To Aspirin or Not To Aspirin

To aspirin or not to aspirin

That is the question

Whether ‘tis nobler in the mind to suffer

The slings and arrows of cardiovascular disease

Or to take meds against a sea of troubles

And by opposing end them.

 

Unlike Shakespeare, medical recommendations are not timeless. A medication may presently be prescribed for a given condition, but if new information comes out casting doubt on it’s effectiveness, then it may fall out of favor. The use of aspirin in the primary prevention of heart disease is the latest example of this, as reported by a new US government document. 

 

Aspirin’s anti-inflammatory and blood thinning properties are well suited for preventing heart disease. Aspirin thins the blood due to its effect on platelets.  Platelets are cells which circulate in the bloodstream. If there is a tear in the wall of a blood vessel (a cut) or if a cholesterol-laden plaque in an artery breaks open, the platelets rush to the site of the injury and initiate the body’s blood-clotting mechanism.  The resulting clot prevents bleeding from a cut or produces a clot within a heart artery, stopping the flow of blood and causing a heart attack.  Aspirin inhibits the platelet’s ability to form a blood clot. This puts the person taking aspirin at risk for bleeding (since the platelets cannot form a blood clot) and the blood is “thinned”.  Aspirin may cause bleeding in the stomach, the colon or the brain. 

 

Aspirin is a mainstay in preventing future cardiovascular events in patients who already have heart disease. This is termed secondary prevention. In a patient who already has had a heart attack, aspirin has been shown to reduce the risk of a second heart attack, stroke or death by 33%. In secondary prevention, the enormous benefit of aspirin in reducing the risk of a second event overwhelms the small increase in the risk for bleeding. Aspirin’s role in secondary prevention is not controversial and well established.

 

Primary prevention attempts to prevent a heart attack or cardiovascular event in a patient who does not already have heart disease. Aspirin’s role in primary prevention is less well established and quite controversial.  The issue in primary prevention is that aspirin lowers the risk for cardiovascular events by a little bit and raises the risk for bleeding a little bit with the bleeding risk outweighing the benefit (for the record, aspirin provides a 0.41% reduction in heart events but a 0.47% increase in bleeding). Whether to start aspirin in primary prevention is based on age, risk for heart disease and the risk for bleeding. In 2016, the US Preventive Services Task Force (USPSTF) recommended a low dose (81 mg) aspirin for adults aged 50 to 69 years old, who have a 10% or greater risk for cardiovascular disease (based on the American College of Cardiology cardiovascular risk calculator: http://tools.acc.org/ascvd-risk-estimator/), are not at increased risk for bleeding, and have a life expectancy of at least 10 years. In 2017, several large primary prevention studies looked at patients over the age of 60. These trials were consistent in showing that aspirin provided minimal benefit but had significant bleeding risks. Therefore, initiating aspirin for those over 70 years old for primary prevention was discouraged. 

 

In October 2021 the USPSTF updated their recommendations based on a review of 13 new trials, encompassing 161,000 patients.  They found that using aspirin for primary prevention:

1)  lowered the risk for heart attack or stroke but not cardiovascular death or all cause deaths

2)  increased the risk for gastrointestinal bleeding by 58% and bleeding into the brain by 31% compared to non-aspirin users.

3)  low dose aspirin (81 mg) didn’t lower the risk for brain bleeding compared to higher doses.

They concluded that aspirin use for primary prevention had a small benefit for people aged 40 to 59 years old with 10% or greater 10-year risk.  There is no benefit for persons 60 years or older. Lastly, the USPSTF saw no benefit for continuing aspirin for primary prevention in patients older than 75 years. 

 

After the release of the recommendations, the news media reporting left many people confused about whether to take aspirin. In an effort to clarify whether to take aspirin, consider the following scenarios. Realize that startingaspirin is different from continuingaspirin. The USPSTF’s recommendations are for initiating aspirin. So, if you are currently taking aspirin for secondary prevention, for any of the conditions listed below, DO NOT STOP ASPIRIN.

