Massive vitamin-D/omega-3 trial for prevention of CardioVascular Disease

As you have read, I am intrigued but not convinced with all the recent data regarding the importance of vitamin D for cardiovascular health. Although there have been many postive reports, the use of vit D has not been shown to be helpful when tested on a large population of patients.

I have been witness to the hype of many substances that showed promise initially only to have been proven to have not effect or even be harmful when tested on a large scale (vitamin E, folic acid, ...). It is for this reason that, for now, I recommend getting sufficient vitamin D in your diet "that the best way to ensure that you have enough Vit D is to get at least 10-15 minutes of sun every day and consume vitamin D rich foods like drinking fortified milk and eating oily fish (salmon, mackeral, herring, sardines)."

It is exciting that the National Institutes of Health has announced the VITamin D and OmegA-3 TriaL (VITAL) trial. This study will trial whether vit D or fish oil can reduce the development of cancer, heart disease or stroke in 20,000 healthy middle-aged American men and women. The trial plans to begin enrollment in 2010 and run for 5 years. Therefore, we will not know the answer till at least 2015. However, I do expect that sometime in 2011 we will start to seem some preliminary 1 and 2 year data.

The lower, the better

For some time now, I have been very aggressive with lowering my patients LDLs to <70mg/dL with statins. The evidence has shown multiple times that patients with the lowest LDLs have the lowest event rates.

Patients and their families always ask me will lowering my cholesterol end up shrinking or reducing the extent of blockages in my heart, leg, or neck arteries. My answer is maybe. There is evidence that using Crestor, researchers were able to document a small amount of plaque regression with very low LDLs. I tell my patients that more important than plaque regression is plaque stabilization. Unstable plaques crack and lead to acute events (heart attacks and strokes).

A new study recently presented at the Society for Vascular Surgery 2009 Vascular Annual Meeting reported that after twelve months of Lipitor therapy, patients with LDL levels < 70 had significantly more carotid plaque stabilization that patients with LDLs 70-100.\

This is important for a few reasons:

1. It seems that ability of statins to stabilize a plaque is not compound dependent but class dependent. (ie: its not which statin you use, but is the statin you are using lowering your LDL below 70)
2. Plaque stabilization does occur and probably explains why patients with very low LDLs have the lowest event rates

Michael Jackson - Sudden Cardiac Death

I read and watched with sorrow as the news filtered in on death of Michael Jackson. It appears that he suffered a cardiac arrest. The official results are still not public but this does give us a chance to learn something about cardiac arrest.

Cardiac arrest (or sudden cardiac death) is caused by a chaotic irregular fibrillation of the heart that is not sustainable with life. There are many causes of this. The most common in the US is caused by a ongoing heart attack or as a result of the scar left from an old heart attack. Other causes of these fatal heart rhythms included genetic disorders, inherited or acquired weakening of the heart muscles, or toxin induced (cocaine, amphetamines ...).

As the AHA states in its letter to the Jackson family, more than 300,000 people suffer sudden cardiac arrest outside the hospital. More than 90% of these individuals do not survive. Treatment of these patients must included immediate CPR and then defibrillation (electrical shock - like seen on TV). It has been shown that the most important part of the CPR process is the chest compressions. This circulates the blood to the brain and also oxygenates the blood by expanding compressing and decompressing the lungs. We have been trying to promote this "hands on" approach in my community. Forget about the mouth to mouth component and just start chest compressions and call 911 immediately. If patients are treated like this within 4 minutes, must will have an excellent outcome. If patients are treated in 4-8 minutes, the results are iffy. If patients are not treated for over 10 minutes, the results are dismal.

As I wrote about in my previous blog, Absolutely Amazing, a defibrillator makes all the difference. Whether it is implanted in a patient or brought to the seen by the EMS, life will not be restored if the patient is not shocked out of fibrillation.

Please make yourself aware of the signs and symptoms of a heart attack. Call 911 immediately if you or anyone near you if suffering any of these symptoms.

If you see a person collapse assess them. If there is no pulse or they are not breathing - call 911 and start CPR. In most urban and suburban communities, emergency medical services should be able to reach you in less than 5 minutes. Most firetrucks and policecars now carry defibrillators and the service men have been trained in their use.

