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Statin myopathy:(muscle aches) => tolerability of statin rechallenge

Statin myopathy:(muscle aches) => tolerability of statin rechallenge | Heart and Vascular Health | Scoop.it

My comment: this is one of the great challenges in the practice of cardiovascular medicine.  Statins have great results for prevention of stroke and heart attack, but do cause muscle aches in a minority of patients.  Sometimes the muscle aches are not from the drug so rechallenging can be helpful to sort this out

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Statin myopathy is a generally encountered side effect of statin usage. Both muscle symptoms and a raised serum creatine kinase (CK) are used in case definition, but these are common manifestations of other conditions, which may not be statin related. Statin rechallenge assuming no contraindication in selected cases is an option before considering a different class of lipid-lowering agent.

Patients with statin myopathy constitute 10.2% of our Lipid Clinic workload. They are predominantly female (62.0%), Caucasian (63.9%), with a mean age of 58.3 years and mean BMI of 29.3 kg/m(2). The serum CK and ESR were statistically higher compared to patients with statin intolerances with no muscular component or CK elevations. Secondary causes of statin myopathy were implicated in 2.7% of cases. Following statin myopathy to simvastatin we found no statistical difference between the tolerability rates between atorvastatin, rosuvastatin, pravastatin, and fluvastatin. Fibrates, cholestyramine, and ezetimibe were statistically better tolerated in these patients.

CONCLUSIONS: Statin rechallenge is a real treatment option in patients with statin myopathy. Detailed history and examination is required to exclude muscle diseases unrelated to statin usage. In patients developing statin myopathy on simvastatin, we did not find any statistical difference between subsequent tolerability rates to rosuvastatin, pravastatin, and fluvastatin.

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Can This Treatment Help Me? There’s a Statistic for That

Can This Treatment Help Me? There’s a Statistic for That | Heart and Vascular Health | Scoop.it

Medical care is often far less effective than most believe. Just because you took some medicine for an illness and became well again, it doesn’t necessarily mean that the treatment provided the cure.

This fundamental lesson is conveyed by a metric known as the number needed to treat, or N.N.T. Developed in the 1980s, the N.N.T. tells us how many people must be treated for one person to derive benefit. An N.N.T. of one would mean every person treated improves and every person not treated fails to, which is how we tend to think most therapies work.  What may surprise you is that N.N.T.s are often much higher than one. Double- and even triple-digit N.N.T.s are common.

Seth Bilazarian, MD's insight:

The number needed to treat (NNT) or the number needed to harm (NNH) are easy ways to quantify the benefit.  The calculation is done by dividing 100 by the difference in the rate of the problem in the two groups (called the absolute risk reduction (ARR)).  If one group has an event rate of 20% and the other group has a rate of 15% the ARR is 5% so the NNT is 100/5 or 20.  Simply put then 20 people need to be treated to prevent one of the bad outcomes.  This is a very helpful context but only part of shared decision making sensible for patients. See also http://www.thennt.com/

 

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Cardiovascular and Cerebrovascular Effects of Red Bull & Mental Stress

Cardiovascular and Cerebrovascular Effects of Red Bull & Mental Stress | Heart and Vascular Health | Scoop.it

The sale of energy drinks is often accompanied by a comprehensive and intense marketing with claims of benefits during periods of mental stress. As it has been shown that Red Bull negatively impacts human hemodynamics at rest, we investigated the cardiovascular and cerebrovascular consequences when Red Bull is combined with mental stress. In a randomized cross-over study, 20 young healthy humans ingested either 355 ml of a can Red Bull or water and underwent 80 minutes after the respective drink a mental arithmetic test for 5 minutes. Continuous cardiovascular and cerebrovascular recordings were performed for 20 minutes before and up to 90 minutes after drink ingestion. Measurements included beat-to-beat blood pressure (BP), heart rate, stroke volume, and cerebral blood flow velocity. Red Bull increased systolic BP (+7 mm Hg), diastolic BP (+4 mm Hg), and heart rate (+7 beats/min), whereas water drinking had no significant effects. Cerebral blood flow velocity decreased more in response to Red Bull than to water (−9 vs −3 cm/s, p <0.005). Additional mental stress further increased both systolic BP and diastolic BP (+3 mm Hg, p <0.05) and heart rate (+13 beats/min, p <0.005) in response to Red Bull; similar increases were also observed after water ingestion. In combination, Red Bull and mental stress increased systolic BP by about 10 mm Hg, diastolic BP by 7 mm Hg, and heart rate by 20 beats/min and decreased cerebral blood flow velocity by −7 cm/s. In conclusion, the combination of Red Bull and mental stress impose a cumulative cardiovascular load and reduces cerebral blood flow even under a mental challenge.

