SNORING MEN GET HEART BENEFITS WHEN BRETHING MASK IMPROVES SLEEP IN STUDY

A face mask used to treat a nighttime breathing disorder called obstructive sleep apnea can reduce a patient’s blood pressure, cholesterol and stomach fat, potentially improving their heart health, researchers found.

The condition affects as many as 18 million Americans, primarily men, and is often first recognized by the patient’s partner. It is marked by a brief collapse of the airway, which leads the patient to stop breathing for a few seconds until the brain sends a signal to wake up. The result is a fractured night’s sleep, daytime drowsiness and a host of health issues.

Standard treatment is a mask attached to a continuous positive airway pressure, or CPAP, machine. The machines can be cumbersome, leading many to quit using them within a year. The results should help persuade patients to stick with the therapy, said Surendra Sharma, lead author of the study released today by the New England Journal of Medicine.

“These patients need to be properly counseled for regular use of CPAP machines,” because compliance is associated with greater benefits, said Sharma, head of the department of internal medicine at the All India Institute of Medical Sciences in New Delhi, in an e-mailed response to questions. “In a real- life situation, the machine will be used for a longer period and more benefits will be observed.”

Pfizer Inc. funded the trial through an investigator- initiated research grant. The New York-based company, the world’s largest drugmaker, doesn’t manufacture or sell (PFE) devices for sleep apnea and wasn’t involved in the design, conduct or analysis of the study, the researchers said.

Growing Market
The global market to diagnose and treat patients with sleep apnea is about $2.9 billion and growing, with CPAP devices accounting for about one-third of the total, according to Global Industry Analysts Inc., a market research firm based in San Jose, California. Amsterdam-based Royal Philips Electronics NV (PHIA), ResMed Inc. (RMD) of Poway, California, and Fisher & Paykel Healthcare Corp. of Auckland, dominate the industry.

The study involved 86 patients recruited from the sleep laboratory at the All India Institute of Medical Sciences. They were treated with either a legitimate CPAP machine or a doctored device that included an airflow-restricting connector and tiny escape holes. Patients used each of the machines, which looked the same, for three months, with a one-month break between treatment.

Blood Pressure
After treatment, patients’ systolic blood pressure, measured during heart contractions, dropped an average of 3.9 millimeters of mercury or mmHg, while their diastolic blood pressure, when the heart fills with blood, fell by 2.5 mmHg. Previous studies of drug treatment found a 5 mmHg decline cut heart disease risk by 15 percent and strokes by 42 percent.

The CPAP machines also reduced total cholesterol by 13.3 mg per deciliter and artery-clogging bad cholesterol by 9.6 mg per deciliter, the study found. Benefits also were seen in abdominal fat content, weight loss and improved hemoglobin levels, the researchers said.

A constellation of heart risk factors, known as the metabolic syndrome, also appeared to reverse in 11 of the 86 patients after CPAP treatment. Those who were most adherent to the therapy showed a reduction in plaque buildup in the walls of the arteries leading to the brain, the study found.
“These results suggest a significant clinical benefit that will lead to a reduction in cardiovascular risk,” the investigators concluded.

ANTICOAGULANT MONITORING, DOSING MANAGED BY PATIENTS AT HOME MAY BE SAFE

MedPage Today (12/1, Phend) reports, "Anticoagulant monitoring and dosing managed by patients at home is safe and decreases clotting risk," according to a meta-analysis published online in The Lancet. Investigators found that "major bleeding event and mortality rates actually tended to favor self-management over usual care, although not significantly so (hazard ratios 0.88 and 0.82, both P=0.18)." Meanwhile, "thromboembolic events were nearly halved by self-monitoring (HR 0.51, P=0.01), with even greater benefits in patients younger than 55 and in those with mechanical heart valves."

HealthDay (12/1, Reinberg) reports, "Among older patients, who are at risk for major bleeding, self-monitoring reduced the risk of dying and didn't increase the risk of complications.

POSTED BY: Steven Almany M.D.

HOLIDAY SCHEDULE 2011

Please make sure to get all your prescriptions filled at least one week prior to the holiday to ensure you have them in time.

Christmas:
CLOSED- Monday December 26

New Years:
CLOSED- Monday January 2

LONG-TERM STATIN USE MAY BE SAFE

ABC World News (11/22, story 8, 0:30, Stephanopoulos) reported that research published in The Lancet suggests that statins' "benefits increase the longer someone takes them with no long-term risks such as cancer."

Reuters (11/23) reports that investigators looked at data from the Heart Protection Study (HPS), which included approximately 20,000 patients.

The Forbes (11/23) reports, "The main results of the HPS, published in 2002, showed a significant 23% reduction at 5.3 years in major vascular events associated with simvastatin treatment among the...patients with coronary disease enrolled in the trial." For the new research, "the HPS investigators report the followup results after a mean of 11 years."

HealthDay (11/23, Gordon) reports, "The 11-year study found that simvastatin (brand name Zocor) reduced the risk of cardiovascular disease by almost one-quarter." The investigators also "found no increase in illness or deaths from cancer or other non-vascular causes."

MedPage Today (11/23, Fiore) reports, "In an accompanying editorial, Payal Kohli, MD, and Christopher Cannon, MD, of Brigham and Women's Hospital...said the results, 'provide contemporary and confirmatory evidence that extended use of statins is safe with respect to possible risk of cancer and non-vascular mortality.'" The editorialists "noted that the original concerns about statin safety were from observational data, which were likely 'heavily confounded.'" Also covering the story are the UK's Telegraph (11/23, Smith) and AFP (11/23).

POSTED BY: Steven Almany M.D.

MICHIGAN HEART GROUP DISCOVERS TWITTER!!!!

Attention Twitter followers.....MHG is now on Twitter

I'm not a Tweeter...so I'm new at this, however if you are on Twitter, please follow us. Our new website will also have a link to our twitter acct. Hoping to have the new website launched in the next couple days at the latest.....STAY TUNED!!!

STACIE BATUR
Physician Liaison

COLCHICINE MAY HELPL PREVENT AFIB AFTER HEART SURGERY

MedPage Today (11/19, Susman) reported, "The oral agent colchicine -- a drug almost as old as the hills-- appears to offer a new way to prevent atrial fibrillation (Afib) after heart surgery," according to a study presented at the American Heart Association meeting and published in Circulation. Investigators found that "the relative risk of developing postop Afib was reduced 42.1% if patients were treated with colchicine rather than placebo (P=0.002)." The researchers found that "the incidence of atrial fibrillation at 12 months was 8.9% in patients given colchicine compared with 21.1% among patients randomized to placebo."

POSTED BY: Steven Almany M.D.

HOLIDAY SCHEDULE 2011

Please make sure to get all your prescriptions filled at least one week prior to the holiday to ensure you have them in time.

Christmas:
CLOSED- Monday December 26

New Years:
CLOSED- Monday January 2

PANEL COVENED BY NHLBI RECOMMENDS CHOLESTEROL TESTING FOR KIDS

In a front-page story, the Wall Street Journal (11/12, A1, Winslow, Dooren, Subscription Publication) reported that experts now say that all kids should undergo testing for high cholesterol at some point between the ages of 9 and 11, and then again sometime between the ages of 17 and 21.

The Washington Post (11/14, Stein) "The Checkup" blog reports that "the recommendation comes from by a 14-member expert panel convened by the National Heart, Lung and Blood Institute [NHLBI] and endorsed by the American Academy of Pediatrics, which will publish the panel's report (pdf)...in the journal Pediatrics."

The Los Angeles Times (11/12, Roan) reports, "Such guidelines already exist to address heart disease risk in adults, but until now there has been none outlining what works best for children." Also covering the story were the AP (11/14, Marchione, Tanner), the NPR (11/12, Shute) "Shots" blog, the Boston Globe (11/12, Kotz), HeartWire (11/14, O'Riordan), MedPage Today (11/14, Phend), WebMD (11/14, McMillen), and HealthDay (11/14, Preidt).

POSTED BY: Steven Almany M.D.

HOLIDAY SCHEDULE 2011

Please make sure to get all your prescriptions filled at least one week prior to the holiday to ensure you have them in time.

Christmas:
CLOSED- Monday December 26

New Years:
CLOSED- Monday January 2

FEW PHYSICIANS FOLLOW GUIDELINES FOR SCREENING YOUNG ATHLETES FOR HEART TROUBLE

The Los Angeles Times (11/14, Roan) "Booster Shots" blog reports that while "the deaths of high school athletes who collapse suddenly during practice or a game have led to new" American Heart Association (AHA) "guidelines for screening prep athletes for hidden heart problems before the start of a season," research presented at the AHA meeting "shows that the vast majority of doctors charged with such screenings don't follow the recommendations."

HealthDay (11/14, Mann) reports that researchers found that "less than half of physicians and only 6 percent of high school athletic directors in Washington state were aware of the life-saving guidelines -- potentially leaving many young athletes at risk." The association's "screening guidelines call for eight specific medical-history questions and four key elements in a physical exam, all designed to help doctors understand whether an athlete is at risk."

POSTED BY: Steven Almany M.D.

HYPERTENSION IN EARLY ADULTHOOD MAY BE LINKED TO FUTURE HEART PROBLEMS

The Los Angeles Times (11/22, Roan) "Booster Shots" blog reports that "high blood pressure in early adulthood spells future heart problems and that it shouldn't be ignored," according to a study published in the Journal of the American College of Cardiology. Investigators "followed almost 19,000 male students from Harvard who had their blood pressure measured when they entered college between 1914 and 1952." Participants "also responded to a health questionnaire mailed in the 1960s when they were an average age of almost 46."

HealthDay (11/22, Preidt) reports that "the researchers then looked at death certificates issued for participants until the end of 1998."

MedPage Today (11/22, Ullman) reports that participants "with prehypertension and stage 1 and 2 hypertension had an elevated risk of all-cause mortality, cardiovascular disease mortality, and coronary heart disease mortality." The investigators found that, "even after adjusting for middle-age hypertension, researchers found that the mortality risk was 'somewhat attenuated,' but the pattern remained."

HeartWire (11/22, Wood) reports that "One surprise, however...was that stroke mortality was not significantly increased among those with elevated blood pressure decades earlier."

POSTED BY: Steven Almany M.D.

HOLIDAY SCHEDULE 2011

Please make sure to get all your prescriptions filled at least one week prior to the holiday to ensure you have them in time.

Christmas:
CLOSED- Monday December 26

New Years:
CLOSED- Monday January 2

MICHIGAN HEART GROUP'S PHYSICIAN LIAISON IS HERE TO HELP YOU

Michigan Heart Group has a Physician Liaison on staff to assist with questions, concerns or problems you, your staff or your patients may have with our office.

Stacie Batur is available Monday through Thursday at (248) 267-5050 (x6509). She is often between two buildings or visiting referring physician offices. If you get her voice mail, please leave a message and she will call you back shortly. If you need to speak to her immediately you can reach her on her cell phone at (248) 765-4466.

