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Wednesday, November 15, 2017

How Do I Lower My Blood Pressure?

As I wrote in my last blog post, the AHA/ACC earlier this week released new guidelines for the management of hypertension (HTN or blood pressure). The biggest change to these guidelines is the new definition of high blood pressure...

  • Now anyone with a blood pressure > 130/80 is classified as having Stage 1 HTN
  • Anyone with a blood pressure > 140/90 is classified as having Stage 2 HTN
The treatment recommendations have also been changed...
  • Stage 1 HTN with increased cardiac risk should be treated medically to BP < 130/80 + adopt aggressive life style modifications known to lower BP
  • Stage 1 HTN with no increased cardiac risk should adopt aggressive life style modifications known to lower BP
  • Stage 2 HTN should be treated medically + adopt aggressive life style modifications known to lower BP
So, what are some of the known life sytle modifications we can adopt that are known to lower BP
  • Eat a low salt diet or specifically follow the DASH Diet 
  • Lose weight 
  • Exercise (30-45min at least 3-5x week)
  • Decrease alcohol intake (no more than 2 glasses/day for men and 1 glass/day for women)
  • Avoid supplements known to raise BP (ephedra, St John's wort)
  • Avoid medications known to raise BP (amphetamines, decongestants, non-steroidal anti-inflammatory drugs/NSAIDs (ibuprofen/Advil and Celebrex), and prednisone
As with any of my recommendations, I suggest you discuss you BP/diet/medications with your physician

Tuesday, November 14, 2017

BREAKING NEWS: Definition of High Blood Pressure Drops

Just yesterday, the American Heart Association and the American College of Cardiology announced new guideline for hypertension. Below is an excellent summary of this new report. Please discuss the following with your doctor. 

By Dennis Thompson

HealthDay Reporter

MONDAY, Nov. 13, 2017 (HealthDay News) -- Nearly half of all adult Americans will be considered to have high blood pressure under new guidelines issued Monday by the nation's top heart health organizations.

The new guidelines lower the diagnostic threshold for stage 1 high blood pressure to 130/80, down from the previous level of 140/90, according to a joint statement from the American Heart Association and the American College of Cardiology.

Further, the guidelines also call for more aggressive treatment of high blood pressure, asking doctors and patients to set 130/80 as the new goal of therapy.

High blood pressure can lead to heart attacks, strokes and heart failure.

But the guidelines also press for more judicious treatment of high blood pressure -- sometimes called hypertension -- and an emphasis on lifestyle risk factors. Prescriptions for blood pressure drugs are not expected to leap under the guidelines, experts said.

The two heart organizations announced the new guidelines Monday at the American Heart Association's annual meeting, in Anaheim, Calif. The guidelines were last revised in 2003.

This change means that 103 million Americans will be considered to have high blood pressure, or about 46 percent of the adult population, said Dr. Paul Whelton. He is chair of the 2017 Hypertension Practice Guidelines and a professor of Global Public Health at Tulane University School of Public Health and Tropical Medicine in New Orleans.

That's a 14 percent increase from the previous guidelines, under which 72.2 million Americans (32 percent of adults) were considered to have high blood pressure.

The latest medical evidence has proven that people with blood pressure in the 130-139 range carry a doubled risk of heart attack, stroke, heart failure and kidney failure, compared to those with lower blood pressure, said Dr. Joaquin Cigarroa, a member of the clinical guidelines task force.

Previously, those people were considered to have prehypertension, but not actual high blood pressure.

"By incorporating the latest science, we recognize the risk is doubled," said Cigarroa, chief of cardiology and clinical chief of the Knight Cardiovascular Institute at Oregon Health & Science University, in Portland. "This now allows 14 percent of our population to understand that's a call to action. We have to empower them with the tools to make a difference."

The impact of the new guidelines is expected to be greatest among younger people. High blood pressure is expected to triple among men under age 45 and double among women under 45, according to the guidelines report.

However, only about 30 percent of people with stage 1 high blood pressure under the guidelines will require drug therapy, Whelton said.

That's because everyone with stage 1 high blood pressure will be evaluated for heart disease. Only those with heart disease or at high risk for developing it during the next decade will be prescribed drugs, the guidelines state.