Heart attack

Heart stent

Bypass surgery

Stroke or mini stroke (TIA)

Stable angina (blockage in the heart arteries)

 

If you are taking aspirin for any of the following conditions, DO NOT STOP ASPIRIN. 

Plaque in the neck (carotid) arteries, aorta or leg arteries

Congestive heart failure 

Atrial fibrillation

Valve surgery (especially TAVR)

Elevated coronary calcium score

 

If you are taking aspirin for primary prevention, DO NOT STOP ASPIRIN. It would be beneficial to talk with your doctor about the pros and cons of continuing to take aspirin.  If you are considering starting aspirin to prevent a heart attack or stroke, realize that the benefit is only for younger, high-risk patients. For the vast majority of patients, starting aspirin in the absence of any of the conditions noted above is not beneficial.

 

So, farewell aspirin for primary prevention. Parting is such sweet sorrow.

 

 

Don’t Forget About The Flu

 

In September 2021, the United States surpassed 700,000 deaths due to COVID 19. This is certainly an enormous and tragic loss of life, but it is significant for another reason. The US now has more deaths from COVID 19 than it did during the 1918 influenza pandemic (675,000).  While COVID 19 has caused more morbidity and mortality, these sobering numbers remind us not to forget about the flu. How does influenza affect the heart and how much protection does the flu vaccine offer?

 

Influenza (“the flu”) is a very common, very contagious respiratory illness.  It is caused by an RNA virus. Influenza has three subtypes, A, B and C with A being the most common in humans (influenza can affect animals as well, causing, for example, swine flu or bird flu).  The virus consists of an RNA core surrounded by proteins. The most significant surface proteins are hemagglutinin (H) and neuraminidase (N).  When someone is infected with the flu, these surface proteins are targeted by the immune system.   In addition, these surface proteins help identify the type of influenza virus. For example, in 2009 there was a major pandemic caused by the H1N1 strain of influenza.  There are 17 H and 9 N types, but the most common human pathogens are H1, H2 or H3 and N1 or N2. H3N2 and H1N1 are the most common types of influenza A that infect humans. 

 

Influenza inflicts a huge burden on the healthcare system each year. It is responsible for almost a million hospitalizations and about 30,000 deaths per year in the United States.  Most cases of the flu resolve on their own, but certain populations are at risk for complications from influenza. This includes people over 65 years old, those with weakened immune systems, obese individuals, diabetics, and patients with underlying heart or lung disease. 

 

How does influenza affect the heart? During the acute phase of the illness, influenza stresses the body due to the symptoms and high fever. This causes an elevated heart rate and either a significant increase in blood pressure or severe lowering of the blood pressure. These effects put an increased demand on the heart and can precipitate a heart attack or congestive heart failure (CHF).  The virus may also infect the heart muscle directly and cause myocarditis (infection of the heart). In addition, influenza causes an intense inflammatory response. Inflammation plays a critical role in the progression of blockage in the heart arteries. Influenza infection accelerates the atherosclerotic process resulting in heart attacks. The inflammatory response also depresses heart function, leading to CHF.  Over the years, many studies have shown that influenza infection increases the risk for heart attack, cardiovascular death and overall deaths. The flu vaccine helps to prevent these cardiac complications.

 

The influenza vaccine is designed to produce an immune response to the virus.  Once the immune response occurs (usually within two weeks after vaccination) and someone becomes infected with the flu, the body is able to fight it off.  The key is to include the influenza viruses most likely to cause infection in a given year. The flu viruses are constantly changing and can change from one year to the next or even within a single flu season. Each year an FDA committee meets and picks the strains of influenza that it deems likely to be prevalent that year. Then manufacturers produce the vaccine. Trivalent vaccines include strains of influenza A in the H1N1 and H3N2 families plus a strain of an influenza B virus. Quadrivalent vaccines include the H1N1, H3N2 strains plus two types of influenza B strains. The ideal time for vaccination is before the flu season begins, allowing the body to develop the immune response. Typically this between September and November, but the vaccine may still be effective even in the middle of flu season.  Due to the wide variation in the strains of the influenza virus, the vaccine is only between 40 and 60% effective at preventing the flu (the Pfizer and Moderna COVID vaccines have an efficacy of about 95%). Now Pfizer and Moderna are working on flu vaccines based on the RNA technology used for COVID with trials starting soon. The RNA technology allows for more flexibility and more rapid manufacturing, potentially allowing for better strain matching. 