RESEARCH SUGGESTS LINK BETWEEN CHOCOLATE CONSUMPTION, REDUCED STROKE RISK

Reuters (10/11, Joelving) reports that, according to research published in the Journal of the American College of Cardiology, chocolate consumption may be linked to a reduced risk of stroke.

HealthDay (10/11, Gordon) reports, "The study included more than 33,000 Swedish women between the ages of 49 and 83. None of the women had any history of stroke, heart disease, cancer or diabetes when the study began in 1997."

MedPage Today (10/11, Phend) reports, "Overall stroke risk dropped 14% with each 50 g (1.8 oz) of chocolate a woman ate each week after accounting for other factors." The investigators found that "cerebral infarction risk similarly fell 12% for those eating the equivalent of about 1.2 chocolate bars or 100 chocolate chips (adjusted relative risk 0.88, 95% confidence interval 0.77 to 0.96)." Meanwhile, "hemorrhagic stroke risk dropped 27% per 50 g of weekly consumption (adjusted RR 0.73, 95% CI 0.54 to 0.99)." WebMD (10/11, Doheny) also covered the

POSTED BY STEVEN ALMANY, MD

HOLIDAY SCHEDULE 2011

Please make sure to get all your prescriptions filled at least one week prior to the holiday to ensure you have them in time.

Christmas:
CLOSED- Monday December 26

New Years:
CLOSED- Monday January 2

SERUM TESTOSTERONE LEVELS MAY BE LINKED TO RISK OF CV EVENTS IN ELDERLY MEN

HeartWire (10/4, Nainggolan) reports that "elderly men in the highest quartile of serum testosterone levels have around a 30% lower risk of cardiovascular events over five years compared with men in the lower three quartiles," according to a study published in the Journal of the American College of Cardiology. Investigators found that "the association remains even after adjustment for traditional cardiovascular risk factors and excluding those with CVD at baseline."

POSTED BY STEVEN ALMANY, MD

HOLIDAY SCHEDULE 2011

Please make sure to get all your prescriptions filled at least one week prior to the holiday to ensure you have them in time.

Thanksgiving:
CLOSED- Thursday November 24
CLOSED- Friday November 25

Christmas:
CLOSED- Monday December 26

New Years:
CLOSED- Monday January 2

DIETARY CHANGES MAY LOWER CHOLESTEROL BETTER THAN STATINS

On its website, ABC News /Good Morning America (10/24, Main) reports that dietary changes may "do a better job" than taking statins to lower cholesterol. In a study published in the Journal of the American Medical Association, researchers "followed 345 people with high cholesterol who were placed on one of two vegetarian, low-cholesterol diets for six months." Those in the "low-saturated-fat diet...were told simply to eat low-fat dairy and get more fruits and vegetables into their meals." The second group incorporated "specific cholesterol-lowering foods into their meals," such as "soy proteins, nuts, oats, peas, and beans. That group saw a drop in cholesterol three times higher than the group on the regular low-saturated-fat diet, and both diets proved to be at least as successful as early trials of statins."

POSTED BY STEVEN ALMANY, MD

WOMEN WITH HPV MAY HAVE INCREASED HEART ATTACK, STROKE RISK

The New York Times (10/25, D5, Grady, Subscription Publication) reports, "Women infected with the human papillomavirus, or HPV, are two to three times as likely as uninfected women to have had a heart attack or stroke, according to a report" published in the Journal of the American College of Cardiology. After "researchers analyzed the data and adjusted for heart risks like smoking, blood pressure and weight, they found that women with HPV were 2.3 times as likely as those without the virus to have heart disease." However, investigators "said that if the link is real, heart disease, like cancer, would be likely to develop only in people with lingering HPV infection."

The Wall Street Journal (10/25, Hobson) "Health Blog" notes that HPV also suppresses the action of retinoblastoma protein, another tumor suppressor that has been linked to atherosclerosis.

An accompanying editorial observed, "This finding re-emphasizes the potential roles that a variety of chronic infectious agents may play in the pathogenesis of atherosclerosis," Forbes (10/25, Husten) reports.

MedPage Today (10/25, Neale) reports, "Although HPV status was not related to various metabolic risks, it was strongly associated with cardiovascular disease after adjustment for demographics, health and sex behaviors, medical comorbidities, and cardiovascular risk factors and management." However, "the cross-sectional design of the study precludes any conclusions about a cause-and-effect relationship between HPV infection and cardiovascular disease."

POSTED BY STEVEN ALMANY, MD

HOLIDAY SCHEDULE 2011

Please make sure to get all your prescriptions filled at least one week prior to the holiday to ensure you have them in time.

Thanksgiving:
CLOSED- Thursday November 24
CLOSED- Friday November 25

Christmas:
CLOSED- Monday December 26

New Years:
CLOSED- Monday January 2

VITAMIN E AND THE RISK OF PROSTATE CANCER: THE SELENIUM AND VITAMIN E CANCER PREVENTION TRIAL (SELECT)

Date Posted: October 31, 2011

Authors:
Klein EA, Thompson IM Jr, Tangen CM, et al.

Citation:
JAMA 2011;306:1549-1556.

Study Question:
What is the long-term effect of vitamin E and selenium on risk of prostate cancer in relatively healthy men?

Methods:
A total of 35,533 men from 427 study sites in the United States, Canada, and Puerto Rico were randomized between August 22, 2001, and June 24, 2004, in the SELECT study (Selenium and Vitamin E Cancer Prevention Trial). Eligibility criteria included a prostate-specific antigen (PSA) of 4.0 ng/ml or less, a digital rectal examination not suspicious for prostate cancer, and age 50 years or older for black men and 55 years or older for all others. The primary analysis included 34,887 men who were randomly assigned to one of four treatment groups: 8,752 to receive selenium; 8,737 vitamin E; 8,702 both agents; and 8,696 placebo. With a median follow-up of 5.5 years, there was no benefit from either antioxidant or combination, but there was a signal for increased prostate cancer. This analysis reflects the final data collected by the study sites on their participants, with extension through July 5, 2011.

Results:
This report includes 54,464 additional person-years of follow-up (median 7 years) and 521 additional cases of prostate cancer since the primary report. Compared with the placebo (referent group) in which 529 men developed prostate cancer, 620 men in the vitamin E group developed prostate cancer (hazard ratio [HR], 1.17; 99% confidence interval [CI], 1.004-1.36; p = 0.008); as did 575 in the selenium group (HR, 1.09; 99% CI, 0.93-1.27; p = 0.18), and 555 in the selenium plus vitamin E group (HR, 1.05; 99% CI, 0.89-1.22; p = 0.46). Compared with placebo, the absolute increase in risk of prostate cancer per 1,000 person-years was 1.6 for vitamin E, 0.8 for selenium, and 0.4 for the combination.

Conclusions:
The authors concluded that dietary supplementation with vitamin E significantly increased the risk of prostate cancer among healthy men.
Perspective:
The antioxidant supplement story continues to evolve with no evidence of benefit for cancer or cardiovascular disease risk reduction from beta carotene, folate, vitamin E, selenium, or vitamin C, and increased risk of lung cancer with high-dose beta carotene and risk of polyps with high-dose folate. Yet so many patients take large doses, some of which is prescribed by well-intended physicians including specialists in aging/dementia, ophthalmology, and urology. The authors concluded with the following message for providers and the public: ‘The lack of benefit from dietary supplementation with vitamin E or other agents with respect to preventing common health conditions and cancers or improving overall survival, and their potential harm, underscore the need for consumers to be skeptical of health claims for unregulated over-the-counter products in the absence of strong evidence of benefit demonstrated in clinical trials.’ Clearly, long-term implications of taking nutraceuticals and dietary supplements are not known and very hard to assess.

Author(s):
Melvyn Rubenfire, M.D., F.A.C.C. (Disclosure)

POSTED BY DAVID CRAGG, MD

MICHIGAN HEART GROUP'S PHYSICIAN LIAISON IS HERE TO HELP YOU

Michigan Heart Group has a Physician Liaison on staff to assist with questions, concerns or problems you, your staff or your patients may have with our office.

Stacie Batur is available Monday through Thursday at (248) 267-5050 (x6509). She is often between two buildings or visiting referring physician offices. If you get her voice mail, please leave a message and she will call you back shortly. If you need to speak to her immediately you can reach her on her cell phone at (248) 765-4466.

HOLIDAY SCHEDULE 2011

Please make sure to get all your prescriptions filled at least one week prior to the holiday to ensure you have them in time.

Thanksgiving:
CLOSED- Thursday November 24
CLOSED- Friday November 25

Christmas:
CLOSED- Monday December 26

New Years:
CLOSED- Monday January 2

OMEGA-3 FATTY ACIDS AND CARDIOVASCULAR DISEASE: EFFECTS ON RISK FACTORS, MOLECULAR PATHWAYS, AND CLINICAL EVENTS

Date Posted:
October 31, 2011

Authors:
Mozaffarian D, Wu JH.

Citation:
J Am Coll Cardiol 2011;58:2047-2067.

Perspective:
The following are 10 points to remember about this state-of-the-art paper:

1. Fish are a major food source of long-chain n-3 polyunsaturated fatty acids (PUFAs) including eicosapentaenoic acid (EPA) (20:5n-3) and docosahexaenoic acid (DHA) (22:6n-3). Alpha-linolenic acid (ALA) (18:3n-3) is an n-3 fatty acid found in plants, including some seeds, nuts, and nut oils. ALA cannot be synthesized in humans. Thus, tissue and circulating levels of EPA and DHA are predominantly determined by their direct dietary consumption.

2. Environmental concerns regarding fish consumption include potential contaminants such as mercury. However, the mercury content of most fish is low, with a few selected species containing higher levels. Availability of sustainable, environmentally sound commercial fishing must also be addressed to preserve this food source into the future.

3. N-3 PUFA has multiple physiological effects that may translate into reduced cardiovascular disease risk. Plasma triglycerides are lowered with n-3 PUFAs by decreased hepatic production of very low-density lipoprotein and enhanced clearance. Lower resting heart rate and blood pressure have also been observed with n-3 PUFA intake, which may occur through improved left ventricular diastolic filling or augmented vagal tone. In short-term trials, n-3 PUFA consumption increases biomarkers of nitric oxide production, mitigates peripheral vasoconstrictive responses to norepinephrine and angiotensin II, improves arterial wall compliance, and enhances vasodilatory responses. Such effects, separately or in sum, could account for lowering of systemic vascular resistance and blood pressure.

4. High doses of n-3 PUFA are considered to have antithrombotic effects; however, n-3 PUFA has not been shown to consistently affect platelet aggregation or levels of coagulation factors. No excess in clinical bleeding outcomes have been observed in randomized trials. Improved flow-mediated arterial dilation has been observed with n-3 PUFAs, along with lower circulating markers of endothelial dysfunction.

5. Some observational studies have noted a higher incidence of type 2 diabetes with n-3 PUFA or fish consumption. However, among controlled trials, no association has been noted between n-3 PUFAs and biomarkers of glucose-insulin homeostasis.

