Broccoli Before Bedtime

 

Leg pain and leg discomfort are very common complaints. These symptoms could be due to serious medical problems or may be due to more benign disorders. If there is leg cramping, deep pain, aching in the calf muscles while walking and relieved by rest the likely diagnosis is peripheral artery disease, a lack of blood flow to the legs. This is a serious condition that should be evaluated by your doctor. When leg symptoms occur at rest, usually at night, two common processes are possible; restless leg syndrome and nocturnal leg cramps. These two disorders are often confused, but they are different entities with different treatments. 

 

Restless leg syndrome is an uncomfortable sensation in the legs with an urge to move the legs. It most often occurs at night, but can occur while sitting in a car or plane. It does not cause pain, it lasts for a few minutes and is relieved with movement. The sensation is described as a creeping, crawling, pulling or throbbing in the legs. It is quite common, occurring in about 7% of people. There is no known cause for restless leg syndrome, but it is associated with an imbalance of a brain chemical called dopamine. It is associated with iron deficiency anemia (low blood count), neuropathy, kidney disease, Parkinson’s disease and pregnancy (affecting 3% to 30% of pregnant women). The treatment depends on the underlying cause. If there is anemia, treatment with oral or intravenous iron is beneficial. However, the vast majority of restless leg syndrome cases are idiopathic, or without known cause. For these patients, nonpharmacologic therapy can include good sleep habits, hot soaks or massage for the legs, and avoiding caffeine at bedtime. Exercise can help. Thirty minutes of aerobic exercise three times per week can improve symptoms, but avoid exercise within a few hours of bedtime. Medications such as gabapentin can relieve symptoms. The use of medications has to be tempered by the risk of side effects; the medication cannot cause significant problems since restless leg syndrome is basically a benign condition. This is the case with ropinirole (Requip). Ropinirole increases the levels of dopamine in the brain and helps symptoms when used for a short period of time (a few weeks). If used long term, symptoms of restless leg paradoxically worsen. In fact, in September 2024, the American Academy of Sleep Medicine recommended against using ropinirole for restless leg syndrome.

 

Nocturnal leg cramps are painful contractions of the leg muscles that occur at night. The cramps are relieved by stretching the muscle. The leg cramps (or charley horses) are common, with up to 60% of people reporting symptoms. In 20% of patients, the cramps are severe enough to cause significant insomnia. The cause of nocturnal leg cramps is not known, like restless leg syndrome an idiopathic process. Leg cramps are not associated with dehydration or low blood levels of potassium or sodium. Nocturnal leg cramps can be caused by a myriad of medications. It can also be associated with peripheral artery disease, heart artery disease, neuromuscular diseases (neuropathy, Parkinson’s disease, multiple sclerosis) and pregnancy. The acute treatment of leg cramps includes stretching and massage of the affected muscle. Mild exercise on a stationary bike or treadmill before bed can help decrease cramping. Multiple medications and supplements have been tried to relieve the symptoms of nocturnal leg cramps. However, like restless leg syndrome, the side effects of the treatments cannot be severe as the disease process itself is not severe. Quinine is a medication that has been shown to reduce the intensity of the cramps and reduce days with cramps; it reduces the number and severity of the cramps. Unfortunately, quinine has serious side effects including low platelets and heart arrythmias. In 2006, the FDA advised against using quinine for nocturnal leg cramps. Magnesium supplements have been used to prevent cramps. Unfortunately, numerous studies have failed to show any benefit. One promising avenue may be vitamin K supplementation. A recent study of 199 patients over the age of 65 showed that a vitamin K tablet decreased the frequency of leg cramps compared to placebo. In general, there are no adverse reactions with vitamin K supplementation. The only contraindication to vitamin K is in patients who are on warfarin, a blood thinner. Vitamin K is used to reverse the effect of warfarin. Vitamin K is found in green leafy vegetables such as kale, spinach, cabbage, lettuce, Brussels sprouts, cauliflower and broccoli. We don’t know whether the same reduction in leg cramping will occur with increasing the intake of vitamin K laden foods; theoretically it should. How would that work? One cup of broccoli contains 164 micrograms of vitamin K, while the supplement used in the trial had 180 micrograms. So, potentially one cup of broccoli at bedtime each night might chase those cramps away. 