 

How effective are influenza vaccines at preventing heart complications?  In patients who have been hospitalized with the flu, there is a lower risk of heart attack and CHF in those vaccinated versus those who are unvaccinated. There is an 18% reduction in both heart deaths and overall deaths. In patients hospitalized with an acute heart attack, vaccinated patients had a 28% reduction in death or repeat heart attack over the following year compared to unvaccinated heart attack patients.  In people with CHF, getting the vaccine resulted in a 50% drop in death during the flu season and a 20% risk of death during the rest of the year. This is why every hospitalized patient is asked whether they want the vaccine during their hospital stay. This is why every doctor touts the vaccine for his or her patients.  Yet despite these impressive benefits and the public campaign for vaccination, only about 50% of heart patients over the age of 50 receive the flu vaccine in any given year.   

 

So remain vigilant regarding COVID 19 but don’t forget about the flu. Go out today and get your vaccine, especially if you have underlying heart disease.

 

 

 

The Cardiac Consequences of 9/11

The terrorist attacks on the World Trade Center on September 11 2001 shocked the nation, causing deep and lasting psychological and physiological effects.  Over the ensuing twenty years, numerous health problems have been described in the survivors of the attacks as well as the rescue workers. These effects include respiratory illnesses (chronic cough, asthma, bronchitis, sinus disease), several cancers (especially prostate and thyroid cancer, multiple myeloma, lymphoma, leukemia) and post traumatic stress disorder (PTSD).  The diseases are due to two main factors: dust inhalation and stress (both acute and long term). Do these same factors affect the heart? What are the cardiac consequences of the terrorist attacks?

 

Immediately after the World Trade Center attack there was an increase in heart attacks and arrhythmias, in the New York City area and beyond.  One hospital in Brooklyn reported a 35% increase in the rate of heart attack in the 60 days following the attacks. Another study looked at hospitals in New Jersey within a 50-mile radius of the World Trade Centers. The researchers showed a 49% increase in heart attacks within 60 days of the attack.  In addition, there was an increase in severe arrhythmias (irregular heart rhythms). Patients with an automatic implantable defibrillator (AICD) routinely have their devices interrogated. At the time of interrogation, any arrhythmia that has occurred since the last interrogation can be detected and the amount and severity of arrhythmia determined.  In the New York City vicinity, there was a significant increase in life-threatening arrhythmias seen in the AICD patients. The incidence of ventricular tachycardia and ventricular fibrillation (each of which can lead to cardiac arrest) doubled in the 30 days after the attack. This finding was not confined to New York City. AICD patients in Florida had a similar doubling of ventricular arrhythmias in the same time period. 

 

Did the attacks and the aftermath have any long-term effect on heart health? The World Trade Center Health Registry has followed rescue workers and lower Manhattan residents and office workers since the attacks. In 2010, they reported an increase in hospitalization for heart disease and stroke in the enrollees. PTSD (found in 22% of the women and 15% of the men) increased the risk for heart disease. Another study followed nearly 10,000 firefighters who responded on 9/11 and helped in the recovery afterwards. Over 16 years, there was an increase in heart attack, heart stents, heart surgery and heart deaths in this cohort of firefighters. The risk increased in those who responded earlier (44% higher risk for firefighters responding on 9/11 versus those who arrived later) and those who had longer exposure to the World Trace Center dust. 