"We're more specific about who should get treatment," Whelton said. "It's a nice combination of understanding accurately average blood pressure and also understanding underlying risk. We didn't have that in previous guidelines."

The rest of those at risk under the new guidelines will be urged to reduce their blood pressure through lifestyle changes -- losing weight, eating healthful foods, cutting down on salt, increasing potassium-rich foods, exercising regularly and moderating their drinking, said Dr. Bob Carey. He is vice chair of the 2017 Hypertension Practice Guidelines and dean emeritus of the University of Virginia School of Medicine.

The experts estimate "a projected increase in patients with stage 1 hypertension requiring drug therapy of 1.9 percent," Carey said. "This amounts to 4.2 million people, based on the U.S. population."

The new guidelines also stress the importance of using proper technique to measure blood pressure, with a person's level based on an average of two to three readings on at least two different occasions.

Home blood pressure monitoring also will be emphasized to avoid "white-coat hypertension" -- the tendency for some people to have higher blood pressure in a medical setting than they do in everyday life, the report said.

The U.S. government in 2013 asked the AHA and ACC to draft new guidelines for blood pressure management, said ACC President Dr. Mary Walsh. She is medical director of Heart Failure and Cardiac Transplantation at St. Vincent Heart Center of Indiana.

The new guidelines are the product of a 21-member committee, following a three-year review of medical evidence that included more than 900 studies, Whelton said. The studies were reviewed by 52 experts who submitted close to 1,000 questions, and approved by 11 partnering medical organizations.

The new guidelines "take advantage of evidence almost up to the minute, so they are very current," Whelton said.

Blood pressure categories in the new guidelines are:

Normal: Less than 120 systolic pressure (the top number).
Prehypertension: 120 to 129.
Stage 1: Systolic between 130 and139.
Stage 2: Systolic of 140 or higher.
Systolic pressure is the amount of pressure in your arteries during contraction of the heart muscle.

WebMD News from HealthDay


Copyright © 2013-2017 HealthDay. All rights reserved.


Monday, November 13, 2017

Do Statins Raise Odds for Type 2 Diabetes? Maybe, but heart benefits likely outweigh any potential risk from the drugs, experts say

The following is an article recently published on WebMD. Many patients have mentioned to me the reports about statins increasing the risk of developing Type 2 Diabetes. I definitely agree with Drs Crandall and Donovan (see statements in orange below). The benefits of statins in terms of prevention of cardiovascular events outweigh the slight increase risk in HgbA1C/DM.