6. It remains unclear if n-3 PUFAs have anti-inflammatory effects. In several trials, n-3 PUFA supplementation reduced plasma and urine levels of arachidonic acid (AA)-derived eicosanoids such as leukotriene E4. Findings for other circulating biomarkers of inflammation, such as interleukin-1-beta and tumor necrosis factor-alpha, are mixed.

7. N-3 PUFA affects a myriad molecular pathways, including alteration of physical and chemical properties of cellular membranes, direct interaction with and modulation of membrane channels and proteins, regulation of gene expression via nuclear receptors and transcription factors, changes in eicosanoid profiles, and conversion of n-3 PUFA to bioactive metabolites.

8. In prospective observational studies and adequately powered randomized clinical trials, the benefits of n-3 PUFA seem most consistent for coronary heart disease mortality and sudden cardiac death. Potential effects on other cardiovascular outcomes are less well established, including conflicting evidence from observational studies and/or randomized trials for effects on nonfatal myocardial infarction, ischemic stroke, atrial fibrillation, recurrent ventricular arrhythmias, and heart failure.

9. Research gaps include the relative importance of different physiological and molecular mechanisms, precise dose responses of physiological and clinical effects, whether fish oil provides all the benefits of fish consumption, and clinical effects of plant-derived n-3 PUFA.

10. Overall, current data provide strong concordant evidence that n-3 PUFAs are bioactive compounds that reduce risk of cardiac death. National and international guidelines have converged on consistent recommendations for the general population to consume at least 250 mg/day of long-chain n-3 PUFAs or at least two servings/week of oily fish.

Author(s):
Elizabeth A. Jackson, M.D., F.A.C.C. (Disclosure)
Topic(s):
Prevention/Vascular, General Cardiology

POSTED BY DAVID CRAGG, MD

LOW VITAMIN D LEVELS MAY BE LINKED TO RISK FACTORS FOR CARDIOVASCULAR DISEASE

USA Today (10/4, Marcus) reports, "Low vitamin D levels are common and are linked to a number of risk factors for cardiovascular disease," according to research published in the Journal of the American College of Cardiology. Investigators looked at data from "more than 75 previous studies, most of which were observational." The study's lead author said, "There's evidence low vitamin D levels affect blood pressure, insulin resistance, coronary artery disease.".

POSTED BY STEVEN ALMANY, MD

MANY AFIB PATIENTS NOT BEING PRESCRIBED ANTICOAGULANTS

MedPage Today (9/3, Susman) reported, "A first look at a massive international registry of treatment for atrial fibrillation indicates that a high percentage of individuals are not being prescribed anticoagulation treatment that can reduce their risk of stroke, researchers said" at the European Society of Cardiology meeting. Researchers found that "of the nearly 10,000 patients in the initial cohort of the Global Anticoagulant Registry in the Field (Garfield), CHADS2 scoring showed 55% of them to be eligible for anticoagulation therapy, but 33% of them didn't get it." MedPage Today pointed out that "guidelines call for treatment with anticoagulation to prevent strokes in patients with CHADS2 scores of 2 or higher."

POSTED BY STEVEN ALMANY, MD

RESEARCHERS SAY ITALIAN PREPARTICIPATION SPORTS SCREENING PROGRAM IS COST-EFFECTIVE

HeartWire (8/30, O'Riordan) reports that "the Italian model for a preparticipation sports screening program, one that includes a 12-lead electrocardiogram (ECG) for all individuals participating in athletics, is a cost-effective mass-screening program, according to researchers who performed the analysis," which was presented at the European Society of Cardiology 2011 Congress. HeartWire points out that "the cost of widespread screening, as well as the risk of false-positive ECGs that might prevent healthy individuals from participating in sports and the battery of unnecessary tests they will face, have limited the adoption of mass-screening programs in other countries. In the US, the American College of Cardiology and the American Heart Association limit screening to a physical examination and medical history."

POSTED BY STEVEN ALMANY, MD

CHOCOLATE CONSUMPTION MAY BE LINKED TO REDUCED RISK OF HEART DISEASE, STROKE

ABC World News (8/29, story 10, 0:30, Sawyer) reported that "chocolate may be a kind of secret weapon against heart disease."

Bloomberg News (8/30, Torsoli) reports that "regular consumption" of chocolate "may slash the risk of developing heart disease by a third, according to research published in the British Medical Journal and presented...at the European Society of Cardiology's conference in Paris."

The Los Angeles Times (8/30, Stein) "Booster Shots" blog reports that investigators analyzed data from "seven studies looking at the link between eating chocolate and a reduction in heart disease that included 114,009 people."

The Time (8/30, Melnick) "Healthland" blog reports, "Five of the seven studies showed some benefit to eating chocolate. Overall, people with the highest chocolate consumption levels had 37% lower risk of heart disease and a 29% lower risk of stroke than those who ate the least chocolate."

The CNN (8/30) "The Chart" blog points out that "the studies, notably, did not differentiate between dark or milk chocolate and included consumption of different types of chocolate (bars, shakes, etc.)."

MedPage Today (8/30, Neale) reports that one of the researchers "noted that most commercially available chocolate products are high in fat, sugar, and calories, and that overindulging could counteract any of the potential benefits, a sentiment echoed by Janet Wright, MD, vice president of science and quality for the American College of Cardiology." In an interview, Dr Wright said, "We tend to take a little bit of advice and think that more is better," but "in this case, more is probably not better because of the fat content and the calorie content."

Also covering the story were the UK's Telegraph (8/30, Adams), BBC News (8/30), the NPR (8/30, Shute) "Shots" blog, the Grand Rapids Press (8/30, Thoms), WebMD (8/30, Laino), HealthDay (8/30, Reinberg), HeartWire (8/30, O'Riordan).

POSTED BY STEVEN ALMANY, MD

EXPERTS PREDICT 165 MILLION AMERICANS WILL BE OBESE BY 2030

ABC World News (8/25, story 7, 2:00, Stephanopoulos) reported, "Tonight, sobering new numbers on America's struggle with obesity." A new series on obesity published in "the medical journal Lancet says if trends continue, half of all American men will be obese by 2030."

Bloomberg News (8/26, Gerlin) reports, "US health-care spending will rise by as much as $66 billion a year by 2030 because of increased obesity if historic trends continue," the study suggested. "Almost 100 million Americans and 15 million Britons are already considered obese, based on body-mass index, a ratio of weight to height, Y. Claire Wang, an epidemiologist at Columbia University's Mailman School of Public Health in New York, said yesterday at a London news conference." Yet "another 65 million American adults and another 11 million British adults would join them in the next two decades based on past trends, said Wang."

The Washington Post (8/26, Huget) "The Checkup" blog reported that a "four-part series by a number of international public health experts argues that the global obesity crisis will continue to grow worse and add substantial burdens to health-care systems and economies unless governments, international agencies and other major institutions take action to monitor, prevent and control the problem." The blog adds, "The series, which had support from the federal government and foundations, is published in advance of the first High-Level Meeting of the United Nations General Assembly focused on non-communicable disease prevention and control, which will take place in New York City Sept. 19 and 20."

According to CNN's (8/26, Cooper) "The Chart" blog, one report in the series "includes suggestions for ways governments can implement policies that it says will reduce obesity and save money. Proposals include a tax on unhealthy foods and beverages, school programs to promote good nutrition and physical activity, and cutting junk food advertising."

POSTED BY STEVEN ALMANY, MD

CALCIFICATION IN ARTERIES MAY BE LINKED TO FUTURE RISK OF DEMENTIA, STROKE

Medscape (8/26, Lowry) reports, "Arterial calcification in major vessel beds outside the brain, as shown with magnetic resonance imaging (MRI), is associated with vascular brain disease and may be linked to future risk for dementia and stroke, a new study shows." Investigators "used computed X-ray tomography (CT) scans to measure calcification in the coronary arteries, aortic arch, and extracranial and intracranial carotid arteries. They also used brain MRI scans to assess cerebral infarcts, microbleeds, and WMLs, which are considered important markers of vascular brain disease." Altogether, 885 patients were involved in the study.

HealthDay (8/26, Preidt) reports, "The researchers found that calcium build-up in each of the four arteries was associated with white matter lesions and small strokes in the brain, and that the amount of calcified plaque in the vessels closest to the brain (carotid arteries) was most strongly linked with signs of vascular brain disease." The study, published in Arteriosclerosis, Thrombosis and Vascular Biology, found that "the strongest associations were between intracranial carotid calcification and the volume of white matter lesions, and extracranial carotid calcification and small strokes."

MedPage Today (8/26, Gever) reports, "The researchers cautioned, however, that the clinical implications may be limited. They noted that the problem of radiation exposure raises questions about the practicality of large-scale CT screening of neurologically healthy people."

POSTED BY STEVEN ALMANY, MD

STUDY SUGGESTS EXCESSIVE TV WATCHERS MAY HAVE SHORTER LIFE SPANS

WebMD (8/16, Warner) reports that watching six hours or more of television daily "could shorten the average life expectancy by nearly five years," according to a study in the British Journal of Sports Medicine. TV watching "time may have adverse health consequences that rival those of lack of physical activity, obesity and smoking," wrote study authors J. Lennert Veerman, of the University of Queensland, Australia, and colleagues.

HealthDay (8/16, Reinberg) reports that the researchers analyzed data on "11,000 people aged 25 and older from the Australian Diabetes, Obesity and Lifestyle Study" and looked at national "population and mortality figures." The study team found that in 2008, "Australian adults watched a total of 9.8 billion hours" of TV; and individuals who watched "more than six hours of TV were in the top 1 percent." The statistics indicated too much TV watching "may be as dangerous as smoking and lack of exercise." For example, the researchers said smoking "can shorten of life expectancy by more than four years after the age of 50. That represents 11 minutes of life lost for every cigarette and that's the same as half an hour of TV watching." They concluded that for every hour of TV watched "after age 25, lifespan fell by 22 minutes

POSTED BY STEVEN ALMANY, MD

DEPRESSION MAY RAISE WOMEN'S STROKE RISK

USA Today (8/12, Manning) reports, "A study published Thursday in Stroke: Journal of the American Heart Association reports that women with a history of depression have a 29% greater risk of having a stroke than non-depressed women, and those who take antidepressants, particularly selective serotonin reuptake inhibitors, or SSRIs...face a 39% higher risk."

According to the Huffington Post (8/12, Pearson), depression "can cause certain physiological and hormonal changes in the body that in turn increase stroke risk." John Lynch, of the NIH's National Institute of Neurological Disorders and Stroke, who was not associated with the study, explained, "Depression may be contributing to increased risk through a number of mechanisms, including brain hormone pathways, or an increased prevalence of poor health behaviors or medical disorders associated with stroke in depressed individuals."

HealthDay (8/11, Mann) reported that after following "80,574 women aged 54 to 79 who took part in the Nurses' Health Study from 2000 to 2006 and had no prior history of stroke," researchers also found that "depressed women were more likely to be single, smoke and be less physically active than their non-depressed counterparts." In addition, the depressed women were "slightly younger, had a higher body mass index and more coexisting conditions, such as high blood pressure, heart disease, and diabetes."