Seth Bilazarian, MD's insight:

Blood pressure increase of 7/3 and reduced mental acuity.  This data certainly adds to the plausibility that these energy drinks can sometimes cause serious cardiovascular consequences.

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Healthy Weight Loss

Healthy Weight Loss | Heart and Vascular Health | Scoop.it

A useful approach is to select the best diet that works for you. This
is the eating plan you can live with.
What You Need to Know About Weight Loss
A total of 3500 calories equals 1 pound of body weight. This means if you decrease (or increase) your intake by 500 calories daily, you will lose (or gain) 1 pound per week. (500 calories per day × 7 days = 3500 calories.)
All foods have carbohydrate, protein, and fat.

Carbohydrates provide 4 calories per gram.

Proteins provide 4 calories per gram.
Fats provide 9 calories per gram.
Carbohydrates are either simple or complex. Simple carbohydrates cause more  weight gain than complex carbohydrates. Simple carbohydrates include sugar and starches (potatoes, pasta,and rice). Complex carbohydrates include fruits, vegetables, and whole grains.

Seth Bilazarian, MD's insight:

A 500 calorie reduction every day is a good basic rule to begin to have an understanding how to move weight down by about a pound per week - its a good start.  Slightly more advanced calculators are more accurate and can help understand how to move weight to a goal or ideal weight.  For those motivated to change habits on caloric intake these calculators can be very helpful.  See the Pennington Biomedial caculators at

 http://www.pbrc.edu/research-and-faculty/calculators/weight-loss-predictor/

 

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Triglycerides on the rise: should we swap seats on the seesaw?

Triglycerides on the rise: should we swap seats on the seesaw? | Heart and Vascular Health | Scoop.it

For decades, cardiovascular risk attributed to lipids beyond LDL has focused on HDL.  Observational data show a consistent inverse relationship between HDL & cardiovascular risk. However, multiple strategies to raise HDL levels have thus far failed to forestall events in clinical trials [e.g. currently available fibrates, niacin, &  cholesteryl ester transfer protein (CETP) inhibitors. 

Apolipoprotein C3 regulates triglyceride-rich lipoprotein can promote inflammation and the preponderance of current genetic evidence sways the seesaw surely to the triglyceride side.

Recent genetic studies show that a lifetime of lower exposure to APOC3 reduced cardiovascular risk. 

Seth Bilazarian, MD's insight:

From author Peter Libby:

In the meantime, what should clinicians do to manage patients who present with hypertriglyceridemia? These new data regarding a causal role for triglycerides in increasing cardiovascular risk should prompt us today to redouble our efforts to reduce hypertriglyceridemia in our patients using non-pharmacological approaches. We should examine the medication list for agents that might raise triglyceride levels such as estrogens and retinoic acid products.  We should consider whether alcohol consumption or thyroid disease contributes to dyslipidemia in individual patients. We should strive to achieve optimum control in diabetic patients. We can discourage excessive carbohydrate consumption in those with hypertriglyceridemia.

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Bypass Surgery Vs. Drug-Eluting Stents for Patients With Proximal Left Anterior Descending Stenosis

Bypass Surgery Vs. Drug-Eluting Stents for Patients With Proximal Left Anterior Descending Stenosis | Heart and Vascular Health | Scoop.it

Although clinical practice guidelines carry a higher class of recommendation for CABG surgery (Class IIa) than for catheter-based deployment of drug eluting stents (DES) (Class IIb), when revascularization is indicated for patients with ischemia due to significant stenosis in CAD isolated to the PLAD, a comprehensive registry in the state of New York found no differences between these approaches in either mortality rates or the combined rates of mortality, MI, and/or stroke, although CABG was associated with lower rates of repeated revascularization.

Seth Bilazarian, MD's insight:

For many years we have had good evidence that there is not a significant difference in death or other major hazard between bypass surgery or angioplasty with stents.  This information from the New York State registry adds important information because of its size and the use of drug eluting stents.  The one significant difference is that the angioplasty group needed more repeat procedures over 3 years; Repeat procedures were needed in 1 in 17 of the bypass patients and 1 in 9 of the stent patients.  This information is welcome addition to help our patients make an informed decision about whiich option is best for them.

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Resolving the Paradox of Vitamin D Deficiency in Black Populations

Resolving the Paradox of Vitamin D Deficiency in Black Populations | Heart and Vascular Health | Scoop.it
Researchers at Massachusetts General Hospital demonstrated that the historic deficiencies in Vitamin D observed in African American populations are a result of conventional assays that neglect bioavailability.
Seth Bilazarian, MD's insight:

Thadhani at MGH and others are developing assays to measure bioavailable vitamin D that could help guide recommendations for vitamin D supplements. Until then, he suggests considering whether the individual has indications of poor bone health, and also other measures linked to vitamin D deficiency, such as low calcium and high parathyroid hormone levels. This can help put total vitamin D levels into the context of other clinical risk factors for a more informed decision about whether to recommend supplementation.