 

There appear to be two mechanisms which increased the risk for heart disease after the terrorist attacks, exposure to dust and stress. It is well known that people exposed to air borne particulate matter are at risk for heart disease. For example, populations living in cities that have heavy air pollution are at higher risk for heart disease than those who live in cleaner air. The particulate matter from the World Trade Center dust was similar to air pollution. With more than million tons of dust, the exposure was extreme. The highest concentration was during and immediately after the collapse of the towers. This explains why firefighters with early exposure had more subsequent heart disease than others. Acute stress reactions, such as occur with natural disasters, are known triggers for heart attacks. An increase in heart attacks was reported after several earthquakes and the tsunami in Japan in 2011. The World Trade Center attacks certainly provoked acute stress reactions in many people.  Acute stress will activate the sympathetic nervous system, revving up the body. This in turn can lead to a heart attack, analogous to the out of shape man running for a bus in the cold. Since the body is not used to such a severe reaction, plaque in a heart artery can rupture, blood clotting is initiated and a heart attack occurs.  Chronic exposure to stress (for example, PTSD or living in chronic fear of a terrorist attack) keeps the sympathetic nervous activated, causing an elevated blood pressure and heart rate, increases inflammation, and promotes plaque formation in the heart arteries. In addition, the hormonal changes lessen the body’s ability to defend itself from a heart attack.

 

The World Trade Center attack was a horrible and tragic event on multiple levels. However, some good rises from the ashes. There are a couple of lessons for keeping the heart healthy that we can learn from aftermath of the attack.  The first lesson is to try to avoid areas with dust or particulate matter in the air (for example in the workplace or in polluted cities).  The second lesson is the importance of managing stress.  There are two ways to handle stress. The first is to avoid stress, which is difficult in our modern world. The second way is to manage stress by changing the reaction to it; to change the perception of stress. There are a variety of methods to cope with stress. These include meditation, yoga, deep breathing, laughter and pet ownership. In addition, exercise is an excellent way to relieve stress. Try taking a good brisk walk. Preferably outdoors. Preferably in clean air. 

 

 

How to Avoid Holiday Heart Syndrome

 

Labor Day marks the traditional end to summer. Families and friends will celebrate the holiday by getting together, barbequing and having a few cocktails. How many of those holiday revelers will end up in the hospital the following week with atrial fibrillation (Afib) and Holiday Heart Syndrome?

 

Afib is a fast, irregular heartbeat from the upper chambers of the heart (the atria). If left untreated it is associated with stroke and heart failure.  Holiday Heart Syndrome occurs in a patient who has recently had alcohol. It typically will occur two to four days after someone has had more alcohol than they usually are accustomed to. It is often seen after binge drinking, such as occurs during a holiday, thus the name.  The Afib episodes usually start during the night. Most of the time the Afib resolves on its own, but Holiday Heart Syndrome is serious. Patients may need cardioversion (having their heart shocked back into a normal rhythm) or may need long-term treatment with heart medications and blood thinners. In addition, 20-30% of patients will have recurrent Afib events within a year of the initial presentation. 

 

How much alcohol is required to induce Holiday Heart Syndrome?  The exact amount is not known, but some recent studies have shed some light on the question. One study concluded that drinking alcohol increased the risk for Afib within a few hours and the more alcohol, the higher the risk.  After only a single drink of alcohol, the risk of Afib increased two times in the next four hours.  After two drinks, the risk increased to three times and there was a linear increase in risk from there (more alcohol, more risk).  The conclusion of this study was that no amount of alcohol is safe for patients with Afib.  Another trial from England showed that four drinks per week or less did not increase the risk for Afib. Higher amounts did increase the risk (resulting in a J shaped curve).  They also showed that the type of alcohol mattered.  Wine (both red and white) was not associated with increased risk for Afib, while beer and cider, in any amount, increased the risk. 

 

But isn’t alcohol supposed to be cardioprotective?  It is true that light drinkers live longer than those who do not drink and those who drink heavier amounts of alcohol (also a J shaped curve). Light drinking (approximately one alcoholic beverage per day) reduces total cholesterol, increases HDL (the “good” cholesterol) and may be associated with a lower risk for heart attack. However, the data for the harmful effects of alcohol is stronger than the data for its beneficial effects. 