Floss For Your Life

 

You know that you are supposed to brush your teeth twice per day and floss regularly to prevent significant dental problems. However, did you know that keeping those pearly whites in tip top shape also helps with overall health, especially heart health? How are your teeth and your heart related? How can better dental health lead to better cardiac health?

Periodontal disease is extremely common and has well know associations with various forms of heart disease. Periodontal disease is a process that affects the supporting structure of the teeth, the gums, the surrounding tissue and the bones supporting the teeth. Periodontal disease is caused by plaque or bacteria on the teeth. This leads to inflammation causing local damage. The bacteria can also enter the bloodstream and lodge in arteries, including the heart arteries. There are two types of periodontal disease: gingivitis and periodontitis. Gingivitis is the milder form of the disease and involves only inflammation of the gums. Periodontitis is a more serious process and a chronic inflammatory disease that affects the teeth, the gums and the bones. Symptoms of periodontal disease include red, swollen, painful or bleeding gums, loose teeth, loss of teeth, and pockets of infection between the teeth and the gums. It is reported that periodontal disease affects more than 1 billion people and is considered the sixth most common disease worldwide.

Many studies have tied periodontal disease to systemic inflammation. Inflammation can be good and it can be bad. Inflammation can fight an injury to the body and help promote healing once the injury has been cured. However, unchecked and ongoing inflammation can also cause long term tissue damage. The bacterial infection in periodontal disease provides a textbook example. Bacteria that are present in dental plaque are also found in the blood stream. The bacteria enter the body through small perforations in the dental tissue and can also be released by tooth brushing. Once in the blood, the bacteria lodge in various arteries, including the heart arteries. Once there, they initiate an inflammatory reaction which leads to damage of the arterial wall and ultimately plaque and blockage in the heart artery. In addition, the dental bacteria increase low density lipoprotein (LDL cholesterol) which then promotes further plaque and blockage in the heart arteries. Studies have shown increased levels of C reactive protein (a marker of inflammation in the blood) associated with periodontal disease.  Treatment of periodontal bacteria with antibiotics decrease bacteria in dental plaque, lower levels of C reactive protein and reduce LDL cholesterol. 

Many, many studies in thousands of patients and in populations from around the world have linked periodontal disease to heart artery disease, heart attack, stroke and cardiac death. Two large studies tied periodontitis (the severe form of periodontal disease) to heart attack. One study reported a 16% increased risk for heart attack with periodontitis and the other had a 28% increased risk. A more recent study (October 2024) found a 9% increase in heart artery disease in all patients with periodontal disease (gingivitis and periodontitis). Another recent study was the first to show that periodontal disease was associated with congestive heart failure (CHF). 

Last month (February 2025), an additional association was made between periodontal disease and atrial fibrillation (Afib) and stroke. The study followed 6200 people, average age 62, for 25 years. Patients who flossed their teeth at least once per week had a 22% lower risk for stroke and a 12% lower risk for Afib. Flossing more led to even further reductions in risk. The benefit of flossing was on top of tooth brushing and regular dental appointments. This may be because flossing cleans the gums better than tooth brushing, removing food and plaque from in between teeth. 

To treat periodontal disease, dentists will prescribe antibiotics. Antibiotics have been shown to kill the bacteria found in dental plaque and reduce inflammatory markers. To treat severe cases, oral surgeons will do surgery.  To prevent periodontal disease and subsequent heart artery blockage and heart attack, stop smoking (smoking causes both periodontal disease and heart disease), brush your teeth twice per day and go for regular dental checkups. To prevent Afib and stroke, floss for your life.

Hearts on Fire

 

The wild fires that have engulfed California are now considered one of the worst natural disasters in US history. Homes have been lost, communities have been destroyed and 40,000 acres have burned, fueled by Santa Ana winds and a prolonged drought. Across the globe, wild fires have become more frequent. In the US, there are more than 70,000 fires per year and the acreage burned has more than doubled over the past 30 years. In addition to property damage, the particulate matter in wild fire smoke is a huge health concern. Cardiac and respiratory deaths have increased over the past twenty years due to wild fires. How do wild fires and the smoke they produce affect heart health?