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Patients in Cardiac Arrest Report Conscious Awareness

Patients in Cardiac Arrest Report Conscious Awareness | Heart and Vascular Health | Scoop.it
Nearly 40% of 140 cardiac arrest survivors claimed memories from when they were in cardiac arrest.

Awareness during anesthesia has been well described, but what about during cardiac arrest? Researchers performed a 4-year multicenter observational study involving a qualitative and quantitative interview of 140 post-cardiac arrest patients in the hospital (52) and after discharge (90).

Overall, 39% of patients believed they had memories from the time they were in cardiac arrest. Using a validated near-death-experience scale, 9% of patients reported such experiences, but only two patients claimed explicit recall of actual events related to their resuscitations. No other patient had memories related to any medical procedure, pain, or experience.

Seth Bilazarian, MD's insight:

Comments by Dr. Kristi Koenig - This is the first study to quantify awareness during cardiac arrest. This study's results might be biased, because there was no consistency in the timing of interviews, and some patients did not complete the interview. Whether these memories “formed” during arrest or later or represent some other psychological phenomenon is not known. Nevertheless, the bottom line is to be careful what you say during resuscitations — you never know if patients can hear you! 

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Inflammation and Myocardial Infarction

Inflammation and Myocardial Infarction | Heart and Vascular Health | Scoop.it

A myocardial infarction (MI), or heart attack, is caused by a sudden blockage in the arteries that supply the heart muscle, known as the coronary arteries. Most of these blockages occur as a result of atherosclerosis, a process by which cholesterol and white blood cells accumulate in the wall of the artery.

Seth Bilazarian, MD's insight:

Whether reducing inflammation alone will lower vascular event rates is a major public health question. The National Heart, Lung, and Blood Institute is sponsoring a 7000-patient randomized trial called the Cardiovascular Inflammation Reduction Trial (CIRT). The study is enrolling patients in the United States and Canada at >300 centers to determine whether patients without arthritis but with known coronary disease might also benefit from LDM. CIRT is designed to test whether lowering inflammation can prevent MI and other cardiovascular events, such as stroke.

The study tests the effects of treating cardiovascular inflammation by using LDM, a safe and effective anti-inflammatory medication that does not reduce cholesterol or decrease blood pressure. LDM is a generic drug that has been widely used to treat arthritis for 40 years and has been taken safely by hundreds of thousands of adults.

CIRT is currently enrolling adults who within the past 5 years have had an MI or were diagnosed with coronary artery disease in >1 coronary artery. Patients must also have either diabetes mellitus or metabolic syndrome, 2 conditions with a high inflammatory state. For more information about the study, visit the trial website at www.theCIRT.org.

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Mini-Cog Performance: A Novel Marker of Post-Discharge Risk Among Patients Hospitalized for Heart Failure

Mini-Cog Performance: A Novel Marker of Post-Discharge Risk Among Patients Hospitalized for Heart Failure | Heart and Vascular Health | Scoop.it

Congestive Heart Failure (HF) guidelines recommend screening for cognitive impairment (CI) but do not identify how. The Mini-Cog is an ultra-short cognitive 'vital signs' measure that has not been studied in patients hospitalized for HF. 

Methods and Results—We analyzed 720 patients who completed the Mini-Cog as part of routine clinical care during hospitalization for HF. Our primary outcome was time between hospital discharge and first occurrence of readmission or mortality. There was a high prevalence of CI as quantified by Mini-Cog performance (23% of cohort). During a mean follow up time of 6 months, 342 (48%) patients were readmitted, and 24 (3%) died.

Poor Mini-Cog performance was an independent predictor of composite outcome & was identified as most important predictor among 55 variables.

Secondary analysis of initial 30-days post-discharge showed effect modification by venue of discharge, whereby patients with CI discharged to a facility had longer time to outcome as compared with those discharged home.

Conclusions—Mini-Cog performance is a novel marker of post-hospitalization risk. Discharge to facility rather than home may be protective for those HF patients with CI. It is unknown if structured in-home support would yield similar outcomes.

Seth Bilazarian, MD's insight:

The Mini Cog test is a simple test to evaluate patients cognition.  It's brief and easy to administer.  It's online here at:

http://www.alz.org/documents_custom/minicog.pdf

 

The test uses recall of 3 words and a clock drawing test to score for impairment:

3 recalled words = Negative for cognitive impairment
1-2 recalled words + normal CDT = Negative for cognitive impairment
1-2 recalled words + abnormal CDT = Positive for cognitive impairment
0 recalled words = Positive for cognitive impairment.