 

Alcohol doesn’t only affect the heart. Alcohol use affects brain function. One study showed that any alcohol use decreased brain structure and function compared to those who do not drink. The conclusion of the study was that no amount of alcohol is safe for the brain. Similarly, when it comes to cancer, no amount of alcohol is safe. Alcohol has been linked to several cancers including cancers of the mouth, throat, esophagus, colon, rectum, and breast as well as leukemia and multiple myeloma. The more alcohol consumed, the higher risk for cancer. Even light drinking was associated with esophageal and breast cancer. 

 

To summarize, the effects of alcohol on the heart are conflicting and confusing. Low amounts of alcohol intake can decrease mortality and help with the plumbing (less blockage in the heart arteries), but even those low levels can increase the risk for electrical problems (Afib). In addition, there is no safe amount of alcohol in cancer and for the brain. However, there is no safe level of driving. If you never get in a car, then you can never have a motor vehicle accident.  No one recommends that people stop driving. Some level of risk is present in everything that we do.  The idea is to balance the risk of everyday life versus hiding in a closet.

 

In order to stay safe this Labor Day Holiday and reduce the risk for Holiday Heart Syndrome, here are some recommendations.  If you have a history of AFib, it is likely best to avoid alcohol, or, if you must drink, have only a single drink on rare occasions.  If there is no history of AFib, limit alcohol use to one drink maximum per day and drink only a few days per week. Taking a day off from drinking helps the body to recover. Also, consider consuming wine rather than beer or cider. Stay safe and have a Happy Holiday.

 

Which Sport Wins the Gold Medal for Best Exercise?

The Olympic torch will finally be lit for the 2020 Olympics next week in Tokyo! More than 11,000 athletes will compete in 339 events representing 33 different sports. Before the Opening Ceremony begins, we will explore which sport is the best type of exercise.  Six different Olympic sports, tennis, running, cycling, weightlifting, golf and soccer, will be examined in terms of their exercise benefit but also some rarely considered downsides.  Orthopedic risks will not be covered; that is a topic for another time and for another writer. 

 

Exercise can be divided into two distinct classes: dynamic or isotonic exercise and static or isometric exercise. Most high intensity dynamic exercise is done aerobically. Dynamic exercise increases cardiac output and cardiac endurance.  Static exercise is mostly anaerobic, strengthens and increases muscle mass, increases bone density and helps with balance and coordination.  These two types of exercise are at the opposite end of the spectrum, but most sports involve both static and dynamic components.

 

Tennis is a sport with worldwide appeal, played by professionals as well as recreational athletes. Tennis has a high dynamic component but a low static component: it builds cardiac endurance but doesn’t add a lot of muscle mass.  Do the beneficial cardiac effects of tennis translate into better outcomes? The Copenhagen Heart Study followed 8500 people for 25 years and concluded that playing tennis increased life span by 9.7 years compared to sedentary individuals.  In fact, tennis was the top sport for extending life span, providing more years than running, cycling or weightlifting.  In another study of 80,000 British adults, tennis reduced the chance of death by 47% and cardiovascular disease by 59%.  Tennis certainly provides an exercise benefit, but why is it so effective at extending life compared to other sports? One reason may be that tennis players had the lowest body mass index in the Copenhagen study. In addition, the social aspect of tennis may be a factor. Socializing during and after tennis matches is quite common and it is known that having strong social connections improves quality and quantity of life. In addition, there is the mental aspect of tennis; there is a constant “mental chess game” throughout a match, helping to improve cognition and reduce the risk for dementia. What are the hidden risks for tennis? One study calculated the sun exposure risk for the various Olympic sports in Tokyo.  With higher sun exposure, the risk for melanoma and other skin cancers increases. The study concluded that tennis players had the highest risk for sun exposure due to long daytime matches, the reflective surface of the courts and clothing that is breathable but not protective from the sun’s rays.

 

The track and field events are among the most exciting contests of the Olympics. The men’s 100 meter dash crowns the “World’s Fastest Man” and the marathon is a signature event. Recreational running is one of the most popular sports worldwide with almost 60 million participants. Sprinting is a moderate dynamic, moderate static exercise while long distance running is high dynamic, low static. Running will extend life by 3.2 years (Copenhagen study) and reduce the risk for dying by 43% (British study).  However, running may not be fully protective against the development of heart disease. Several studies have shown that runners have high coronary calcium scores and more plaque in the heart arteries than would be expected.  In addition, studies have found more scar in the heart muscle of long distance runners. The reason for the scar and the heart plaque is not clear, as is the significance of these findings. 