WebMD (8/11, Doheny) reported that the "use of antidepressants is not thought to be linked with stroke risk." Study author An Pan, PhD, a research fellow at the Harvard School of Public Health, explained that the "'medication use could be a marker for depression severity.' The most depressed were probably most likely to be on the medicine." MedPage Today (8/12, Walsh) and Medscape (8/12, Lowry) also cover the story.

POSTED BY STEVEN ALMANY, MD

USE OF WARFARIN AMONG AFIB PATIENTS MAY BE INSCONSISTENT

MedPage Today (8/3, Kaiser) reported that, "among atrial fibrillation patients who were candidates for warfarin therapy, only about half were on the drug, with rates ranging widely across practices," according to an analysis which used data from "the American College of Cardiology's National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) program." While just "55.1% of patients were taking warfarin, the mean CHADS2 score for all patients -- on warfarin or not -- was 2.5, 'suggesting an almost random pattern of treatment.'" Meanwhile, "the treatment rate differed significantly at the practice level, ranging from 25% to 80%." The research is published online in the American Journal of Cardiology.

POSTED BY STEVEN ALMANY, MD

MEDIA CLIPS: 5-HOUR ENERGY- WWJ and DR. STEVEN ALMANY

http://www.blogger.com/img/blank.gif

http://www.blogger.com/img/blank.gif

http://www.blogger.com/img/blank.gif

http://www.blogger.com/img/blank.gif

http://www.blogger.com/img/blank.gif

DOCTORS SAY MICHIGAN HIGH SCHOOL PHYSICALS ARE "OUTDATED," DON'T SCREEN FOR SERIOUS HEALTH DEFECTS

DETROIT (WXYZ) - High School athletes suddenly collapsing and dying on the court or on the field; It’s happened dozens of times in Michigan during the last decade.

In Michigan, the only pre-screening for sports that your kids have to have is a physical. The type of physical, the tests that are run, and the questions http://www.blogger.com/img/blank.gifthat are asked are entirely up to you and your doctor. And that has a lot of physicians and families asking – should more be done to keep your children safe?


CLICK HERE FOR THE 4 PAGE MHSAA PHYSICAL FORM


The game winning shot quickly turned into tragedy. In March, 16-year-old Wes Leonard – star of the Fennville High School basketball team – collapsed on the court, and later died. Doctors said the High School Junior died from cardiac arrest due to an enlarged heart. According to the American Heart Association, the vast majority of sudden deaths in young athletes are due to severe heart deformities that have been present since birth – but usually go undetected.

“Miss her every day, and I think about her every day. It left a big hole in our family,” said Randy Gillary.

Gillary knows all too well the pain of losing a child to cardiac arrest. His 15-year-old daughter, Kimberly, died during a water polo match at Groves High School.

“We basically lost her on the pool deck,” said Gillary.

Gillary believes high school athletes need more screening to detect heart defects and he’s helped push the Michigan High School Athletic Association, or MHSAA, to adopt new, more detailed guidelines for student physicals. Since 1999, 47 students in Michigan have died from cardiac arrest.

“If we would’ve had more effective screening, substantial number of those kids could have been saved,” said Gillary.

The MHSAA is a non-profit organization that runs post-season tournaments for sports at about 1540 Michigan high schools and middle schools. When it comes to pre-screening athletes – the only requirement that the MHSAA has is that students must have a yearly physical. The physical can be done by a doctor, nurse practitioner or physician’s assistant, and there is no standardized medical history form that all students must use.

For decades, the MHSAA offered a simple two-sided card that medical professionals now call “outdated.” It asks about things like polio and scarlet fever – no detailed questions about heart problems or family medical history.

So after more than a year of meetings with health professionals – the MHSAA just created a new, more specific medical history form. It asks about chest pain, irregular heartbeats, fainting, and high cholesterol. Doctors say the dozens of new questions are great – but using the form is still just optional.

15-year-old Rebecca Krause says many of her family members have had heart attacks, so when she needed her physical to join the Track and Field Team for Chippewa Valley High School – Rebecca’s doctor sent her for additional heart screening. Rebecca says using the more detailed medical history form would give her peace of mind.

“It’s a smarter decision to ask more questions, and be aware of what your body limits are. And be able to do the things you love, without worrying about, ‘Oh, am I going to collapse on the field today,’” said Rebecca Krause.

St. John Pediatrician Dr. Marcus DeGraw says the MHSAA should make the new physical forms with additional heart health questions mandatory.

“Having everybody do the exact same questions with the exact same focus during the physical exam would allow you to catch a lot of these kids earlier,” said Dr. DeGraw.

John Johnson is the spokesman for the MHSAA.

“Is this organization doing enough to keep student athletes safe,” asked Catallo.

“There’s only so much you can do with a staff of two dozen people here in Lansing. It’s the schools that make the rules, schools that adopt the rules, schools that take care of the day to day activities of school sports,” said Johnson.

Johnson says districts barely have enough money to keep sports programs going – that’s why they don’t want to burden the schools by dictating what kind of physicals students should have.

“So it’s basically whatever a doctor will sign off on, and whatever a parent will allow their doctor to sign off on for their kid, and then the school to accept that,” said Johnson.

“I have a huge problem that it’s optional. I think it should be mandatory. And I think in a lot of states you’ll see it will become mandatory,” said Dr. Steven Almany.

Dr. Almany is the Chief of Cardiology at Beaumont Hospital. In 2007, Dr. Almany and his collegaues started Beaumont’s Healthy Heart Check Screening Program. Channel 7 has partnered with them to provide free EKG and echocardiogram heart checks for more than 5,000 student athletes. While there is no one test that can catch every heart problem, Dr. Almany says other countries mandate EKG’s and other tests for all athletes.

“About 90% of the issues that might cause sudden death, we can probably pick up with an exam,” said Dr. Almany.

So who pays for the additional heart screening? The schools? Parents? While the debate about that continues -- Randy Gillary says the answer is tragically simple.

“How do you put a value on your son or daughter’s life? I would have paid anything to get our daughter back,” said Gillary.

Doctors tell us that typically, if you don’t have insurance an EKG test can cost anywhere from $30 to $150. If that test picks up a problem, your child may need the more expensive echocardiogram ultrasound of the heart, and that can run more than $400.

Even though the new MHSAA physical form that will soon be sent to schools isn’t mandatory, if parents want an even more detailed questionnaire, they can download a 4 page physical form on the MHSAA website.

Kimberly Gillary’s family started a non-profit organization after her death. The Kimberly Ann Gillary Foundation raises money to donate Automated External Defibrillators (AEDs) to every school in Michigan. An AED can help restart a heart after cardiac arrest.

POSTED BY STACIE BATUR, MICHIGAN HEART GROUP

TOOL MAY HELP PREDICT WARFARIN-ASSOCIATED HEMORRHAGE RISK IN PATIENTS WITH ATRIAL FIBRILLATION

MedPage Today (7/13, Neale) reported that "a score based on five clinical variables performs well for predicting the risk of warfarin-associated hemorrhage in patients with atrial fibrillation," according to a study published in the Journal of the American College of Cardiology. Investigators found that "the model, which included anemia, severe renal disease, an age of 75 or older, prior hemorrhage, and hypertension, outperformed six other published and validated risk scores." The investigators reported that "the rate of warfarin-associated major hemorrhage ranged from 0.4% per 100 patient-years in the low-risk group to 5.8% in the high-risk group."

Posted by Steven Almany, MD

ANTICOAGULATION FOR DVT IN CALF MAY REDUCE CLOT PROPAGATION RISK

MedPage Today (6/18, Phend) reported, "Anticoagulation for deep vein thrombosis (DVT) in the calf reduces risk that the clot will propagate and may improve other clinical outcomes as well," according to the research presented at the Society for Vascular Surgery's Vascular annual meeting in Illinois. Among the more than 2,300 studies Randall R. De Martino, MD, of Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and colleagues, "pooled the results of eight studies in adults with ultrasound- or venogram-confirmed calf DVT who were followed for at least one month after treatment with an anticoagulant for at least 30 days or no anticoagulation" and found that "patients who received vitamin K antagonists or heparin had dramatically lower rates of pulmonary embolism and clot propagation compared with those who went without anticoagulants."

POSTED BY STEVEN ALMANY, MD

FDA SAYS CHANTIX MAY SLIGHTLY INCREASE RISK OF HEART ATTACK

The AP (6/17, Perrone) reports, "Federal health regulators are warning doctors and patients that Pfizer's anti-smoking drug Chantix [varenicline] may slightly increase the risk of heart attack and other cardiovascular problems." On Thursday, the FDA "said...a study of 700-heart disease patients taking Chantix showed a small uptick in heart problems among those taking the smoking-cessation drug versus those taking placebo." The agency "will add new warnings to the drug's label about the study's findings."

Bloomberg News (6/17, Larkin, Edney) reports that the agency will also require "Pfizer...to further evaluate the heart risks with an analysis of existing studies."

Reuters (6/17) reports that in a statement, the agency said, "The known benefits of Chantix should be weighed against its potential risks when deciding to use the drug in smokers with cardiovascular disease."

The Los Angeles Times (6/16, Cevallos) "Booster Shots" blog pointed out that "heart problems aren't the only warning associated with Chantix. In 2009 the FDA warned that the drug might increase the risk of suicidal thoughts and behaviors." Also covering the story were Dow Jones Newswire (6/17, Dooren, Subscription Publication), AFP (6/17), HeartWire (6/16, O'Riordan), MedPage Today (6/16, Peck), HealthDay (6/16), and WebMD (6/16, Mann).

POSTED BY STEVEN ALMANY, MD

FDA IS RECOMMENDING PHYSICIANS RESTRICT PRESCRIBING HIGH-DOSE SIMVASTATIN (ZOCOR, MERCK) TO PATIENTS, GIVEN INCREASED RISK OF MUSCLE DAMAGE

June 8, 2011 (Silver Spring, Maryland) — The Food and Drug Administration is recommending that physicians restrict prescribing high-dose simvastatin (Zocor, Merck) to patients, given an increased risk of muscle damage [1]. The new FDA drug safety communication, issued today, states that physicians should limit using the 80-mg dose unless the patient has already been taking the drug for 12 months and there is no evidence of myopathy.

"Simvastatin 80 mg should not be started in new patients, including patients already taking lower doses of the drug," the agency states.

In addition, the FDA is requesting that additional changes be made to the drug's label. The label will be changed to include the new dosing recommendations, as well as warnings not to use the drug with various medications, including itraconazole (Sporanox, Jannsen Pharmaceutica), ketoconazole (Nizoral by Ortho-McNeil Pharmaceutical), posaconazole (Noxafil, Merck), erythromycin, clarithromycin, telithromycin (Ketek, Sanofi-Aventis), HIV protease inhibitors, nefazodone, gemfibrozil, cyclosporine, and danazol.