The authors have successfully correlated cognitive impairment with risk for readmission.  

The ability for patients to manage the tasks of medication adherence, restriction of dietary sodium/ salt & weighing themselves daily may not be able to be successfully achieved in some patients with cognitive impairment.  Senior author Eiran Gorodeski @EiranGorodeski has posted examples of the clock drawing tests (above) from his hospital and asks rhetorically "Will she manage her meds without errors?"

 

 

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TAVR: A Plea to Refer Patients for Consideration

TAVR: A Plea to Refer Patients for Consideration | Heart and Vascular Health | Scoop.it
TAVR or DNR -  For some time, I've been thinking about doing a blog called, "TAVR or DNR." I often see patients being managed by other physicians in our community who aren't referred for even consideration of transcatheter aortic valve replacement (TAVR)—patients who are octogenarians or nonagenarians with severe aortic stenosis, but the patient's internist and cardiologist haven't felt it appropriate or reasonable to send them for a TAVR consultation. These patients then end up having an ST-segment elevation myocardial infarction (STEMI), or they're in the hospital with congestive heart failure and acute pulmonary edema or worse. One patient I saw recently had STEMI with cardiogenic shock. We're asked to perform percutaneous coronary intervention or support in these patients in the setting of a severe aortic stenosis that might have been better managed electively, or they could have at least had a conversation about TAVR.
Seth Bilazarian, MD's insight:

For patient who have severe aortic stenosis - a severe narrowing of the main outlet valve of the heart and want to know more about the option of transcatheter aortic valve replacement (TAVR) the best place to start is at a center approved and doing this procedure in your local area.  There are two aortic valves available on the market in the US  (many more in Europe).  To find a local hospital see:

Edwards Life Sciences ($EW) at http://goo.gl/kWgtZP ;

or 

Medtronic ($MDT)  at  http://goo.gl/bxXhoO ;

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High aerobic fitness in late adolescence is associated with reduced risk of heart attack

High aerobic fitness in late adolescence is associated with reduced risk of heart attack | Heart and Vascular Health | Scoop.it

Aims Cardiovascular disease is the leading cause of morbidity and mortality worldwide, and signs of atherosclerosis are present in all large arteries already in adolescence. We investigated the association between high physical fitness in late adolescence and myocardial infarction (MI) later in life.

Methods and results The study cohort comprised 743,498 Swedish men examined at the age of 18 years during conscription 1969–84. Aerobic fitness (Wmax) and muscle strength at conscription were measured. During follow-up period of 34 years, 11,526 MIs were registered in the cohort. After adjusting for age, body mass index (BMI), diseases, education, blood pressure, and socio-economic factors, one standard deviation increase in the level of physical fitness was associated with an 18% decreased risk of later MI.  The beneficial effects of Wmax were significant across all recognized BMI groups, ranging from lean (BMI < 18.5) to obese (BMI > 30) (P < 0.05 for all). However, obese men (BMI > 30) in the highest fourth of Wmax had a higher risk of MI than did lean men (BMI < 18.5) in the highest (HR 4.6, 95% CI 1.9–11.2), and lowest (HR 1.7, 95% CI 1.2–2.6) fourth of Wmax.

Conclusions We report a significant graded association between aerobic fitness in late adolescence and MI later in life in men. However, obese men with a high aerobic fitness had a higher risk of MI than lean men with a low aerobic fitness.

Seth Bilazarian, MD's insight:

The impact of overweight status and fitness status (both aerobic and strength) in 18 yo men,  predicted heart attack over the next 3 decades.  Although both are important, as can be seen in the graphic, the impact of overweight status (fatness) was of greater risk than being "unfit".  Fatness worse than unfitness.

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Jenny Han's curator insight, December 13, 2014 5:55 AM

Graph shows what we should learn.

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Study says a bad marriage could literally break your heart

Study says a bad marriage could literally break your heart | Heart and Vascular Health | Scoop.it
A study found that older couples in bad marriages, especially wives, have a higher risk for heart disease than those who are happily wed.
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Safety Pills's comment, November 27, 2014 1:51 AM
A lot of marriages broke because of libidos loss. Maintain a healthy sex life to avoid marriage break ups. http://www.safetypills.com/mens-health/blue-pill.html
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Dissection of the chest, by Danny Quirk, Medical Illustrator

Dissection of the chest, by Danny Quirk, Medical Illustrator | Heart and Vascular Health | Scoop.it

There is a whole genre called anatomical tattoos. Chris Nuñez, a tattoo artist and judge on Spike’s TV show Ink Master, has said that this style is all about “replicating a direct organ, body part, muscle, tissue, flesh, bone in the most precise way you can.” Danny Quirk, an artist working in Massachusetts, is doing something similar, only his anatomical tattoos are temporary. He creates body paintings with latex, markers and some acrylic that appear as if his models’ skin is peeled back.

