age (when their cholesterol-years catch up to men).<o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">With this information in mind, let’s rank the scenarios. The 50-year-old office worker has the lowest risk for heart artery disease. His cholesterol only went up over the past two years. He has a low number of cholesterol-years and a lower lifetime exposure to LDL than his counterparts. He should initiate lifestyle changes immediately. The 65-year-old woman has the next lowest risk. Her cholesterol was low until menopause, rising to high levels over the past 10 years. She has been following a good diet and exercising, so she may need to be started on a statin. The 50-year-old construction worker with familial hyperlipidemia has the highest risk. He has about 6.7 grams/dl cholesterol-years (average LDL 135 mg/dl over 50 years) and should also be started on medications immediately. <o:p></o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;"><o:p> </o:p></p><p class="MsoNormal" style="font-family: Cambria; margin: 0in 0in 0.0001pt;">The cholesterol-years approach is a measure of exposure over time and better than relying on a single measurement of LDL. This concept also favors intervening to lower cholesterol at an earlier age, say ages 18 to 30, with lifestyle alterations or medications to protect against cardiac disease later in life. </p>Unknownnoreply@blogger.com0