In addition, the 10-mg dose should not be exceeded in patients taking amiodarone, verapamil, and diltiazem, and the 20-mg dose should not be exceeded with amlodipine (Norvasc, Pfizer) and ranolazine (Ranexa, Gilead).

The changes to the label are based on the Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine (SEARCH), a study reported by heartwire . In that trial, 52 patients taking the 80-mg dose developed myopathy compared with one patient treated with the 20-mg dose. In addition, 22 patients treated with the high dose of simvastatin developed rhabdomyolysis compared with none treated with the 20-mg dose.

The FDA notes that the risks of myopathy and rhabdomyolysis were highest in the first year and that older age and female sex increased the risks.

In statement released today following the FDA alert [2], Merck notes that it has launched a new information website and is encouraging patients who think the prescribing changes might affect them to speak with their doctors.

POSTED BY STEVEN ALMANY, MD

REMOVING TONSILS, APPENDIX MAY BE LINKED TO INCREASED RISK OF EARLY HEART ATTACK

HealthDay (6/1, Dallas) reported that "although the tonsils and appendix are not considered vital to the body, Swedish researchers have found that people who had them taken out before the age of 20 may be at a slightly greater risk of an early heart attack." Investigators "identified 54,449 appendectomies and 27,284 tonsillectomies performed on Swedish residents under the age of 20 years." The participants were followed for an average of more than 23 years. The researchers "concluded that tonsillectomy increased the relative risk of a heart attack by 44 percent, and appendectomy increased the relative risk by 33 percent." The study was published online in the European Heart Journal.

POSTED BY STEVEN ALMANY, MD

SCREENING COLLEGE ATHLETES MAY HELP PREVENT INCIDENTS OF SUDDEN CARDIAC DEATH

HealthDay (6/1, Dallas) reported that "screening college athletes for heart conditions before they participate in sports could help prevent incidents of sudden cardiac death, according to a new study" published in The American Journal of Medicine. In the study, "nearly one in four athletes tested either had a distinct heart abnormality or symptoms that required further screening." The authors of the study "noted that American Heart Association/American College of Cardiology guidelines for pre-participation screening effectively identified nearly 25 percent of athletes who were candidates for heart screening based on history or symptoms

POSTED BY STEVEN ALMANY, MD

NEARLY 20% OF YOUNG ADULTS IN US MAY HAVE HIGH BLOOD PRESSURE

ABC World News (5/25, story 6, 0:25, Sawyer) reported that research published online in Epidemiology indicates that nearly one-fifth "of Americans who are 24 to 32 years old have high blood pressure."

USA Today (5/26, Marcus) reports, "For the National Longitudinal Study of Adolescent Health, dubbed Add Health, funded by the National Institutes of Health, researchers from the University of North Carolina-Chapel Hill asked 14,000 men and women between the ages of 24 and 32 about their high blood pressure history and then took blood pressure readings of participants." The investigators "found that 19% of participants had high blood pressure." These "findings...are significantly higher than other recent research from another large, ongoing health study, the National Health and Nutrition Examination Survey (NHANES), which found only 4% of adults 20 to 39 have high blood pressure."

The CNN (5/25) "The Chart" blog reported that lead study author Kathleen Mullan Harris said that "among those measured with high blood pressure, only 25% had been told previously that they had high blood pressure." Also covering the story were the Raleigh News & Observer (5/26, Price), Reuters (5/26, Steenhuysen), WebMD (5/25, Mann), HealthDay (5/25, Dallas), and MedPage Today (5/25, Neale).

POSTED BY STEVEN ALMANY, MD

TRIAL OF EXTENDED-RELEASE NIACIN (NIASPAN, ABBOTT) HALTED PREMATURELY

May 26, 2011 (Bethesda, Maryland) — A trial of extended-release niacin (Niaspan, Abbott) given in addition to statin therapy in patients with a history of cardiovascular disease, high triglycerides, and low levels of HDL cholesterol has been halted prematurely, 18 months ahead of schedule, because niacin offered no additional benefits in this patient population [1].

There was also a small, unexplained increase in ischemic stroke in the high-dose, extended-release niacin group, in the Atherothrombosis Intervention in Metabolic Syndrome with Low HDL Cholesterol/High Triglyceride and Impact on Global Health Outcomes (AIM-HIGH) study, according to a statement from the National Heart Lung and Blood Institute (NHLBI), which sponsored it.

Despite treatment with statin therapy for elevated LDL-cholesterol levels, those with low levels of HDL cholesterol remain at significant risk for cardiovascular events, and AIM-HIGH was designed to examine whether raising HDL using extended-release niacin would be beneficial in such patients. AIM-HIGH was a five-year study of almost 3500 patients, and results were originally expected in September 2012.
The decision to stop the trial was made at a regularly scheduled meeting of the study's independent data and safety monitoring board (DSMB) on April 25, 2011. The DSMB concluded that "high-dose, extended-release niacin offered no benefits beyond statin therapy alone in reducing cardiovascular-related complications in this trial. The rate of clinical events was the same in both treatment groups, and there was no evidence that this would change by continuing the trial."

Patients Should Not Stop Taking Niacin
The NHLBI explains that the rationale for AIM-HIGH was based on data from observational studies and a few small clinical studies. "This study sought to confirm earlier and smaller studies," says Dr Susan B Shurin (acting director of the NHLBI) in the statement. "Although we did not see the expected clinical benefit, we have answered an important scientific question about treatment for cardiovascular disease.”

Several other trials testing this hypothesis, including a large international trial of high-dose, extended-release niacin, the Heart Protection Study 2 Treatment of HDL to Reduce the Incidence of Vascular Events (HPS2-THRIVE), are still under way; results of HPS2-THRIVE are expected in 2013. Extended-release formulations of niacin are being used in these trials because the immediate-release form of niacin is associated with a high incidence of flushing.

Previous studies do not suggest that stroke is a potential complication of niacin, and it remains unclear whether this trend in AIM-HIGH arose by chance or was related to niacin administration or some other issue, says the NHLBI. "Patients who were not in the AIM-HIGH trial should not stop taking high-dose, extended-release niacin without talking to their doctor first," says Shurin.

All AIM-HIGH study participants have been informed of the results and will be scheduled for clinic visits within the next 2.5 months. Participants will be followed for an additional 12 to 18 months.

AIM-HIGH co–principal investigator Dr Jeffrey Probstfield (University of Washington, Seattle) said: "The lack of effect on cardiovascular events is unexpected and a striking contrast to the results of previous trials and observational studies. The AIM-HIGH findings do not support the trial’s hypothesis that, in the population studied, adding extended-release niacin to simvastatin in participants with well-controlled LDL cholesterol can provide additional clinical benefit.”
AIM-HIGH enrolled 3414 participants in the US and Canada with a history of cardiovascular disease, low HDL cholesterol, and high triglycerides, who were all prescribed simvastatin and who were also randomized to either high-dose, extended-release niacin in gradually increasing doses up to 2000 mg per day (n=1718) or placebo (n=1696). Of the participants, 515 were given a second LDL-cholesterol–lowering drug, ezetimibe (Zetia, Merck/Schering-Plough), in order to maintain LDL-cholesterol levels at the target range between 40 and 80 mg/dL.

Participants who took high-dose, extended-release niacin and statin treatment had increased HDL cholesterol and lowered triglyceride levels than participants who took a statin alone. However, the combination treatment did not reduce fatal or nonfatal MI, strokes, hospitalizations for acute coronary syndrome, or revascularization procedures.

During the 32-month follow-up period, there were 28 strokes (1.6%) reported among participants taking high-dose, extended-release niacin vs 12 strokes (0.7%) in the control group. Nine of the 28 strokes in the niacin group occurred in participants who had discontinued the drug at least two months and up to four years before their stroke.

CALCIUM SUPPLEMENTS MAY INCREASE RISK FOR HEART ATTACKS AND STROKES IN WOMEN

The Washington Post (4/19, Stein) "The Checkup" blog reported that "an analysis of data collected about more than 16,000 women who participated in the landmark Women's Health Initiative found that those who started taking calcium as part of the study were at increased risk for heart attacks and strokes." The research, "published in...BMJ, found that the women who were not taking calcium when the study started but began taking it when they got into the research project were at between 13 and 22 percent increased risk. The risk occurred regardless of whether the women were taking calcium alone or combined with vitamin D, the researchers found."

HealthDay (4/19, Gardner) reported that "the case against calcium became stronger when researchers added in data from 13 other, unpublished trials involving almost 30,000 women. Now the increased risk for heart attack was 25 to 30 percent and, for a stroke, 15 to 20 percent."

MedPage Today (4/19, Kaiser) reported that "the authors suspect that the abrupt change in blood calcium levels after taking a supplement causes the adverse effect, rather than it being related to the total amount of calcium consumed." Also covering the story are the UK's Press Association (4/20), the UK's Telegraph (4/20, Adams), the UK's Daily Mail (4/20, Hope), WebMD (4/19, Mann) and HeartWire (4/19, Wood).

Posted by Steven Almany, MD

TIME IT TAKES TO RUN ONE MILE IN MIDDLE AGE MAY HELP PREDICT RISK OF FUTURE HEART PROBLEMS

The New York Times (5/24, Parker-Pope) "Well" blog reports that, "for people in midlife," the amount of time it takes to run one mile "may help predict their risk of heart problems as they age." In two different studies, one published in the Journal of the American College of Cardiology and the other published in Circulation, "researchers from the University of Texas Southwestern Medical School and the Cooper Institute in Dallas analyzed fitness levels for more than 66,000 people" Altogether, "the research showed that a person's fitness level at midlife is a strong predictor of long-term heart health, proving just as reliable as traditional risk factors like cholesterol level or high blood pressure.

Posted by Steven Almany, MD

REVIEW FINDS NO EVIDENCE OF INCREASED RISK OF MI ASSOCIATED WITH USE OF ARB'S

HeartWire (4/27, Nainggolan) reported that "a new review of 37 randomized trials including almost 150 000 patients has found no evidence of an increased risk of MI associated with the use of angiotensin-receptor blockers (ARBs). For the review, investigators "included all randomized clinical trials comparing ARBs with controls (placebo or active treatment), with follow-up of at least one year, at least 100 participants, and reporting any of the following outcomes -- MI, death, CV death, angina, stroke, heart failure, or new-onset diabetes -- published until August 2010." The investigators found that, "when compared with controls, ARBs were not associated with an increase in the risk of MI (relative risk 0.99, 95% CI 0.92-1.07), death, cardiovascular death, or angina pectoris." The research is published online in BMJ.

Posted by Steven Almany, MD

7 HEALTH EDGE HEART CHECK

A big THANK YOU to Michigan Heart Group Drs. Almany, Ajluni and Bowers for volunteering their time last weekend to screen over 6000 student athletes at Milford High school. For more information on how you can get your child athlete screened by Beaumont Cardiologist, please call (800) 633-7377.

7 HEALTH EDGE HEART CHECK

If you would like more information about how to get your student athlete a Free Heart Check by one of these Michigan Heart Group Cardiologist or another top rated Beaumont Cardiologist, please call (800) 633-7377.