By Serena Gordon
HealthDay Reporter
TUESDAY, Oct. 24, 2017 (HealthDay News) -- Cholesterol-lowering medications known as statins may lower your risk of heart disease, but also might boost the odds you'll develop type 2 diabetes, new research suggests.
"In a group of people at high risk of type 2 diabetesstatins do seem to increase the risk of developing diabetes by about 30 percent," said the study's lead author, Dr. Jill Crandall. She's a professor of medicine and director of the diabetes clinical trials unit at Albert Einstein College of Medicine in New York City.
But, she added, that doesn't mean anyone should give up on statins.
"The benefits of statins in terms of cardiovascular risk are so strong and so well established that our recommendation isn't that people should stop taking statins, but people should be monitored for the development of diabetes while on a statin," she explained.
At least one other diabetes expert agreed that statins are still beneficial for those at risk of heart trouble.
Dr. Daniel Donovan Jr. is professor of medicine and director of clinical research at the Icahn School of Medicine at Mount Sinai Diabetes, Obesity and Metabolism Institute in New York City.
"We still need to give statins when LDL (bad) cholesterol isn't under control. A statin intervention can lower the risk of a cardiovascular event by 40 percent, and it's possible the diabetes may have been destined to happen," he said.
The new study is an analysis of data collected from another ongoing study. More than 3,200 adults were recruited from 27 diabetes centers across the United States for the study.
The research goal was to prevent the progression of type 2 diabetes in people with a high risk of the disease, Crandall said. All of the study participants were overweight or obese. They also all showed signs that they weren't metabolizing sugar properly at the start of the study, but not poorly enough to be diagnosed with type 2 diabetes.
Study volunteers were randomly chosen to get treatment with lifestyle changes that would lead to modest weight loss, the drug metformin or a placebo pill.
At the end of the intervention, they were asked to participate in the 10-year follow-up program. They had their blood sugar levels measured twice a year, and their statin use was tracked, too.
At the start of the follow-up period, 4 percent of participants were taking statins. At the end, about one-third were.
Simvastatin (Zocor) and atorvastatin (Lipitor) were the most commonly used statins.
The study was an observational study, so it couldn't show a cause and effect relationship.
However, Crandall said the researchers measured levels of insulin secretion and insulin resistance. Insulin is a hormone that helps the body usher the sugar from foods into the body's cells to be used as fuel.
Crandall said insulin secretion goes down when people take statins. Less insulin would lead to higher blood sugar levels. She said there was no indication that statins affected insulin resistance.
Donovan added that the study provides important information. "But I don't think the message is stop statins," he said. "Most people are probably developing heart disease before diabetes, and it's important to treat the risk factors you can."
Though they weren't included in this study, people who already have type 2 diabetes should be closely monitored for increases in blood sugar when they start taking a statin, Crandall said. "The evidence so far is rather limited, but there have certainly been anecdotal reports of blood sugar being higher when someone starts statins," she said.
She also suggested that blood sugar levels likely aren't as much of a concern for those without diabetes or risk factors for diabetes when starting a statin. Besides excess weight, those risks include older age, high blood pressure and a family history of diabetes.
Crandall added that there are many people 50 and over with prediabetes who don't know it, so it could be an issue for them.
Findings from the study were published online Oct. 23 in BMJ Open Diabetes Research & Care.

WebMD News from HealthDay


WebMD: Does Sex Really Trigger Cardiac Arrest?

Does Sex Really Trigger Cardiac Arrest?

By Dennis Thompson
HealthDay Reporter
SUNDAY, Nov. 12, 2017 (HealthDay News) -- It's a common Hollywood trope -- an older guy is having enthusiastic sex with a gal half his age when he suddenly flops over dead.
But in real life, sexual activity very rarely causes cardiac arrest, a new study reassuringly reports.
Sex was linked to only 34 out of more than 4,500 cardiac arrests that occurred in the Portland, Ore., metropolitan area between 2002 and 2015. That's a rate of just 0.7 percent, the researchers noted.
Of those cases, 18 occurred during sex and 15 immediately after sex. Time couldn't be determined for the last case.
"I'm a little surprised at the really tiny number," said study senior researcher Dr. Sumeet Chugh, medical director of the Heart Rhythm Center at Cedars-Sinai Medical Center in Los Angeles. "But mostly I feel it's reassuring data."
The news is most welcome for patients with heart problems who aren't sure if sex could be dangerous, Chugh said.
"Previously we would say the risk is probably low, but we don't know how low," Chugh noted. "Now we have data and we can say to them the risk is very low."
The new findings are part of a 16-year study of heart risk factors involving about a million people living in and around Portland.
"Sexual activity is just one variable in the whole big picture" of cardiac risks, but one that hasn't been studied in depth, Chugh added.
Men are more likely than women to have their heart stop as a result of sex. Just two of the 34 cardiac arrest patients were female, the findings showed.
But overall, sex was linked to only 1 percent of all cardiac arrests that occurred in men.
Other heart experts said they weren't surprised by the results.
Sex just isn't as strenuous as people believe. The aerobic activity associated with sex is equivalent to climbing two flights of stairs, explained Dr. Nieca Goldberg. She is director of the NYU Center for Women's Health and an AHA spokeswoman.
Dr. Martha Gulati, chief of cardiology for the University of Arizona College of Medicine, said, "Although a lot of us think sex requires an intense level of activity, even in the most extreme situations it's not as intense as people imagine it."