If you have had a heart attack, you MUST know your ejection fraction. This can be determined easy with a cardiac ultrasound (echocardiogram). Normal is 55-60%. Patients with ejection fractions less than 35% are considered for an impantable defibrillator due to the 1-2% yearly risk of sudden cardiac death.

If you have been told you have a weakened heart (not caused by a heart attack) you to need to know your ejection fraction. If it is less than 35%, you too may benefit from an implantable defibrillator.

Heart Attack Signs and Symptoms

Here is info taken for the Go Red for Women site -- I could not have stated it better

"Heart Attack
Some heart attacks are sudden and intense, causing someone to gasp dramatically, clutch her heart and drop to the ground. No one has any doubts about what's happening. But most heart attacks start slowly, with mild pain or discomfort. Often the people affected aren't sure what's wrong and wait too long before getting help.

Here are some signs a heart attack may be happening:

• Chest discomfort. Most heart attacks involve discomfort in the center of the chest that lasts more than a few minutes, or that goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness or pain.
• Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, the back, neck, jaw or stomach.
• Shortness of breath. This feeling may occur with or without chest discomfort.
• Other signs of discomfort. These may include breaking out in a cold sweat, nausea or lightheadedness.
• As with men, women's most common heart attack symptom is chest pain or discomfort. But women are somewhat more likely than men to experience some of the other common symptoms, particularly shortness of breath, nausea/vomiting and back or jaw pain.

If you or someone you are with has chest discomfort, especially with one or more of the other signs, don't wait longer than five minutes before calling 9-1-1 for help."

Go Red For Women

The American Heart Association's Go Red for Women Campaign (http://www.goredforwomen.org) is a terrifc movement very much in the spirit of this blog. As stated on its website: " Go Red For Women celebrates the energy, passion and power we have as women to band together to wipe out heart disease and stroke." From the home page, you can take the Go Red Heart Checkup to help you assess your 10-year risk of developing heart disease.

I highly recommend this site.

get fit with twitter

Just found a great new tool for trying to stay fit. @twittercize: Get fit, one tweet at a time! Hourly exercises take less than one minute each!

Get fit, stay fit - or else

A new study by Mercedes Carnethon, PhD, of Northwestern University, and colleagues reported online in Diabetes Care that twenty-somethings who aren't physically fit may be at an increased risk of developing diabetes in middle age, researchers said.
The evidence shows that patients with low aerobic fitness levels in their 20's were 2-3 times more likely to develop diabetes than those that maintained their physical fitness.

"[Patients] who have low fitness in their late teens and 20s tend to stay the same later in life or even get worse," Dr. Carnethon said. "Not many climb out of that category."

The finding suggests that the "mechanism by which fitness decreases risk for diabetes is through the regulation of body mass."

Physical fitness may protect against diabetes via weight loss, improved muscle insulin sensitivity, improved endothelial function and autonomic function, or reduced inflammation and oxidative stress, the researchers said.

Absolutely Amazing

This is an absolutely amazing video clip. Its comes via Dr Wes's webblog over on MedPage Today.

It shows a soccer player with a known heart condition collapse on the field, get shocked by his implantable defibrillator and then return to consiousness and sit up just seconds later.

These devices are truly amazing.

We implant them in patients at risk for sudden death or who have survived sudden death with known heart conditions. In young patients these are typically inherited disorders. In older patients, these are typically inherited conditions.

Red Yeast Rice Extract

Red Yeast Rice Extract has been used for centuries in China to treat patients with "circulatory" aliments. This "alternative" substance does contain some a naturallly ocurring version of louvastin (a well established "statin")

A recent study in the Annals of Internal Medicine studied this compound. The investigators took patients with high cholesterol levels and intolerant of a statin (mostly because of the developement of muscle cramps) and randomized them to receive either 1800mg of Red Yeast Rice Extract twice a day or placebo. All patients also were enrolled in a therapeutic lifestyle-change program that included eating a Mediterranean-based diet, an exercise program, and relaxation techniques.

The patients who received Red Yeast Rice Extract had much lower cholesterol levels and the Red Rice Yest Extract was well tolerated.

This seems like it may become a good alternative for patients with high cholesterol levels but intolerant of statins.