ONE IN EVERY 44,000 COLLEGE ATHLETES MAY BE AT RISK FOR SUDDEN CARDIAC DEATH

The Seattle Times (4/4, Wong) reported, "College athletes across the nation suffer from sudden cardiac death up to seven times more frequently than previously reported," according to a study published Monday by in the journal Circulation. The analysis of "400,000 athletes who participate in National Collegiate Athletic Association sports every year," also indicated that women college athletes are at a "far higher risk than previously believed."

According to the AP (4/4), the researchers tracked an "NCAA database of athlete deaths, news media reports and insurance records" and found "45 heart-related deaths over five years among these elite student-athletes, an average of nine a year." The risk equates to "one death among roughly every 44,000 NCAA athletes," noted study author Dr. Kimberly Harmon from the University of Washington.

The Los Angeles Times (4/4) "Booster Shots" noted that incidence "varied dramatically by sport." The highest rate was in "Division 1 basketball, with one death per 3,146 players per year." The study was also covered by WebMD (4/4, Hendrick) and HeartWire (4/4, Miller).

Posted by Steven Almany M.D.

ANGIOGRAPHY THROUGH RADIAL ARTERY GAINING FAVOR

The Los Angeles Times (4/5, Maugh) reports, "Performing angioplasty and angiography through the radial artery of the arm is as effective as the traditional method of entering through the femoral artery of the groin, but has fewer complications and is more comfortable for the patient," according to findings presented at the American College of Cardiology meeting. "And for rescue operations performed while the patient is suffering a heart attack caused by a complete blockage of a coronary artery," the researchers said using the "radial artery is superior."

According to MedPage Today (4/4, Neale), the "30-day rate of death, MI, stroke, or non-CABG-related major bleeding occurred was 3.7% in the radial group and 4% in the femoral group." The findings from the "7,000-patient RIVAL trial" were published in The Lancet on the same day they were presented at the ACC meeting. The study was also covered by the Wall Street Journal (4/4, Winslow, subscription required) and HeartWire (4/4, O'Riordan). For a clinical perspective on this article, go to CardioSource.org.

Posted by Steven Almany M.D.

TOM IZZO GIVES A SHOUT OUT TO OUR VERY OWN DR. ALMANY FOR PIONEERING THIS LIFE-SAVING PROGRAM THAT IS MAKING HISTORY ALL OVER MICHIGAN....

Michigan State basketball coach Tom Izzo Praises 7 Health Edge Heart Check Program

ANTIDEPRESSANTS ASSOCIATED WITH ACCELERATED ATHEROSCLEROSIS IN MIDDLE-AGED MEN

Bloomberg News (4/3, Cortez) reported, "Antidepressants may narrow the arteries of middle-aged men, potentially putting them at risk for heart attacks and stroke," according to a study presented at the American College of Cardiology meeting in New Orleans. In "a study involving 513 male twins, with an average age of 55, found those who took medications like Forest Laboratories Inc.'s Lexapro [escitalopram], Eli Lilly & Co.'s....Cymbalta [duloxetine], or Pfizer Inc.'s Zoloft (sertraline) had thicker blood vessel walls." What's more, "the increase, a measure of fatty-plaque buildup linked to atherosclerosis, was seen regardless of what type of antidepressant the men were taking."

The Los Angeles Times (4/2, Maugh) reported, "Overall, when the researchers adjusted for age, diabetes, blood pressure and other factors, they found that the intima-media thickness of men taking antidepressants was 37 microns (about 5%) thicker than that of men not taking the" medications. "When the team looked at 59 twin pairs in which one twin was taking the drugs and the second was not, the artery was 41 microns thicker in the twin taking" antidepressants.

HealthDay (4/2, Reinberg) reported, "Since each additional year of life is associated with a small increase in intima-media thickness, a brother taking antidepressants is physically four years older than the brother not taking antidepressants," the researchers "contended. They also said that even a small increase in intima-media thickness can increase the risk of a heart attack or stroke by 1.8 percent." Also covering the story were AFP (4/3), HeartWire (4/2, O'Riordan), Reuters (4/3, Berkrot, Pierson), and MedPage Today (4/3, Phend).

Posted by Steven Almany M.D.

RENAL DENERVATION TEATMENT MAY HELP REDUCE BLOOD PRESSURE IN PATIENTS WITH DRUG-RESISTANT HYPERTENSION

HealthDay (3/29, Salamon) reported that "a technique that interrupts nerve signals between the kidneys and brain dropped blood pressure to normal levels in 39 percent of patients with drug-resistant hypertension, according to a small new study" presented at the Society of Interventional Radiology's annual scientific meeting. For the study, carried out "at 24 international sites, 106 patients with uncontrolled high blood pressure (hypertension) randomly received either oral medication or renal denervation treatment, a procedure that uses a catheter-based probe emitting high-frequency energy near the renal artery to deactivate nearby nerves." Researchers found that, "six months later, the patients who received the nerve block procedure had experienced an average systolic blood pressure drop of 32 mm Hg and a diastolic blood pressure drop of 12 mm Hg."

Posted by Steven Almany M.D.

PREDICTORS OF NEW-ONSET DIABETES IN PATIENTS TREATED WITH ATORVASTAIN: RESULTS FROM 3 LARGE RANDOMIZED CLINICAL TRIALS

Date Posted: March 28, 2011
Authors: Waters DD, Ho JE, DeMicco DA, et al.
Citation: J Am Coll Cardiol 2011;57:1535-1545.

Study Question:
What are the incidence and clinical predictors of new-onset type 2 diabetes mellitus (T2DM) within three large randomized trials with atorvastatin?

Methods:
The investigators used a standard definition of diabetes and excluded patients with prevalent diabetes at baseline. They identified baseline predictors of new-onset T2DM and compared the event rates in patients with and without new-onset T2DM. Major cardiovascular events in patients with and without new-onset T2DM were assessed with an extensive time-dependent Cox proportional hazard analysis.

Results:
In the TNT (Treating to New Targets) trial, 351 of 3,798 patients randomized to 80 mg of atorvastatin and 308 of 3,797 randomized to 10 mg developed new-onset T2DM (9.24% vs. 8.11%; adjusted hazard ratio [HR], 1.10; 95% confidence interval [CI], 0.94-1.29; p = 0.226). In the IDEAL (Incremental Decrease in End Points Through Aggressive Lipid Lowering) trial, 239 of 3,737 patients randomized to atorvastatin 80 mg/day and 208 of 3,724 patients randomized to simvastatin 20 mg/day developed new-onset T2DM (6.40% vs. 5.59%; adjusted HR, 1.19; 95% CI, 0.98-1.43; p = 0.072). In the SPARCL (Stroke Prevention by Aggressive Reduction in Cholesterol Levels) trial, new-onset T2DM developed in 166 of 1,905 patients randomized to atorvastatin 80 mg/day and in 115 of 1,898 patients in the placebo group (8.71% vs. 6.06%; adjusted HR, 1.37; 95% CI, 1.08-1.75; p = 0.011). In each of the three trials, baseline fasting blood glucose, body mass index, hypertension, and fasting triglycerides were independent predictors of new-onset T2DM. Across the three trials, major cardiovascular events occurred in 11.3% of patients with and 10.8% of patients without new-onset T2DM (adjusted HR, 1.02; 95% CI, 0.77-1.35; p = 0.69).

Conclusions:
The authors concluded that high-dose atorvastatin treatment compared with placebo in the SPARCL trial is associated with a slightly increased risk of new-onset T2DM.

Perspective:
This study suggests that the use of high-dose atorvastatin is associated with a slight increase in the risk of new-onset T2DM, although the strongest predictors of new-onset T2DM remain baseline fasting glucose and other features of the metabolic syndrome. The mechanism underlying the small increase in new-onset T2DM in patients treated with statins is unknown. It is possible that statins decrease insulin sensitivity in liver or muscle, but there is no direct experimental evidence to support this. Although any potential increased risk of new-onset T2DM with atorvastatin warrants careful monitoring, the benefits of atorvastatin clearly outweigh the risks in patients with coronary or cerebrovascular disease, and it remains uncertain as to whether new-onset T2DM itself increases risk.

Posted bySteven Almany M.D.

FIBRATE, FENOFIBRATE USE INCREASING IN US DESPITE EVIDENCE THEY PROVIDE LITTLE BENEFIT

The Los Angeles Times (3/22, Maugh) "Booster Shots" blog reported that "the use of fibrates and fenofibrates to reduce cholesterol levels has grown sharply in the United States over the past decade, despite mounting evidence that the drugs provide little benefit," according to a study published in the Journal of the American Medical Association. The study also found that "physicians are increasingly prescribing brand-name versions of the drugs, such as TriCor and Trilipix, despite the fact that published evidence so far shows a benefit only for generic forms of the drugs, such as gemfibrozil." HeartWire (3/22, O'Riordan), HealthDay (3/22, Goodwin), and MedPage Today (3/22, Gever) also covered the story. For a clinical perspective on this article, go to CardioSource.org.

Posted by Steven Almany M.D.

INDIVIDUALS WITH ASTHMA MAY HAVE HIGHER RISK OF DEVELOPING HEART DISEASE, DIABETES

HealthDay (3/20, Holohan) reported that individuals "with asthma may have a higher risk of developing diabetes and heart disease, according to a new study that looked at the relationship between asthma and four other inflammatory conditions." To reach that conclusion, researchers "looked at medical records from the late 1960s through the early 1980s," and "found higher rates of diabetes and heart illness among asthmatics than other people." However, the investigators "found that people with asthma were not at greater risk of developing inflammatory bowel disease or rheumatoid arthritis." The research was presented at a meeting of the American Academy of Allergy, Asthma & Immunology.

Posted by Steven Almany M.D.

HIGHER HDL CHOLESTEROL MAY REDUCE RISK FOR COLON CANCER

HealthDay (3/8, Reinberg) reported, "High levels of 'good' cholesterol" may reduce the risk of colon cancer, according to a study published online March 7 in Gut. The researchers compared 1,238 people (779 had colon cancer and 459 had rectal cancer) with 1,238 healthy people, and found that "those with the highest levels of HDL cholesterol and another blood fat called apolipoprotein A (apoA) had the least chance of developing colon cancer, but no impact was seen on rectal cancer." Specifically, for each "16.6 milligrams per deciliter (mg/dL) increase in HDL and 32 mg/dL increase in apoA, the risk of colon cancer was cut by 22 percent and 18 percent," respectively. WebMD (3/8, Boyles) and the UK's Press Association (3/8) also covered the study results


Posted by Steven Almany M.D.

REDUCING CHOLESTEROL MAY HELP BODY'S IMMUNE SYSTEM FIGHT VIRAL INFECTIONS

The UK's Press Association (3/9) reports that "cutting cholesterol could help the body's immune system fight viral infections," according to a study published in the journal PLoS Biology. Investigators "found that when the body succumbs to a viral infection a hormone in the immune system sends signals to blood cells, causing cholesterol levels to be lowered." The "researchers said the findings could lead to new ways of treating viral infections, targeting the cholesterol metabolism." The UK's Telegraph (3/9, Adams) and Reuters (3/9, Kelland) also cover the story.