NYTimes: The Growing Toll of Our Ever-Expanding Waistlines

The Growing Toll of Our Ever-Expanding Waistlines

Paul Rogers 
I hope you’re not chomping on a bagel or, worse, a doughnut while you read about what is probably the most serious public health irony of the last half century in this country: As one major killer — smoking — declined, another rose precipitously to take its place: obesity.
Many cancer deaths were averted after millions quit lighting up, but they are now rising because even greater numbers are unable to keep their waistlines in check.
Today, obesity and smoking remain the two leading causes of preventable deaths in this country.
Reviewing more than 1,000 studies, the International Agency for Research on Cancer and the Centers for Disease Control and Prevention linked the risk of developing 13 kinds of cancer to overweight and obesity, especially cancers that are now being diagnosed in increasing numbers among younger people.
Included are cancers of the esophagus, liver, gallbladder, colon and rectum, upper stomach, pancreas, uterus, ovary, kidney and thyroid; breast cancer in postmenopausal women; meningioma and multiple myeloma. Only for colorectal cancers has the overall incidence declined, primarily the result of increased screening and removal of precancerous polyps.
In most cases, the studies revealed, cancer risk rose in direct proportion to the degree of excess weight. In other words, the heavier you are, the more likely you will be to develop one of these often fatal cancers.
From 2005 to 2014, the C.D.C. reported in October, there was a 1.4 percent annualincrease in cancers related to overweight and obesity among people aged 20 to 49, and a 0.4 percent rise in these cancers among people 50 to 64.
“Nearly half of all cancers in people younger than 65 were associated with overweight and obesity,” C.D.C. experts reported in JAMA. And they predicted that given the current “high prevalence of overweight and obesity among adults, children and adolescents,” going forward there will be additional increases in weight-related cancers and cancer deaths among Americans.
The experts called upon clinicians who treat children and adults to do their due diligence and spend more time assessing body mass index (B.M.I.) and counseling patients about how to avoid or reduce excess weight. The payoff in terms of health, life and dollar savings would likely far outweigh the costs of society-wide professional and public health measures to curb America’s expanding waistlines.
Of course, it is not just cases and deaths from cancer that such an effort could prevent. Overweight, and especially obesity, are major risk factors for Type 2 diabetes, heart disease and stroke, high blood pressure, osteoarthritis, gout, gallbladder disease, and respiratory disorders like sleep apnea and asthma.
However, even when the costs of weight assessments and counseling are fully covered by insurance, it seems they are rarely done. In November 2011, the Obama administration offered free weight-loss counseling to obese seniors on Medicare, with no co-payment or deductible for those with Medicare Part B insurance. The benefit, which is still available, applied to the approximately 30 percent of Medicare beneficiaries with a B.M.I. of 30 or more.
Yet in the first three years, only about 120,000 seniors, representing less than 1 percent of those on Medicare, took advantage of this benefit, a result weight-loss specialists have called “very disappointing” and “a huge lost opportunity.”
The free coverage includes weekly counseling for the first month, a session every other week for months two through six, then monthly sessions for another six months for those who lose at least 6.6 pounds by the sixth month. Participants who fail to hit the six-month target can get a second chance six months later, with no limit to how many times they can take advantage of this benefit if their B.M.I. is still 30 or higher.
To be sure, many of those with serious weight problems have probably tried and failed to lose weight and keep it off, leading them to think there’s little hope that yet another effort will bring success. But it is worth noting that for most people who managed to quit smoking, it typically took anywhere from eight to 30 attempts.
The fault with weight-loss failures may lie almost as much with health care practitioners as with their patients. Many primary care doctors have little to no training in how to counsel patients who need to lose weight. Some have told me that they are afraid patients won’t come back if they focus on a need to lose weight. And patients are often turned off by what they perceive to be their health care providers’ negative attitudes toward people with weight problems.
An online survey by researchers at Yale University’s Rudd Center for Food Policy and Obesity revealed that people considered terms like “obese,” “fat” and “morbidly obese” to be stigmatizing and blaming language used by doctors. Nearly one participant in five said they would avoid future medical appointments, and 21 percent said they would seek a new doctor, if they felt stigmatized about their weight.
The Medicare opportunity notwithstanding, there is a growing need to tackle weight issues much earlier in life. Researchers at the Harvard School of Public Health reported in JAMA in July that 23 percent of women and 13 percent of men gained 44 pounds or more between the ages of 18 and 55. And Dr. William H. Dietz of the C.D.C., who noted in an accompanying editorial that “obesity-related cancers in both men and women were associated with moderate weight gain during adulthood,” added that “efforts to prevent and control obesity in young adults should be accorded a high priority.”
Dr. Dietz also pointed to a doubling in the prevalence of obesity between the childhood ages of 6 to 11, now at 17 percent, and young adulthood ages of 20 to 29, now at 34 percent.
Why are so many young Americans seriously overweight? The prevalence of high-calorie snacks and fast foods and cutbacks in physical activity both within and outside of school are not the only reasons. The problem can start as soon as babies are weaned and able to eat solid foods. Too often parents and caretakers, in the interest of keeping youngsters subdued, ply them with snacks all day long, creating in some a lifelong oral drive linking comfort and food.
And, for too many, I’m afraid, an increased risk of developing and dying from cancer.