The project began in 2012, when Halloween provided the occasion for Quirk to paint his roommate’s face and neck. From there, he made other anatomical paintings on the arms, backs and legs of willing friends, and his photographs went viral.


Read more: http://www.smithsonianmag.com/science-nature/should-we-use-body-painting-to-teach-anatomy-180947826/#HzpSKqA8qIpUel8e.99

 

or 

http://protomag.com/articles/danny-quirk-living-cadavers-art

 

Seth Bilazarian, MD's insight:

Medical Illustrations help understand anatomy.  These dynamic illustrations as body art are fantastic by @DannyArtQuirk.

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Super Bowl outcome associated with cardiovascular death

Super Bowl outcome associated with cardiovascular death | Heart and Vascular Health | Scoop.it

A previous analysis from Los Angeles showed that death rates increased among hometown fans after losing the Super Bowl in 1980 and decreased after a win in 1984. D

Two high drama and intense Super Bowls were analyzed: New York beat New England (Massachusetts) in 2008 and Pittsburgh defeated Arizona in 2009. Daily death certificate data were obtained. The case period included eight consecutive days beginning Super Bowl day. The control period included eight consecutive days beginning Super Bowl day in non-case period Super Bowls from 2005 to 2009.

After Massachusetts’ defeat, circulatory deaths increased by 20 % (p = 0.0004) and ischemic heart disease deaths increased by 24 % (p = 0.01) in Massachusetts. After Pittsburgh’s victory circulatory deaths decreased by 25 % (p = 0.046), ischemic heart disease deaths decreased by 31 % (p = 0.03), and myocardial infarction deaths decreased by 46 % (p = 0.01) in Pittsburgh. Cardiovascular death rates did not change in Arizona (all p > 0.19). Massachusetts and Pittsburgh show stronger support for their home teams compared with Arizona.

Conclusions A Super Bowl with high drama/intensity can be associated with changes in cardiovascular death rates among a fan base with a strong attachment to the team even in the contemporary era. An increase in death rates can be associated with a loss and a decrease in death rates can be associated with a win.

Seth Bilazarian, MD's insight:

Looks like hospitals and cardiac catheterization labs in either Seattle or Boston are going to be busier at the beginning of next week.

Should Seahawk & Patriots fans take aspirin and betalocker before the game?  This might theoretically reduce the risk of CAD events and Takotsubo cardiomyopathy.

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Drinking from BPA-lined cans may increase Blood Pressure

Drinking from BPA-lined cans may increase Blood Pressure | Heart and Vascular Health | Scoop.it

Consuming food and drinks from cans or plastic bottles coated with bisphenol A may cause increases in blood pressure, according to research published in Hypertension.
Researchers demonstrated that concentrations of bisphenol A (BPA) in urine were higher in participants who drank from cans lined with material containing the chemical vs. from glass bottles.

The investigators measured individuals’ urinary BPA concentration, blood pressure (BP) 2 hours after consuming each beverage; 

Urinary BPA concentrations were >1,600% higher after drinking from cans compared with drinking from glass bottles. Systolic BP, adjusted for daily variance, rose approximately 4.5 mm Hg after consuming two canned beverages vs. two glass-bottled beverages (P=.02).  A 5 mm Hg increase in systolic [BP] by drinking two canned beverages may cause clinically significant problems, 

Seth Bilazarian, MD's insight:

The FDA says that BPA is safe http://goo.gl/4vV0w and says "Consumers may use the resin code appearing on plastic containers as a guide to the possible presence of BPA. A resin code of 7 indicates that the container may be made of a BPA-containing plastic. " But the NRDC.org says "A number of canned foods and plastic bottle manufacturers have stopped using BPA, though because there is no labeling requirement, consumers do not know which products contain BPA and which don't."

In our home there are no cans with resin code 7.  Whether this represents accurate labeling or not is unclear.  The nearly 5 mm Hg increase in BP could be meaningful over many years.  The importance of this will need continued study. The practical recommendation for grocery shoppers is that this is another reason to opt for fresh or frozen foods rather than canned.

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Risk of Developing Coronary Artery Disease Following a Normal Coronary Angiogram in Middle-Age

Risk of Developing Coronary Artery Disease Following a Normal Coronary Angiogram in Middle-Age | Heart and Vascular Health | Scoop.it

Atherosclerosis begins in the teenage years & progresses over time. It is unknown, however, whether coronary angiography in middle-aged adults showing no evidence of atherosclerosis identifies individuals at low risk for coronary artery disease (CAD).

In 4068 patients ≥40 years of age who had at least two coronary angiograms, 227 patients (5.8%) had no CAD and 251 patients (6.4%) had mild atherosclerotic disease (stenosis <30%) on the initial angiogram.