Posted by Steven Almany M.D.

SUGARY DRINKS MAY BE LINKED TO HYPERTENSION

The Los Angeles Times (2/28, Mestel) "Booster Shots" blog reported that a study published online in the journal Hypertension suggests that sugary drinks may be linked to hypertension. Researchers "analyzed data from 2, 696 middle-aged adults in the US and UK."

CNN /Health.com (3/1, Gardner) reports that the investigators found that "each additional soda, lemonade, or fruit drink the study participants consumed on a daily basis was associated with a small but measurable uptick in systolic and diastolic blood pressure of 1.6 and 0.8 points, respectively."

HealthDay (2/28, Mozes) reported that "those drinking more than one sugar-sweetened beverage a day also registered higher average body-mass indexes (BMI) compared with those who drank none, suggesting that those who consumed such drinks also consumed less healthy food." Also covering the story are the UK's Press Association (3/1), HeartWire (2/28, O'Riordan), BBC News (3/1, Roberts), MedPage Today (2/28, Fiore), Reuters (3/1, Kelland), WebMD (2/28, Boyles), and the Time (2/28, Park) "Healthland" blog.



Posted by Steven Almany M.D.

HIGHER DIETARY CONSUMPTION OF POTASSIUM MAY BE ASSOCIATED WITH LOWER RATES OF STROKE

HeartWire (2/28, Nainggolan) reported that "the largest meta-analysis so far conducted examining the impact of potassium intake on cardiovascular outcomes has found that higher dietary consumption of this mineral is associated with lower rates of stroke and could also reduce the risk of coronary heart disease (CHD) and total CVD." These findings "apply to all sectors of society and not just to specific 'at-risk' subgroups, say Dr Lanfranc D'Elia (University of Naples Medical School, Italy) and colleagues in the study, published in the March 8, 2011 issue of the Journal of the American College of Cardiology.

Posted by Steven Almany M.D.

INTERPRETATION AND SIGNIFICANCE OF ELEVATED CARDIAC TROPONIN LEVELS IN PATIENTS WITH RENAL DISEASE WITH AND WITHOUT A POSSIBLE ACUTE CORONARY SYNDROME

Christopher R. DeFilippi, M.D., F.A.C.C.
Ana Paunovic, M.D., M.Sc.

End-stage renal disease (ESRD) affects nearly 500,000 people in the United States. Approximately 50% of those patients will die from cardiovascular disease, although only 20% of cardiac deaths are attributed to myocardial infarction (MI).1 Traditional cardiac risk factors cannot fully account for this high cardiovascular event rate.

Early after the introduction of cardiac troponin T (cTnT), it was recognized that levels were frequently elevated in asymptomatic patients on dialysis.2 This was initially attributed to nonspecific antibody interactions, but even with a second generation revision of the assay that resulted in nearly 100% cardiac specificity, elevated levels were common in this population.3,4 In contrast, cardiac troponin I (cTnI) was infrequently detectable in these same patients.3,4 Subsequently, a substantial amount of literature has been generated over the past 11-12 years to investigate the significance of these findings.

Both troponin assays remain useful diagnostic and prognostic markers for acute coronary syndromes (ACS) in patients with chronic kidney disease, including those on dialysis. However, caveats apply in their interpretation compared to those without impaired renal function.

According to the National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines of 2007, class I evidence supports measurement of cTn in renal failure patients with signs and symptoms of ACS for evaluation of MI.5 In those ESRD patients who have baseline elevation of cTn and present with signs and symptoms of ACS, a dynamic change defined as an increase in troponin value of at least 20% (when the baseline cTn level starts elevated) should be considered diagnostic of an acute MI.5 Utilizing serial change in troponin levels is incorporated in the revised universal definition of MI, recognizing the importance of separating chronic elevations in conditions such as renal disease from ACS.6

In addition to having a diagnostic role in renal failure patients with suspected ACS, cTnT maintains a prognostic role in ACS patients with renal failure. Aviles et al. identified a large cohort of patients with a spectrum of renal disease and suspected ACS, enrolled in the Global Use of Strategies to Open Occluded Arteries IV (GUSTO IV) trial.7 An elevated cTnT at presentation independently predicted short-term (30-day) risk of death and MI across the spectrum of renal function, with the noted limitation of inclusion of only a small number of patients on dialysis.

For patients on dialysis without suspected ACS or other cardiac symptoms, cTn levels, particularly cTnT, remain independently prognostic of all-cause and cardiovascular mortality. A meta-analysis by Khan et al., including 28 studies, best summarizes these findings (Figure 1).8 Evidence for the association of cTnI level and all-cause mortality is more mixed, although overall, the findings from the meta-analysis showed cTnI level to predict all-cause, but not cardiac-specific death in dialysis patients (Figure 2).8




A variety of different assays and diagnostic cut-offs may have accounted for the inconsistent association of cTnI level and mortality in dialysis patients. Several biologic explanations have been offered for the difference in cTnT and cTnI findings, including the presence of immuno-reactive fragments of the cTnI molecule in hemodialysis patients.9 However, the presence of cTnT fragments has been refuted by others.10 Most likely, disparities in assay sensitivity and standardization between cTnT and cTnI are the explanations for the observed differences.

Supporting this hypothesis was the finding in predialysis renal disease patients, without cardiac symptoms, using a newer generation sensitive cTnI assay. This study showed that the prevalence of elevated cTnI levels was similar to cTnT.11 Furthermore, elevation of either cTnT or cTnI with the sensitive assay was associated with a similar poor prognosis compared to those subjects without detectable levels.11 Preliminary data using new highly sensitive cTnT and cTnI assays show a similar proportion of values above the 99th percentile of a normal population in ambulatory renal disease patients not on dialysis. Furthermore, significant associations remain for both assays for the extent of coronary calcium and a history of coronary disease.12

In summary, additional studies will be needed to establish the prognostic value of cTnI in ESRD. Both tests remain critical to the diagnosis of ACS in these patients, and while a single value carries important prognostic information in the presence or absence of symptoms, change in levels by serial measures is required to diagnose MI.5,6

Potential Etiologies of Elevated Cardiac Troponins in Patients With End-Stage Renal Disease
The exact pathophysiologic mechanism for etiology of cTn elevation in asymptomatic patients with renal disease remains unknown. Several associations have been investigated to provide insight into the probable mechanisms of release from the myocardium. These include epicardial coronary artery disease with associated microinfarctions and left ventricular hypertrophy (LVH). In support of an epicardial coronary disease hypothesis is a strong association between increasing cTnT levels and a progressively higher prevalence of multi-vessel coronary disease in 67 asymptomatic ESRD patients volunteering for coronary angiography.13

Additionally, asymptomatic multi-vessel coronary artery stenosis is frequently present at the start of dialysis in patients with detectable cTnT,14 although this association has not been a consistent finding.15 This negative finding may be a result of an overall younger and healthier population selected for pretransplant evaluation versus an all-comers study, but also points to alternative mechanisms for cTn elevation in ESRD.

To follow-up this hypothesis, cardiac magnetic resonance imaging with delayed enhancement gadolinium has been utilized to identify detection of small foci of myocardial necrosis, which can represent epicardial coronary plaque embolization. In this small study of 26 ESRD subjects, one-half of whom had an elevated cTnT level, no significant association was found between cTnT level and presence of delayed enhancement gadolinium.16 The study was limited by the small number of subjects, but with the subsequent recognition of the risk of nephrogenic systemic fibrosis in renal patients exposed to gadolinium contrast, additional studies are unlikely to be performed.

Last, several studies have evaluated the association of LVH and troponin levels. LVH may result in subendocardial ischemia/injury or may be the result of a cardiomyopathic process, both of which could be a source of cardiac injury unrelated to coronary disease. LVH has been associated with elevated troponin in asymptomatic hemodialysis patients.4 Similarly, elevated LV mass index was associated with elevated cTnT levels and was the second strongest predictor of troponin elevation after age.17 However, as with coronary disease, the association of LVH and elevated cTnT is not consistent.13,16

Alternative explanations for elevated cTn levels in the absence of obvious imaging evidence of cardiac pathology may also include uremia-associated cardiac fibrosis. Patients with ESRD and fibrosis ≥30% on cardiac biopsy have a known poor prognosis.18 Fibrosis may represent the link between elevated troponin levels and the poor cardiac prognosis in patients with ESRD that is unrelated to MI. Advanced imaging techniques may eventually be able to test this association.

In conclusion, cardiovascular disease is a major cause of death in patients with ESRD. Elevated levels of cTnT and cTnI are associated with a poor prognosis in both those with and without a diagnosis of ACS. As the sensitivity of both assays improves, there is likely to be little that differentiates them in this patient population.

Currently, the pathology behind cTn elevations in the absence of ACS is incompletely understood. A better understanding of the pathologic process underlying cTn elevations in the absence of symptoms could lead to eventually using these tests to guide therapy prior to the onset of symptomatic cardiovascular disease, or worse, sudden death.

Posted by Steven Almany M.D.

TRAFFIC EXPOSURE, AIR POLLUTION BIGGEST POPULATION-LEVEL TRIGGERS FOR MI

Diepenbeek, Belgium - A comparative risk assessment of various triggers for MI suggests that cocaine is most likely to trigger an event in an individual, but traffic and exposure to air pollution has the greatest effect on triggering an MI at the population level [1].

"Many papers have studied the effects of various triggers of myocardial infarction, but our question was, well, at the population level, which one is the most important one?" lead investigator Dr Tim Nawrot (Hasselt University, Diepenbeek, Belgium) told heartwire. "Cocaine use, in this paper, is definitely the most important risk factor, with a 24-fold increased risk of having an event while using it, but not that many people use cocaine, making it rather weak at the population level. On the other hand, air pollution, in general, has quite a weak individual risk, but because many people are exposed to it at the population level, about 5% to 7% of myocardial infarctions are triggered by this risk factor."

The results of the study are published online February 23, 2011 in the Lancet.

Exposure prevalence ranges from 0.04% to 100%

In the paper, the researchers reviewed 36 epidemiologic studies assessing population-attributable fractions (PAF) of various triggers for MI. The PAFs are calculated using the odds ratios and frequencies of each trigger and provide an estimate of the proportion of MIs that could be avoided if the risk factor were removed. As Nawrot noted, the exposure prevalence in the analysis ranged from 0.04% for cocaine use to 100% for air pollution.

In ranking the triggers based on the odds ratios, cocaine use was associated with 24-fold increase risk of MI, far and away the most significant trigger for an event. The consumption of a heavy meal, smoking marijuana, experiencing negative emotions, physical exertion, experiencing positive emotions, getting angry, sexual activity, traffic exposure, coffee consumption, and air pollution were also associated with a significantly increased risk of MI.