Wednesday, August 24, 2016

Cancer on Course to Become Americans' Top Killer

Cancer on Course to Become Americans' Top Killer

Report shows it will probably eclipse heart disease as leading cause of death in coming years

WebMD News from HealthDay

By Dennis Thompson

HealthDay Reporter

WEDNESDAY, Aug. 24, 2016 (HealthDay News) -- Cancer is on track to become the leading cause of death in the United States, closing in on heart disease as America's number one killer, a new government study shows.

Heart disease has consistently been the leading cause of death for decades, and remained so in 2014, according to a report from the National Center for Health Statistics (NCHS) at the U.S. Centers for Disease Control and Prevention.

But the gap between heart disease and the second-leading cause of death, cancer, has been narrowing since 1968, the researchers said.

Cancer actually surpassed heart disease as the leading cause of death for 22 states in 2014, the study found. Back in 2000, Alaska and Minnesota were the only two states where cancer killed more people than heart disease.

In addition, cancer is now the leading cause of death for a number of minority groups, including Hispanics, Asians and Pacific Islanders, the report showed.

"It's been edging this way for a while," said co-author Robert Anderson, chief of the Mortality Statistics Branch at the NCHS. "We've taken for granted that heart disease is the leading cause of death, but now because of prevention efforts and advances in treatment, we're making substantial progress with heart disease, to the point where now it's roughly on par with cancer."

Annual heart disease deaths have decreased nationwide from a peak of just over 771,000 in 1985 to nearly 597,000 in 2011. In the meantime, cancer deaths have nearly tripled from just under 211,000 in 1950 to almost 577,000 in 2011, the report stated.

Dr. Mariell Jessup is a spokeswoman for the American Heart Association. She pointed out that new medicines have made it easier for people to control their blood pressure and cholesterol, treatment advances like angioplasty and heart bypass surgery saves the lives of many heart patients, and more people have quit smoking and started eating healthier diets.

"One could argue that we're doing a better job of keeping people with heart disease alive," said Jessup, who is a professor at the Hospital of the University of Pennsylvania in Philadelphia. "It's not that people aren't experiencing heart disease, but they're not dying from it."

Report shows it will probably eclipse heart disease as leading cause of death in coming years


Another expert agreed, with a twist on the thinking.

Essentially, modern medicine has gotten so good at dealing with heart disease that people are living much longer, making them more apt to eventually develop cancer, said Dr. Richard Schilsky. He is chief medical officer for the American Society of Clinical Oncology.

"We have to keep in mind that everyone's going to die eventually from something. Any time we reduce the risk of death for any particular cause, we increase the risk you're going to die from another cause," Schilsky explained.

"Cancer is a disease that is fundamentally associated with aging. If you outlive all the competing causes of mortality, there's a greater and greater likelihood that you're going to get cancer," Schilsky added.

That view is reflected in the states where cancer has overtaken heart disease, said Rebecca Siegel, strategic director of Surveillance Information Services for the American Cancer Society.

In those states, people seem to be healthier overall than in states where heart disease reigns supreme. Death rates for both heart disease and cancer were lower in the states where cancer was the leading cause of death, Siegel said.

"It's not that cancer rates are high in those states at all," Siegel said. "We all have to die from something, right?"

She added that heart disease treatment and prevention has benefited from rapid progress because it's a more narrow field of medicine.