 

Cycling is a high dynamic, high static sport.  Cycling will increase longevity by 3.7 years (Copenhagen study) and reduces the risk for death (British study).  In addition, a long-term study found that Tour de France riders lived longer than the average French male. Cyclists had a lower coronary calcium score and less heart artery plaque than runners, soccer players or tennis players. What are the hidden downsides to cycling? Cyclists had the third highest sun exposure due to long periods of riding outdoors and the body’s position which tends to catch more of the sun’s rays compared to other athletes. Another factor to consider is that cycling is non-weight bearing, so it may put too little pressure on the bones. This was proven in a study showing that cyclists had a lower bone density than runners. 

 

Weightlifting is at the other end of the spectrum compared to the previously mentioned sports. It is the classic low dynamic, high static exercise; it is designed to increase muscle mass and build bone strength.  Does weightlifting reduce the risk for dying? The data is less clear for weightlifting compared to endurance sports. One study of 18,000 US adults showed that weight lifting was not associated with reduced mortality.  Why is this? One study of weightlifters showed that blood pressure rises rapidly and to very high levels during lifting (the average peak systolic blood pressure was over 300 mmHg).  These high pressures thicken the heart muscle. While a large biceps muscle is good for fitness, a thickened heart muscle puts the athlete at risk for arrhythmias and congestive heart failure. 

 

Golf is classified as a low dynamic and low static sport. Despite the low aerobic and muscle building potential, regularly playing golf can raise life expectancy by about 5 years. This proves the point that any activity is better than being sedentary. Another factor may be the socializing aspect of golf. On the downside, golf has the second highest sun exposure risk. In addition, there is the Mark Twain quip about golf being “a good walk spoiled”.

 

Soccer is the most popular sport around the world and a good number of people play soccer for fun on the weekend as well.  Soccer, like tennis and long distance running, is a high dynamic, low static exercise. Soccer will extend life by 4.7 years (Copenhagen study). A study of former Scottish soccer players found a lower risk for dying and heart disease compared to the general population.  However, the same study found a much higher risk for dementia.  All of those headers seemed to have taken their toll. 

 

Currently choosing a sport is a matter of personal preference but can a more precise exercise regimen be tailored to the individual? The answer is yes. By using your own data from a stress test, a cardiologist can issue a personalized exercise prescription (http://sportscardiology.blogspot.com/2017/08/an-exercise-prescription-to-get-fitt.html).  Even more precision may be on the horizon.  Researchers at Harvard found 102 proteins in the blood that may be able to predict a person’s response to physical exercise. So, based on their blood profile, one person may be prescribed endurance exercise while another might be nudged towards a high static exercise. 

 

Until personal physical exercise proteins become mainstream, here are some considerations for deciding which sport is right for you. First, choose a sport that you like to do. If you like the exercise, you are more likely to do it, especially on those days when you don’t feel like exercising. Second, minimize the risks. For example, if you like to play tennis, split your time between outdoor and indoor matches to lower the sun exposure and lower the risk for skin cancer. If you like to cycle, don’t ride exclusively. Balance it with an activity that will help with weight bearing and bone strength such as weightlifting.  Lastly, participating in any of these sports is better than sitting on the couch and watching the Olympics on television. At a bare minimum, get on your treadmill or stationary bike and then cheer on your favorite athletes.

 

 

Thumbs Up For Aortic Screening

 

 

The thumb is a remarkable appendage.  By allowing us to grasp objects, to use tools, to write, the thumb has helped us evolve above and beyond all other animal species. Can the thumb also be useful in helping us detect an enlarged aorta? 