Remember, statins remain one of the most powerful medication we have to reduce primary or secondary cardiovascular events. We also know that some drugs (like ezitimide) may lower the cholestrol level, but might not prevent events. We are actively trying to figure out, "Is how we low the cholesterol just as important as how low the number gets"

Another problem with all non-FDA regulated substances is the lack of consistency of just how much medication is contained in each pill - from one pill to another and from more manufacturer to another.

For now, statins remain the best "proven" drug to treat high cholesterol and reduce events.

I will consider using Red Yeast Rice Extract in my patients intolerant of other proven cholesterol lowering medications.

I anxiously await an outcomes study regarding the efficacy of Red Yeast Rice Extract in preventing events.

Bye Bye White Coats

Nosocomial infections (infections aquired in a hospital or nursing home setting) remain a very serious problem. Infections continue to be more and more serious with the spread of antibiotic resisitant organism like C diff and VRE.

In a move to try and reduce the transmission of these organisms from patient to patient, the American Medical Association (AMA) recently voted to recommend that hospitals ban the "white coat" and long sleeves to reduce transmission of these gross bug from the sleeves of the physicians that can come in contact with the patient. The AMA also voted to recommend the ban of "ties". How many men routinely wash their ties?

I think this is a great move. Anything to reduce the chance of spreading infection, should be encouraged.

I do worry about whether or not patients will miss physicians wearing a tie and white coat. Will we garner the same respect without these items? Will we be considered as professional? How long will it take for hospitals to adopt these recommendations?

What do you think?

Medicine in the digital era

A recent posting caught my attention. Please refer to "Top 10 Most Creative People in Helath Care" - http://scienceroll.com/2009/06/16/top-10-most-creative-people-in-health-care/

#3 is Dr Jay Parkinson - founder of Hello Health. This is a "conceirge" like primary care practice in Brooklyn, NY. They focus on a digital connection with your MD. What really caught my attention was their very clearly delineated fees, including a month subscription. As stated on the website: *Why do we have a monthly subscription fee? Every month you'll be charged $35, which goes directly toward those wonderful emails, quick questions, and all the time your doctor spends keeping you well between visits. Small price to pay for keeping the doctor away."

With all Obama's talk regarding helath care reform, where will a practice like this fit in?

I remain curious as to how many patients would opt for this type of practice. Given the increasing infiltration of the internet into patients homes (let alone smart phones being one of the brightest items that are selling like hotcakes during this tough ecomomy - re: BlackBerries and iPhones), will more and more patients be looking for this type of access to their physicians? Will they be willing to pay for it?

Please leave your comments and let me know what you think

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Ted

For news, education, and opinion on heart disease and nutrition for the everyday person -- follow me @ drportnay.blogspot.com

Gum disease and Heart Disease

There have been several studies to date which have shown that patients with periodontal disease have an increased risk for cardiovascular disease. Both diseases are inflammatory processes. Chronic inflammation of one area of the body, may cause untoward effects on other systems. Both diseases are very common. Cardiovascular disease is the leading cause of death in the US and Periodontal disease is the most common cause of adult tooth loss.

A consensus paper is being published online by the American Academy of Periodontology and the American Journal of Cardiology. In the paper the two societies make the following recommendations:

• Patients with periodontitis who have 1 known major atherosclerotic CVD risk factor such as smoking, immediate family history for CVD, or history of dyslipidemia should consider a medical evaluation if they have not done so within the past 12 months.
• A periodontal evaluation should be considered in patients with atherosclerotic CVD who have: signs or symptoms of gingival disease; significant tooth loss, and unexplained elevation of hs-CRP or other inflammatory biomarkers.
• A periodontal evaluation of patients with atherosclerotic CVD should include a comprehensive examination of periodontal tissues, as assessed by visual signs of inflammation and bleeding on probing; loss of connective tissue attachment detected by periodontal probing measurements; and bone loss assessed radiographically. If patients have untreated or uncontrolled periodontitis, they should be treated with a focus on reducing and controlling the bacterial accumulations and eliminating inflammation.
• When periodontitis is newly diagnosed in patients with atherosclerotic CVD, periodontists and physicians managing patients' CVD should closely collaborate in order to optimize CVD risk reduction and periodontal care.

I am very interested in following the science behind this association. Is the relationship between heart disease and periodontal disease a causal one (does one disease truly cause the other disease) or a casual one ( is it just that patients with one disease are more likely to have the other disease too).

I will keep you updated as more research is reported.