"Heart disease is basically one disease, whereas with cancer we're looking at more than 100 different diseases," she said. "You have very effective ways to prevent and treat heart disease, and we've had them for quite some time, whereas knowledge about the biology of cancer and how to prevent it and treat it is still in its infancy."

In recent years -- between 2011 and 2014 -- heart disease and cancer deaths have both increased in roughly parallel fashion, the report noted.

Heart disease deaths increased by 3 percent between 2011 and 2014, from 596,577 to 614,348, while cancer deaths increased by 2.6 percent during the same period, from 576,691 to 591,699, the findings showed.

Report shows it will probably eclipse heart disease as leading cause of death in coming years


These increases could be related to the obesity epidemic, Siegel suggested.

"The obesity epidemic is catching up with us," she said. "It's overcoming our ability to prevent and treat heart disease, and there are a lot of cancers that are also associated with obesity."

The report was published online Aug. 24 in the CDC's NCHS Data Brief.

AHA Says Cap Added Sugars for Kids at 6 Teaspoons a Day

AHA Says Cap Added Sugars for Kids at 6 Teaspoons a Day

AHA Says Cap Added Sugars for Kids at 6 Teaspoons a Day

Children should consume less than 25 g, or the equivalent of 6 tsp, of added sugars a day — far below current intake in the United States, according to the first scientific statement on the subject by the American Heart Association (AHA).

Currently, US children ages 2 to 19 years old consume more than three times that amount — about 80 g of added sugar daily — half from food and half from drinks, say the diet and nutrition experts who analyzed National Health and Nutrition Examination Survey data from 2009–2012. And because intake amounts in the surveys were self-reported, the numbers likely even underestimate the problem, the authors of the statement say.

Added sugars include table sugar, fructose, and honey used in processing and preparing foods or drinks and sugars added to foods at the table or eaten separately.

Only 8 Oz of Sugary Drinks a Week, Guidelines Say

Miriam B Vos, MD, MsPH, associate professor of pediatrics at Emory University School of Medicine, Atlanta, Georgia, and fellow committee members write in the statement published August 22 in Circulation: "Current evidence supports the associations of added sugars with increased energy intake, increased adiposity, increased central adiposity, and increased dyslipidemia."

They add that overweight children who continue to ingest more added sugars are also more likely to become insulin-resistant, a precursor for type 2 diabetes.

Beginning July 2018, the Food and Drug Administration (FDA) will require that food labels show not just all sugars but also those that were added.

"Until then, the best way to avoid added sugars in your child's diet is to serve mostly foods that are high in nutrition, such as fruits, vegetables, whole grains, low-fat dairy products, lean meat, poultry, and fish and to limit foods with little nutritional value," Dr Vos said in a press statement.

In addition to limiting intake of table sugar, fructose, and honey, people should watch for labels for brown sugar, corn sweetener, corn syrup, dextrose, glucose, invert sugar, lactose, malt syrup, maltose, molasses, sucrose, trehalose, and turbinado sugar, the AHA suggests.

One of the biggest sources of added sugars is sugar-sweetened beverages, particularly soft drinks, sweet tea, and sports and energy drinks.

The AHA cautions that children and teens should have no more than 8 oz weekly of sugar-sweetened drinks. Parents should avoid all added sugar for children under the age of 2 years. Calorie requirements are only about 1000 a day for infants, so there is less room for added low-value sugars. Also, taste preferences start early in life, so limiting added sugars may help develop healthy eating habits.

"Children should not drink more than one 8-oz sugar-sweetened drink a week, yet they are currently drinking their age in sugary drink servings each and every week," Dr Vos commented.

As to whether using artificial sweeteners such as aspartame, saccharine, and sucralose may be a good solution, the authors point to a dearth of research in that area for both child and adult populations and therefore could not offer a recommendation.

Further research is also needed into the genetic component of bodies' response to sugar and how the interaction between the microbiome and added sugars and consequently CVD risk varies among individuals, the authors suggest.

The AHA guidelines align with the World Health Organization and the Food and Drug Administration recommendations that added sugars should make up less than 10% of calories.

Dr Vos has no relevant financial relationships. Disclosures for the coauthors are listed in the article.

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Circulation. Published online August 22, 2016. Abstract