 

The aorta is the main artery of the body. It arises from the heart, courses through the chest and abdomen and ends by splitting into two arteries to supply blood to the lower extremities. Arteries arise from the aorta to supply blood and oxygen to the heart, brain, stomach, kidneys and all of the muscles of the torso and the upper extremities. The aorta is divided into two main parts, the thoracic (chest) aorta and the abdominal aorta. One of the most serious, and deadly, problems with the aorta is an aortic aneurysm.  An aneurysm is an enlargement of the aorta. As the aortic diameter increases and balloons out, the wall of the aorta weakens.  At some critical size, the wall is so weak that it can burst open. Unfortunately when that happens, the patient most likely will die from bleeding. The keys to managing an aortic aneurysm is to identify an aneurysm, monitor its growth and size and refer the patient to surgery to repair the aorta before it ruptures.  Aneurysms of the thoracic and abdominal aorta have different causes and different ways to monitor them. 

 

The exact cause of abdominal aortic aneurysm (AAA) is not known. It does occur in families and those with a first-degree relative with AAA are at two times the risk. AAA can occur in the setting of atherosclerosis. Risk factors for AAA include male sex, older age, smoking, and hypertension. Aneurysms that are greater than 5.0 cm in diameter are at increased risk for rupture and at that level of dilatation patients are referred to surgery for repair. AAA can be detected by physical examination. A pulsatile mass is felt in the area around the umbilicus. Ultrasound is very good for detection and screening of AAA. It is recommended that men over age 65 who have ever smoked or who have a family history of AAA have a one-time screening (the benefits of screening women hasn’t been determined). Once identified, yearly ultrasounds are used to follow patients with AAA. If there is rapid growth, or the AAA reaches 5.0 cm, then a CT scan is done to further delineate the anatomy and help in planning for surgery.

 

There are many different causes for thoracic aortic aneurysm (TAA). Connective tissue diseases are an important etiology. In these conditions, patients are born with loose muscles and joints. They can perform all kinds of contortions (they are “double jointed”).  The aorta has muscle and connective tissue within its walls; this makes it elastic, allowing it to expand when the heart pumps blood through it and to  relax when there isn’t blood flow. These elastic properties help the aortic wall handle the high pressure of blood flow, without rupturing. Unfortunately the same connective tissue laxness in these patients also causes weakness within the aortic wall. This leads to TAA and these patients are prone to rupture at smaller aortic diameters than other TAA patients.  The most well known connective tissue disease is Marfan’s Syndrome. These patients are tall, skinny and lanky (Abe Lincoln was thought to have it). They may have TAA, their aneurysms can grow rapidly and are at risk for bursting at about 4.5 to 5.0 cm.  Athletes with Marfan’s Syndrome are barred from playing sports because extreme physical activity can increase the risk for their aneurysm bursting. Therefore it is very important to identify and follow these patients. Other causes of TAA are bicuspid aortic valve (the aortic valve has two leaflets instead of the normal three leaflets), atherosclerosis, vasculitis (inflammation of the wall of the aorta), infection (for example, syphilis) and trauma.  Detection and screening for TAA is more difficult than with AAA. The echocardiogram (ultrasound of the heart) can image parts of the thoracic aorta. It is not an ideal screening tool as it can’t view the entire thoracic aorta and measurement of aortic size is fraught with error.  However, it is noninvasive and doesn’t require intravenous contrast.  The gold standard for measuring TAA is either CT scan or MRI, both of which require intravenous contrast. Due to the contrast, the cost and the radiation exposure (for CT scan) these tests are not ideal for screening.  A good, low cost, low risk screening test for TAA is sorely needed. Enter the thumb test. The thumb test is simple. Hold up one hand and keep the palm flat. Stretch the thumb as far as possible across the palm. If the thumb crosses beyond the edge of the palm, the test is positive.  A positive thumb test indicates that the joints are loose, due to a connective tissue disease and that a TAA may be present. The majority of aneurysm patients do not have a positive thumb test, but if the test is positive there is a very high likelihood of having a TAA. A negative test does not exclude the possibility of an aneurysm.

 

If you are a male, over 65 years old and have ever smoked or have a family history of AAA or if you have a positive thumb sign, talk to your doctor about screening for an aneurysm. It may save your life.

