Heart Attacks and Hypertension in the Time of COVID-19

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

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

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

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

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

The Olive Tree

Olive Tree. Naxos, Greece

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

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

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

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

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

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

Coronavirus Exposes the Downside to a Healthy Community

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

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

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

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

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

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

What Could Possibly Be New in the World of Hypertension?

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

What is the definition of high blood pressure?

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

"My blood pressure is all over the place"

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

Where is the best place to measure the blood pressure? 

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

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

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

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

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

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

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

Is alcohol good or bad for the blood pressure?

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

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

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

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

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

The Cardiac Consequence of Sound

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

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

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

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

What's Your Score?

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

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

Low Risk: 0- 5%

Borderline Risk: 5-7.5%

Intermediate Risk: 7.5-20%

High Risk > 20%

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

LDL > 160 mg/dl,

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

triglycerides > 175 mg/dl, 

peripheral arterial disease, 

chronic kidney disease, 

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

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

family history of premature heart disease, or 

premature menopause

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

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

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

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

The Cardiac Christmas Catalogue

What should you get for the heart patient who has everything this holiday season? Technology and digital health are all the rage. Since 2013 the number of people tracking their health data has doubled. Wearable electronic devices can capture a wide range of health data and can be very useful for the health of and the care of the heart patient.  Wearable devices have sensors that are incorporated into a watch or clothing or can be worn like a vest.  What kind of wearables are available for the heart patient in your life?

Fitbit

Apple Watch

Kersh activity monitor

Kionix Accelerometer

SenseWear Pro3 armband

Zephyr BioHarness:

These accelerometers can measure activity and mobility. The devices estimate step counts or the number of miles walked per day. This can be very helpful for the individual to track his or her own activity.  They can differentiate between exercise and standing. Workouts (such as running or cycling) can also be tracked. In addition, the Apple watch has a heart rate monitor and there are available apps which are designed for sleep tracking (measuring sleep time, breathing and snoring).  These features are useful not only for the individual, but they have medical applications.  The accelerometers are being used to monitor cardiac rehab patients and patients with congestive heart failure, with real time interventions to keep the patient active and moving. 

Apple Watch 4 and 5, AliveCor:

The Apple watch uses light sensor technology to see if there are irregular contractions of the heart. If so, an algorithm decides if there is atrial fibrillation (Afib, an irregular rhythm from the upper chambers of the heart).  The AliveCor device has a small external monitor with two electrodes. The patient places two fingers on each electode and an electrocardiogram (EKG) is recorded. Again an algorithm can help decide if Afib is present.  How accurate are these devices in detecting Afib? The Apple Heart Study was a huge study (more than 400,000 participants) recently published in the New England Journal of Medicine. The study claims that the watch was 84% accurate in diagnosing Afib.  This sounds impressive, but the study has flaws.  Only 6% of the participants were over age 65 (the age group most at risk for Afib) while 52% were under 40 years old (a very low risk population).  The Apple watch found an irregular pulse in only 0.16% of those under 40, most of whom did not have Afib on further testing.  In the over 65 age group, 3.2% had an irregular pulse, but again only a small number had Afib.  In all, only a few hundred participants among the more than 400,000 actually were diagnosed with Afib.  We don’t know whether these few hundred participants had clinically significant Afib  (meaning that medications needed to be added or adjusted for the Afib). While the technology seems promising, it needs to be tested in a population that is prone to Afib. 

Omron Heart Guide:

This device is a wrist-based wearable that takes blood pressure (BP).  The smartwatch has a secondary, inflatable strap that works like a small BP cuff on the wrist.  To take a BP reading, the arm is held at chest level and a button is pressed. The BP is displayed, along with a notification (green if the BP is good, red if the BP is high).  It has been shown that BP taken at home is more accurate and more predictable of cardiac outcomes than BP taken in a doctor’s office.  So this device may make a difference for the hypertensive patient. In addition, this device gives 24 hour BP trends, which have also shown to be important. On the plus side, this wearable was approved for use by the Food and Drug Administration (FDA).  On the other hand, it is bigger and heavier than an average smartwatch and it is quite expensive ($500). 

ReDS vest:

This wearable may be beneficial in the detection of and management of congestive heart failure (CHF). CHF occurs when the lungs fill up with fluid.  In the United States, CHF is the most common reason for hospitalization.   The ability to detect fluid build up in the lungs before full-blown CHF occurs would be a major advance for patients, avoiding many hospital stays.  This device works on dielectric principles to estimate the fluid level in the lungs. The vest sensors do not require skin contact and can be worn over clothing. The vest calculates fluid volume in 90 seconds and relays the information to the patient’s doctor. If fluid is accumulating, medication can be adjusted before the patient runs into trouble.  In a study of CHF patients, the ReDS vest reduced hospitalization by 87%.  The vest is FDA approved and commercially available.

Life Vest:

CHF patients with weakened heart muscles are especially prone to sudden cardiac arrest, an irregular rhythm from the lower chambers of the heart. Sudden cardiac arrest is deadly unless the heart is promptly (within 10 minutes) defibrillated (shocked back into normal rhythm).  The automatic implantable cardiac defibrillator (AICD) is a device that is implanted in a patient and can detect these irregular rhythms and internally shock the heart back to normal. The AICD has been shown to save lives. However, there is often a period of several months between the diagnosis of a weakened heart muscle or a heart attack and AICD implantation.  This is where the Life Vest steps in. The Life Vest is worn 24 hours per day and requires skin contact.  It can detect and shock a patient who is in sudden cardiac arrest.  The VEST trial showed a 35% reduction in death between those who wore a Life Vest and those who didn’t. The Life Vest is currently being used as a bridge. If a patient’s heart recovers after an acute event then an AICD my not be needed. If the heart doesn’t recover, the patient is protected and an AICD is placed.

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