In calculating the PAF, however, traffic exposure was the most important trigger for an acute event at the population level, report investigators. This was followed by physical exertion, alcohol consumption, coffee consumption, and a change of 30 µg/m3 of particulate matter with an aerodynamic diameter of 10 µg or less (PM10). Experiencing negative emotions, anger, eating a heavy meal, experiencing positive emotions, and sexual activity had a PAF ranging 3.9% to 2.2%, respectively, while cocaine and marijuana use had a PAF of 0.9% and 0.8%, respectively.
Prevalence of exposure, pooled odds ratio, and PAF for various triggers of myocardial infarction

Triggers of MI Prevalence of exposure(%) Odds ratio(95% CI) PAF, %(95% CI)
Air pollution, 10 µg/m3 100 1.02(1.01-1.02) 1.57(0.89-2.15)
Air pollution, 30 µg/m3 100 1.05(1.03-1.07) 4.76(2.63-6.28)
Alcohol 3.2 3.1 (1.4-6.9) 5.03(2.91-7.06)
Anger 1.5 3.11(1.8-5.4) 3.07(1.19-6.16)
Cocaine use 0.04 23.7(8.1-66.3) 0.90(0.28-2.55)
Coffee 10.6 1.5(1.2-1.9) 5.03(2.08-2.71)
Physical exertion 2.4 4.25(3.17-5.68) 6.16(4.20-8.64)
Sexual activity 1.1 3.11(1.79-5.43) 2.21(0.84-4.53)
Traffic exposure 4.1 2.92(2.22-3.83) 7.36(4.81-10.49)

Commenting on the results, Nawrot said the traffic exposure could be a combination of pollution, stress, noise, and other factors, although it is assumed that air pollution plays a large role, as drivers are exposed to peak levels while idling in traffic. In studies directly measuring air pollution, decreasing PM10 levels 30 µg/m3 would reduce MIs 5%, while reducing PM10 levels 10 µg/m3 would reduce events by 1.6%.

"Not only in this study, but in the many studies that have been conducted, the acute risk of air pollution on acute myocardial infarction is well established and is recognized as such by the American Heart Association," Nawrot told heartwire. "What this study adds is the perspective from the population level. Improving the air we breathe is a very relevant target to reduce the incidence of this disease in the general population."

In an editorial accompanying the study [2], Dr Andrea Baccarelli (Harvard University, Boston, MA) and Dr Emelia Benjamin (Boston University, MA) call the analysis "an exemplary piece of epidemiological work," saying that the evidence stands as a "warning against overlooking the public-health relevance of risk factors with moderate or weak strength that have high frequency in the community."

They note that reducing PM10 levels 30 µg/m3 would bring several European cities toward the 20 µg/m3 annual mean limit recommended by the World Health Organization, but the decrease is larger than needed, or achievable, in most US cities as well as several European cities. In 2000, most US cities had PM10 levels below 30 µg/m3 and many had levels below 20 µg/m3, but the PAF for reducing air pollution 10 µg/m3 is "far from negligible," at 1.57%, and would go a long way toward reducing the triggering burden in communities exposed to low to moderate levels of air pollution. A 10-µg/m3 and 30-µg/m3 reduction in air pollution is well less than what is needed in most Asian cities, they point out.

Sources
1. Nawrot TS, Perez L, Künzli N, et al. Public health importance of triggers of myocardial infarction: A comparative risk assessment. Lancet 2011; DOI: 10.1016/S0140-6736(10)62296-9. Available at: http://www.thelancet.com.
2. Baccarelli A, Benjamin EJ. Triggers of MI for the individual and the community. Lancet 2011; DOI: 10.1016/S0140-6736(10)62348-3. Available at: http://www.thelancet.com.

February 23, 2011 | Michael O'Riordan
http://www.theheart.org/article/1189071.do

Posted by Steven Almany, M.D.

TIMELY ANGIOPLASTIES BRINGING DOWN CARDIAC MORTALITY RATES IN SOUTHEAST MICHIGAN

Crain's Detroit Business (2/28, Greene) reports, "Mortality rates from heart attacks in Southeast Michigan appear to be falling as hospitals have found ways to shorten the 'door to balloon' time between diagnosis of heart attacks and emergency angioplasties." In fact, "most of Southeast Michigan's cardiovascular hospitals have reduced door-to-balloon time to less than 80 minutes, and they have slashed mortality rates to less than 3 percent from as much as eight percent over the past several years, say hospital officials." The article notes that the "National Cardiovascular Data Registry, operated by the American College of Cardiology...collects door-to-balloon time for all patients, including transfers."

Southeast Michigan Emergency Departments Seeing Increase In Heart Attack Patients. Crain's Detroit Business (2/28, Greene) reports, "Cardiologists and emergency physicians at most heart hospitals in Southeast Michigan say there has been an increase over the past year in the number of people arriving at emergency departments with heart attacks, although there are mixed opinions on whether there also is a corresponding increase in emergency angioplasties." Mark Brautigan, MD, chief of emergency medicine at Detroit Medical Center's Sinai-Grace Hospital in Detroit, "said the number of people arriving at the ER with heart attacks has increased during the past year by several percentage points." He stated, "'Shoveling snow is a big precipitator, but people losing their health insurance and not able to control their medical conditions (hypertension, diabetes and heart failure) is a big reason' for the increase."

Posted by Steven Almany M.D.

HOT FLASHES AT START OF MENOPAUSE ASSOCIATED WITH LOWER RISK FOR HEART ATTACK, DEATH

The AP (2/25, Tanner) reports that, according to a study published online Feb. 24 in the journal Menopause, "Women who had hot flashes at the start of menopause but not later seemed to have a lower risk for heart attack and death than women who never had hot flashes, or those whose symptoms persisted long after menopause began." But, "among the few women who developed hot flashes late -- in some cases many years after menopause began -- there were more heart attacks and deaths when compared with the other groups."

For the study, "researchers analyzed data from 60,000 post-menopausal women who were part of the Women's Health Initiative Observational Study," the Los Angeles Times (2/23, Roan) "Booster Shots" blog reported. They found that "women who had hot flashes or night sweats at the start of menopause were actually at a slightly lower risk for stroke, heart disease and death, compared with women who never had hot flashes or night sweats. The risk reductions were 17% for stroke, 11% for heart disease and 11% death."

As to why hot flashes during the start of menopause lowered the risk for heart attack, according to the Time (2/24, Park) "Healthland" blog, "what may be happening," the study's co-author explained, "is that women who experience flushing during menopause could have blood vessels that are responding appropriately to the change in hormone levels occurring at that time, helping them to ward off the hardening of the arteries and plaque-building associated with heart disease." However, "further studies need to confirm whether that's the case."

The CNN (2/24, Landau) "The Chart" blog reported, "Dr. Rita Redberg, cardiologist at the University of California-San Francisco, and spokeswoman for the American Heart Association, said it's unlikely that hot flashes themselves are protective; her theory is that women are more likely to exercise or go to their doctors more regularly because of hot flashes, and those practices can decrease cardiovascular events." WebMD (2/24, Mann), Reuters (2/25), and the UK's Press Association (2/25) also covered the story.

Posted by Steven Almany M.D.

STUDY RANKS RELATIVE CONTRIBUTIONS OF TRIGGERS TO HEART ATTACKS IN THE GENERAL POPULATION

The Chicago Sun-Times (2/24, Thomas) reports that "air pollution contributes to more heart attacks in the population as a whole than negative emotions, sexual activity and cocaine use, according to a new study" published online in The Lancet.

WebMD (2/23, Goodman) reported that investigators "pooled data from 36 studies of exposures that are thought to play a role in triggering heart attacks." The researchers "then calculated the odds that being exposed to that variable would lead to a heart attack."

HealthDay (2/23, Reinberg) reported that "because so many people are exposed to dirty air, air pollution while stuck in traffic topped the list of potential heart attack triggers, with the researchers pegging 7.4 percent of heart attacks to roadway smog." However, "coffee was also linked to 5 percent of attacks, booze to another 5 percent, and pot smoking to just under 1 percent, the...researchers found." Meanwhile, "among everyday activities, exerting yourself physically was linked to 6.2 percent of heart attacks, indulging in a heavy meal was estimated to trigger 2.7 percent, and sex was linked to 2.2 percent."

Reuters (2/24, Kelland) reports that the researchers wrote, "Of the triggers for heart attack studied, cocaine is the most likely to trigger an event in an individual, but traffic has the greatest population effect as more people are exposed to (it)." The UK's Press Association (2/24), the UK's Daily Mail (2/24, Hope) and HeartWire (2/23, O'Riordan) also covered the story.

Posted by Steven Almany M.D.

STUDY: ENERGY DRINKS HARMFUL TO CHILDREN

The AP (2/13) reported, "Energy drinks are under-studied, overused and can be dangerous for children and teens, warns a report by doctors who say kids shouldn't use the popular products. The potential harms, caused mostly by too much caffeine or similar ingredients, include heart palpitations, seizures, strokes and even sudden death," according to a study published in the journal Pediatrics, which "reviewed data from the government and interest groups, scientific literature, case reports and articles in popular and trade media." Notably, these findings come "amid a crackdown on energy drinks containing alcohol and caffeine, including recent Food and Drug Administration warning letters to manufacturers and bans in several states because of alcohol overdoses."

USA Today (2/14, Hellmich) reports, "Surveys show that 30% to 50% of teens and young adults consume energy drinks, but 'we didn't see evidence that drinks have beneficial effects in improving energy, weight loss, stamina, athletic performance and concentration,'" said study author Steven Lipshultz, chair of pediatrics at the University of Miami School of Medicine. "He encourages pediatricians and parents to talk to kids and teens about whether they should be drinking such beverages."

Posted by Steven Almany M.D.

CDC REPORT: ALMOST 30% OF US ADULTS DO NOT EXERCISE

ABC World News (2/16, lead story, 2:45, Sawyer) reported, "A red alert about a health crisis that is threatening lives but something that can be prevented, can be changed. The CDC today announced the results of a huge comprehensive survey which lays out in detail what's needed if Americans are going to cut family doctor bills and the ever-increasing consumption of prescription drugs." ABC correspondent David Muir said that the CDC data indicate that "nearly 30% of adults get no exercise at all."

The CNN (2/17, Caruso) "The Chart" blog says, "A new report from the Centers for Disease Control and Prevention finds people living in parts of Appalachia and the South don't spend enough time exercising." It "found that in most counties in Alabama, Kentucky, Louisiana, Mississippi, Oklahoma and Tennessee, at least 29% of adults reported having no physical activity beyond their jobs." Notably, that figure "was as high as 43%" in some counties. "In contrast, the CDC researchers found that people living on the West Coast and residents of Colorado, Minnesota and parts of the Northeast were more likely to be active in their leisure time."

USA Today (2/16, Marcus) reported, "This is the third in a series of county-focused reports by the federal Centers for Disease Control and Prevention. The first two looked at diabetes and obesity rates, says Ann Albright, director of the CDC's Division of Diabetes Translation." Reuters (2/17, Steenhuysen) also covers the story, as did ABC News (2/16, Blackburn) on its website.

Posted by Steven Almany M.D.