Patients in the normal-angiogram group were younger, more often female, and less likely to use tobacco than patients in the mild-atherosclerosis group, while rates of diabetes and hypertension were the same. Angiographic evidence of any CAD and obstructive CAD was apparent in 26% and 4.8%, respectively of the normal-angiogram group on subsequent angiography performed 75 ± 46 months later. Myocardial infarction and revascularization occurred in 4.8% and 3.5%, respectively.

In summary, 26% of middle-aged adults with a normal coronary angiogram who had subsequent angiography for clinical reasons developed CAD, although the annual rates of myocardial infarction or revascularization were very low. Even mild atherosclerosis on the initial angiogram increased the rate of progression of CAD by 10-fold and the rate of revascularization by 8-fold. 

Seth Bilazarian, MD's insight:

This paper has very practical implications for patients.  If there is no or minimal CAD at the time of a coronary angiogram (catheterization), the chance of progression to significant stenosis or heart attack is around 5%.  This rate is generally categorized as low risk by lipid guidelines over 10 years.  However there is an important value in noting (and showing patients) minimal coronary disease that are areas of coronary plaques, since these plaques identify patients at higher risk for progression and warrant a continued aggressive risk reduction approach with life style modification and statin use.

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Atorvastatin Effect on Fibrous Cap Thickness in Coronary Artery Plaque

Atorvastatin Effect on Fibrous Cap Thickness in Coronary Artery Plaque | Heart and Vascular Health | Scoop.it

More intensive statin therapy reduces cardiovascular morbidity and mortality. However, the mechanism of the dose-dependent effect on plaque stabilization by statin therapy is not fully elucidated.

Micron resolution of optical coherence tomography allows detailed assessment of fibrous cap thickness, which contributes to plaque instability.

Increase in fibrous cap thickness in coronary atherosclerotic plaque benefits from higher dose atorvastatin compared with a lower regimen in patients with unstable angina pectoris.

Larger and longer term studies are needed to determine the direct relationship between an increase in fibrous cap thickness and coronary event risk reduction.

Seth Bilazarian, MD's insight:

This study used imaging called Optical Coherence Tomography (OCT) to assess plaques in the coronary arteries.  Use of statin medications like Atorvastatin (Lipitor) reduces the amount of cholesterol in the blood but this study adds direct evidence that in addition to reducing the plaque size it also thickened the overlying cover of the plaque called the fibrous cap.  When this cap becomes disrupted (erodes or ruptures) clot forms and a heart attack can ensue.  This mechanism of benefit through plaque stabilization is a critical contributor to the benefits of statin therapy in patients with coronary plaques.

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Adrenal Masses & Surgically Correctable Hypertension

Adrenal Masses & Surgically Correctable Hypertension | Heart and Vascular Health | Scoop.it

Many patients have a surgically correctable cause for their high blood pressure: a hormonally active adrenal tumor. Three conditions associated with hormonally active adrenal masses—pheochromocytomas, Cushing’s disease and Conn’s syndrome—all can cause uncontrollable hypertension, among other symptoms.

Approximately 8% of  U.S. population has an adrenal tumor. Only one in 4,000 adrenal tumors is malignant, and most benign tumors are inactive. However, about 25%—much more than previously thought—are hormonally active. The effect of this abnormal activity depends on the hormone.

The most effective therapy for hormonally active adrenal tumors, a laparoscopic procedure to remove the adrenal tumor, often cures patients of hypertension and related problems. Yet the clinical symptoms indicating hormonally active tumors are often unrecognized. Most adrenal tumors are detected during imaging for unrelated issues, yet these patients are infrequently referred for follow-up testing. Better awareness of symptoms, and increased testing of incidentally found tumors, could benefit at-risk patients.

Seth Bilazarian, MD's insight:

Although some patients with adrenal tumors can be effectively treated with medications, most patients should have surgery. Excising hormonally active adrenal masses through a relatively low-risk, minimally invasive operation (laparoscopic adrenalectomy) can resolve hypertension and other health problems, including the obesity, diabetes, hypertension and osteoporosis associated with Cushing‘s syndrome.

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Cytisine vs. Nicotine for Smoking Cessation

Cytisine vs. Nicotine for Smoking Cessation | Heart and Vascular Health | Scoop.it

Motivation, it’s often said, is half the battle of behavior change.  In the battle against nicotine addiction, however, motivation alone may not be enough.  Mass media campaigns have helped to raise awareness about the dangers of smoking.  But for the majority of smokers who already want to quit, the question remains: how? 