 

It is well established that air pollution is a major factor in global health. Air pollution causes millions of premature deaths every year, especially in the very young (children < 6 years old), the elderly (over age 65) and in vulnerable groups (those with pre-existing lung or heart disease). Air pollution has been linked to almost every major cardiac disease process including heart attack, heart failure, arrhythmias, hypertension, stroke and cardiovascular death. Polluted air contains particulate matter, fine particles that are suspended in the air. Particulate matter is produced by burning fossil fuels (for example car exhaust), smoke from manufacturing plants, and agricultural activities (such as burning crop residues). These particles are inhaled into the lungs and enter the blood stream. Once particulate matter has entered the body it can trigger various adverse reactions such as inflammation, oxidative stress, stiffening of the wall of the arteries, loss of function in the blood vessels, and increased risk for blood clotting.  

 

Wildfires produce smoke that have similar effects on the body as air pollution. The smoke contains particulate matter, gases (carbon monoxide, nitrous oxide), heavy metals (lead, mercury), and toxic carcinogens (similar to cigarette smoke- benzene, benzopyrene). Wildfire smoke is especially harmful to human health due the fact that smoke can travel thousands of miles and the particulate matter is very dense (wildfire events can increase particulate matter in the air to levels that equal the most polluted cities). Wildfire smoke can impact health in many different ways. It affects respiratory health by worsening lung function, increasing asthma episodes and increasing the risk for lung infections. Particulate matter is also known to affect the kidneys, the gastrointestinal system and can lead to diabetes. Wildfire smoke is associated with high blood pressure, episodes of chest pain, cardiac arrest and worsening heart failure. Exposure to smoke increases hospital admissions for cardiac events. Even short-term exposure to wildfire smoke can result in harm as this type of smoke is more toxic than the particulate matter found in urban air pollution.  It doesn’t take a full wildfire to produce the risks. Even the particulate matter from wood smoke (such as fire pits or camp fires) can trigger these adverse reactions. 

 

Wildfires are not just something that occur 3,000 miles away on the west coast but have happened in our own backyard as well. The 2023 wildfire season in Canada was among the worst in its history. In June 2023, the wildfire smoke traveled more than 2000 miles and affected the Eastern US.  The smoke was gathered and analyzed on the Piscataway campus of Rutgers University. Researchers found that the smoke had very large concentrations of fine particulate matter as well as high amounts of cancer-causing organic compounds. On June 7 2023, the air quality in New York City was the worst on record in 50 years. In addition, on that day, the level of particulate matter was 10 times higher than the national air quality standard. How did that affect health? Asthma related emergency room (ER) visits increased by 82% on June 7 in New York State and by 63% in New Jersey. The New York area was not the only one involved. In Baltimore, the level of particulate matter was 9 times higher on June 7 than any other day in 2023. This resulted in increased visits to ERs and urgent care facilities for heart and lung related problems.

 

What can you do to protect yourself when the next wave of wildfire smoke descends on New Jersey? The best recommendations include staying indoors, with air conditioning or an air purifier. Don’t do any strenuous activity outside (for example exercising, mowing the lawn, gardening). If you have to go out, wear a face mask, preferably an N95 mask. Let’s hope for a fire free 2025.

 

How To Arrest Sudden Cardiac Death

 

Sudden cardiac death (or sudden cardiac arrest) is a common, deadly problem and is often the first manifestation of heart disease. It 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 350,00 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 leave the hospital, which means the death rate is 90%.

 

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 a plaque or blockage in a heart artery breaks open and a blood clot is formed stopping the blood flow to the heart muscle. 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 sudden cardiac arrest is usually caused by a congenital heart problem. The person is born with an abnormal heart muscle, or an abnormal electrical system, or an abnormal origin of one the heart arteries. 