Humor Explains (And Cures) Everything

Plato and a platypus walk into a bar... This isn’t the start of some highbrow joke, but the title of a book by Harvard trained philosophers Thomas Cathcart and Daniel Klein. In the book the authors plausibly spell out how jokes and humor can explain all of philosophy. Jokes and philosophical concepts are similar in that they both make you think; both flip the world upside down and uncover hidden truths about life. Joking about the three main branches of philosophy, ethics, logic and metaphysics, helps us understand these lofty ideas.  Metaphysics tackles the Big Questions, for example: What is reality? What is the meaning of life? If humor can help us understand metaphysics, humor can therefore explain everything! If humor is this powerful, we need to define it.  The humor writer and philosopher Dave Barry defined humor as, “a measurement of the extent to which we realize that we are trapped in a world almost totally devoid of reason. Laughter is how we express the anxiety we feel at this knowledge“. Speaking of anxiety, Sigmund Freud wrote a book analyzing jokes and their relationship to our dreams, our inhibitions and our unconscious thoughts. So a good joke not only provides a hearty laugh, but can have deep philosophical and psychological meaning as well, allowing us insight into the how the world, or our own mind, works (or at least lets us to blow off steam about the randomness of it all).  Does laughter also have physiologic and therapeutic properties?

 

These are my principles; if you don’t like them, I have others- Grouch Marx

The beneficial effects of laughter have been known for many years. An early reference may be found in the Bible, “A merry heart doeth good like medicine” [Proverbs 17:22]. The modern concept of laughter as medicine was eloquently characterized by Norman Cousins, a noted author, professor, world peace advocate and nuclear disarmament activist in his 1976 New England Journal of Medicine article (and subsequent book by the same name), “Anatomy of an Illness (as Perceived by the Patient)”. He attributes laughter to curing his crippling rheumatologic disease, which doctors previously felt was irreversible. He states that 10 minutes of genuine belly laughter would relieve his arthritis and provide at least two hours of pain free sleep.  Mr Cousins’ writing spawned a series of studies on the effect of laughter leading to some interesting findings. In addition, it lead to the development of laughter clinics, including the Gesundheit community lead by Dr Patch Adams, where laughter is used to help patients with chronic, debilitating diseases find a way forward. 

 

What is the cardiologist’s favorite song? “Statin Alive” by the Bee Gees- Francisco Navarro

What effect does laughter have on the body?  Laughter has been shown produce numerous positive physiologic changes. Laughter relieves stress by decreasing stress hormones and by increasing endorphins (hormones that are usually released while exercising to make one feel good and to keep exercising).  It relaxes blood vessels, reduces blood pressure, decreases the heart rate and aids in muscle relaxation. Laughter improves the immune system and aids in healing after surgery.  A good laugh provides a huge psychological boost as well and helps to fight depression.  Humor is used routinely for stress reduction during cardiac rehabilitation programs. Lastly, if humor is injected into the doctor’s office visit, it will result in better patient satisfaction, greater patient empowerment and a stronger bond with the doctor. Most importantly, laughter and humor has no down side (except perhaps a pulled muscle from laughing so hard!).

 

Don’t trust atoms, they make up everything - Richard Feynman

Is there data to support laughter as medicine?  In a study from Norway spanning 15 years and including 53,000 patients, a good sense of humor lowered overall mortality for women and lowered mortality due to infections in both men and women. In a study of 17,000 people in Japan, those who a good hearty laugh more than once per week lived longer and had less heart disease than those who laughed only once per month or less. Laughter can also help with memory and thinking.  A strong laugh can stimulate the brain and lead to higher cognitive activity. Also, older patients had improved short-term memory and improved recall after watching a humorous video.

 

In summary, humor not only explains everything, but can help cure many ills. So for a long and healthy life, exercise 20-30 minutes a day, eat fresh fruits, vegetables, fish and plant based protein, sleep seven hours a night and socialize with friends and family. And it wouldn’t kill you to have a long, loud, hearty laugh each day too.