A study published this week in NEJM compared the effectiveness of cytisine versus nicotine replacement therapy for smoking cessation.  1300 adult smokers in New Zealand were randomized to receive either cytisine for 25 days or nicotine replacement therapy for 8 weeks.  Participants also received behavioral support. At one month, 40% of participants in the cytisine group reported continuous abstinence, as compared to 31% of those on nicotine replacement therapy (absolute difference of 9.3 percentage points; 95% confidence interval 4.2 to 14.5; number needed to treat = 11).  Abstinence was also higher with cytisine than with nicotine replacement therapy at two and six months.  

Seth Bilazarian, MD's insight:

Today, cytisine use is mostly limited to Eastern Europe.  Considering it is much less expensive than Chantix ($20-$30 for the recommended 25 day treatment course of cytisine versus $500 for 12 weeks of Chantix), if cytisine is indeed more effective than nicotine replacement therapy, as the findings of this study suggests, then introducing it to the US market could yield tremendous value.

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Artificial sweeteners induce glucose intolerance

Artificial sweeteners induce glucose intolerance | Heart and Vascular Health | Scoop.it

Non-caloric artificial sweeteners (NAS) are among the most widely used food additives worldwide, regularly consumed by lean and obese individuals alike. NAS consumption is considered safe and beneficial owing to their low caloric content, yet supporting scientific data remain sparse and controversial. Here we demonstrate that consumption of commonly used NAS formulations drives the development of glucose intolerance through induction of compositional and functional alterations to the intestinal microbiota. These NAS-mediated deleterious metabolic effects are abrogated by antibiotic treatment, and are fully transferrable to germ-free mice upon faecal transplantation of microbiota configurations from NAS-consuming mice, or of microbiota anaerobically incubated in the presence of NAS. We identify NAS-altered microbial metabolic pathways that are linked to host susceptibility to metabolic disease, and demonstrate similar NAS-induced dysbiosis and glucose intolerance in healthy human subjects. Collectively, our results link NAS consumption, dysbiosis and metabolic abnormalities, thereby calling for a reassessment of massive NAS usage.

Seth Bilazarian, MD's insight:

We have been using non-caloric artificial sweeteners for more than a century. Today the food industry is using them in ever-greater quantities in 'diet' foodstuffs and they are recommended for weight loss and for individuals with glucose intolerance and type 2 diabetes mellitus. This report shows that consumption of the three most commonly used non-caloric artificial sweeteners — saccharin, sucralose and aspartame (Sweet-n-Low, Equal & Splenda)— directly induces a propensity for obesity and glucose intolerance in mice, by changing the gut microbiome in a way that leads to absorption of more calories and that compromises glucose tolerance.  In healthy human subjects, and suggest it may be necessary to develop new nutritional strategies tailored to the individual and to variations in the gut microbiota.

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Donovan Baldwin's curator insight, December 29, 2014 9:18 AM

A life without sweeteners of any kind is not actually that bad. However, if you must have sweetness, it appears that artificial sweeteners are still better than sugar. Try the 21 Day Sugar Detox. Learn more at http://nodiet4me.com/review/sugar_detox.html

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How does caffeine affect exercise?

How does caffeine affect exercise? | Heart and Vascular Health | Scoop.it
High levels of caffeine, especially in individuals who do not consume caffeine on a regular basis, may play a role in caffeine toxicity.
Seth Bilazarian, MD's insight:

Given the increase in caffeine availability and reports of adverse events, an understanding of the cardiac effects of caffeine is urgently required. This review summarizes the available medical literature specifically relating to caffeine ingestion and reduced exercise coronary blood flow, suggesting possible mechanisms. This review specifically focuses on the effects of caffeine on the coronary arteries, especially the reduced coronary blood flow noted with exercise.

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Mediterranean diet & telomere length in Nurses’ Health Study

Mediterranean diet & telomere length in Nurses’ Health Study | Heart and Vascular Health | Scoop.it

To examine whether adherence to the Mediterranean diet was associated with longer telomere length, a biomarker of aging.

Nurses’ Health Study, an ongoing prospective cohort study of 121 700 nurses enrolled in 1976; in 1989-90 a subset of 32 825 women provided blood samples.

Association between relative telomere lengths in peripheral blood leukocytes measured by quantitative real time polymerase chain reaction and Alternate Mediterranean Diet score calculated from self reported dietary data.

Greater adherence to the Mediterranean diet was associated with longer telomeres after adjustment for potential confounders. Least squares mean telomere length z scores were −0.038 (SE 0.035) for the lowest Mediterranean diet score groups and 0.072 (0.030) for the highest group (P for trend=0.004).

Greater adherence to the Mediterranean diet was associated with longer telomeres. These results further support the benefits of adherence to the Mediterranean diet for promoting health and longevity.