 

The strategies to prevent sudden cardiac arrest from becoming sudden cardiac death include prompt treatment and primary prevention. Prompt treatment involves recognizing that someone is in cardiac arrest, initiating cardiopulmonary resuscitation (CPR) and performing defibrillation as soon as possible. The American Heart Association recommends hands only CPR (chest compression only, no mouth-to-mouth breathing). The initiation of prompt CPR has been shown to save lives. 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.  Every minute spent waiting for an AED decreases the odds of survival by 7-10%. Having an AED as close as possible to potential victims is lifesaving.  

 

The biggest barriers to successful resuscitation are getting an AED to the victim as soon as possible and having bystanders deploy the device. Fortunately, AEDs seem to be everywhere. About 500,000 to 1 million were sold in the US last year and there are about 3.2 million AEDs in public settings. AEDs are 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. In large public spaces, how close together should AEDs be placed?  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. Aside from large public spaces, where should AEDs placed so bystanders can find and use them? One study from Toronto showed coffee shops and bank ATMs to be the best for coverage. A study from England felt that AEDs near mailboxes was best. A study from Taiwan concluded that bus stops, convenience stores and pharmacies were optimal. All studies emphasized areas where the public would be familiar with the AED location, potentially enhancing the use of AEDs by bystanders. 

 

Unfortunately, only 15% of sudden cardiac arrests take place in a public area. The vast majority (85%) of events take place in a private home. In the private setting, it is estimated that only 6% of sudden cardiac arrest victims might have an AED close enough for use. What is the optimal density of AEDs and how can they be brought to victims in residential areas? Multiple studies have concluded that the optimal density of AEDs is between 5 and 41 AEDs per square mile. Unfortunately, in a country as large as the United States, this density will be difficult to achieve nationwide. To increase AED coverage, especially in remote areas, multiple studies have advocated using drone delivery of AEDs to cardiac arrest patients. One study showed that drone delivery of an AED was 3 minutes faster and beat ambulance arrival in 67% of cases. In a situation where time is critical, drones may make a difference.

 

Unfortunately, even when an AED is available, it may not be used. One recent study reported that even if an AED was one minute walk away from a victim, bystanders only used the device 16% of the time. Fortunately, on December 10 2024, Congress passed the HEARTS Act expanding access to AEDs and increasing training for CPR and AED use. 

 

Primary prevention aims to identify people who may at risk for sudden cardiac arrest before an event occurs. This is especially important since cardiac arrest is often the first manifestation of heart disease in a person. For those over 35 years old, there are no specific recommendations for screening.  General measures to reduce the risk for heart attack are emphasized including following a heart healthy lifestyle (staying active, watching a good diet, not smoking, keeping weight under control, treating high blood pressure and/or high cholesterol). Routine stress testing doesn’t reduce the risk for cardiac mortality, but doing a stress test before starting an exercise program is prudent, especially if there are one or more cardiac risk factors. One way to reduce the risk for sudden cardiac arrest is exercise. One recent study showed that vigorous physical activity of 20 minutes per week reduced the risk for cardiac arrest. Moderate exercise of 360 minutes per week (51 minutes per day) also lowered cardiac arrest risk. 

 

For athletes who are under the age 35, screening is performed. Although cardiac arrest is rare in athletes (1 in 63,00 college athletes have cardiac arrest each year) certain populations are at higher risk. Men have 2 to 10 times the risk as women. Black athletes have 5 times the risk compared to white athletes. Athletes in certain sports (basketball, soccer, cycling and football) are at higher risk. Screening involves a questionnaire asking about symptoms and family history. An electrocardiogram (EKG) is performed on all athletes and a cardiac ultrasound (echocardiogram) is done on those with high risk (for example someone with an abnormal EKG). Many professional athletes (especially football, basketball and soccer players) are screened before a contract is signed.  In addition, Division 1 college athletes are screened. Although screening is controversial, it has been shown that screening prevents sudden cardiac arrest in multiple populations. A recent study reported that sudden cardiac arrest has been steadily declining in college athletes over the past 20 years. 

 

What can the average person do to reduce the risk for sudden cardiac arrest personally and in the community? On a personal level, follow a good heart healthy lifestyle and keep up with the recommended amount of exercise. From the community standpoint, take a CPR class at a local hospital. Most classes teach basic CPR and the proper use of an AED. In addition, take notice of the location of AEDs during your daily activities. You never know when you might use one.