Seth Bilazarian, MD's insight:

What is already known on this topic:
The Mediterranean diet has been consistently linked with health benefits, including reduced mortality and reduced risk of chronic diseases.
No study has examined whether adherence to the Mediterranean diet is associated with longer telomere length, a biomarker of aging.


What this study adds:
Greater adherence to the Mediterranean diet was associated with longer telomeres.
Telomere length variability may be partially explained by lifestyle practices; as accelerated telomere attrition may underlie many chronic diseases, identifying modifiable factors that affect telomere dynamics is important.
The results further support the benefits of adherence to the Mediterranean diet for promoting health and longevity.

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Surgical Treatment of Moderate Ischemic Mitral Regurgitation

Surgical Treatment of Moderate Ischemic Mitral Regurgitation | Heart and Vascular Health | Scoop.it

In patients with moderate ischemic mitral regurgitation, the addition of mitral-valve repair to CABG did not result in a higher degree of left ventricular reverse remodeling. Mitral-valve repair was associated with a reduced prevalence of moderate or severe mitral regurgitation but an increased number of untoward events. Thus, at 1 year, this trial did not show a clinically meaningful advantage of adding mitral-valve repair to CABG. Longer-term follow-up may determine whether the lower prevalence of mitral regurgitation translates into a net clinical benefit.

Seth Bilazarian, MD's insight:

When patient were undergoing open heart surgery for coronary bypass (CABG), the addition of mitral-valve repair for a "leaky valve" was associated with a longer bypass time , longer hospital stay after surgery & more neurologic events.

At one year, moderate or severe mitral regurgitation was less common in the combined-procedure group than in the CABG-alone group (11.2% vs. 31.0%). There were no significant between-group differences in major adverse cardiac or cerebrovascular events, deaths, readmissions, functional status, or quality of life at 1 year.

For now, the best recommendation is to improve heart function with bypass and not "fix" the leaky heart valve.

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Testosterone-Replacement Therapy

Testosterone-Replacement Therapy | Heart and Vascular Health | Scoop.it
Martin is a generally healthy 61-year-old married man who has come to you for his annual physical examination. As you discuss Martin's health concerns, he mentions an interest in receiving a prescription for testosterone.

Which of the following approaches do you think is appropriate for this patient? Base your choice on the published literature, your own experience, recent guidelines, and other sources of information.

1. Recommend testosterone-replacement therapy

2. Recommend against testosterone-replacement therapy

To aid in your decision making, each of these approaches is defended in a short essay by an expert in the field. 

Seth Bilazarian, MD's insight:

Excellent review of the controversial topic of Testosterone replacement.  The controversy is largely driven by a lack of data on safety and longterm hazards vs. small benefits from "Low T " treatment, that might better be achieved with weight loss and exercise.  I voted no.

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In 1964n first angioplasty was called Dotter's Folly

In 1964n first angioplasty was called Dotter's Folly | Heart and Vascular Health | Scoop.it

The first angioplasty procedure was performed 50 years ago. But it was some time before the work of "Crazy Charlie" Dotter caught on.

The patient was an 82-year-old woman whose painful left foot was horribly disfigured by ulcers and gangrene brought on by lack of circulation. Her doctors at what is now Oregon Health & Science University wanted to amputate, but when she objected, she was referred to Charles Dotter, a radiologist at the hospital who was experimenting with new ways to open up narrowed or blocked arteries. At the time, 50 years ago, clearing clogged arteries involved surgery, a long time in the hospital and a high risk of complications. Dotter’s idea was to try unblocking them with catheters—slender, hollow tubes normally used in radiology to prepare for X-rays by injecting contrast dye into blood vessels. 

X-rays showed that the woman’s leg had a narrowing in the femoral artery, which supplies blood to the lower extremities. That made her a perfect first candidate for Dotter’s scalpel-free artery repair. On January 16, 1964, he inserted a guide wire into the patient’s femoral artery and threaded it to the narrowed area. He then passed a catheter along the guide wire, followed by another, wider catheter. The procedure caused the artery to expand, and blood flow quickly returned to the woman’s foot. Several of her badly damaged toes eventually fell off, but the woman was able to walk out of the hospital on her own, living free of foot pain until she died two and a half years later. 

Seth Bilazarian, MD's insight:

Dotter’s innovation, 50 years ago was the beginning of the fields of interventional cardiology and radiology.

Dotter’s ideas, like his personality, were bold enough that many physicians in the United States dismissed him as “Crazy Charlie” and long ignored the procedure he eventually called percutaneous transluminal angioplasty (PTA). Dotter’s approach to clearing arteries had a better reception in Europe. In 1977, German-born physician Andreas Gruentzig introduced the balloon-tipped catheter, which uses tiny inflatable pouches to dilate narrowed coronary arteries. Today, angioplasty is performed on more than a million patients each year.  

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