The Deadly Threat of Silent Heart Attacks - NYTimes.com

http://newoldage.blogs.nytimes.com/2012/10/02/the-deadly-threat-of-silent-heart-attacks/?ref=health

The Deadly Threat of Silent Heart Attacks

For more than six months, Harriett Cooke had been uncommonly tired, panting when she walked her sixth grade science class to the cafeteria and struggling to keep her eyes open when she drove home at night.

One day, during a class trip outside the school, she just couldn't go on. "I sat there on the side, I put my head down on the table, and I knew I shouldn't be feeling like this," said Ms. Cooke, 67, who lives in Durham, N.C.

Making excuses, she left and stopped at her doctor's office, where staff ordered an electrocardiogram (EKG). The test showed that Ms. Cooke had suffered a so-called "silent heart attack" at some indeterminate point, perhaps months earlier.

Few people know about this type of heart attack, characterized by a lack of recognizable symptoms. Yet silent heart attacks are even more common in older adults than heart attacks that immediately come to the attention of doctors and patients, according to a recent study in The Journal of the American Medical Association.

What's more, they're equally deadly.

The research underscores the importance of paying attention to lingering, hard-to-pin-down symptoms in older adults, experts say. Many elderly men and women tend to dismiss these; caregivers shouldn't let that happen.

The JAMA report is based on data from 936 men and women ages 67 to 93 from Iceland who agreed to undergo EKGs and magnetic resonance imaging exams to detect whether heart attacks had occurred. EKGs assess the heart's electrical activity, while M.R.I.'s look at its mechanical pumping activity.

So-called "recognized" heart attacks were identified when signs of heart damage were evident, and the patient's medical record indicated that medical attention had been sought and a diagnosis rendered. "Silent" heart attacks were also signified by heart damage, but in those cases evidence from medical records was lacking.

When results were tallied, silent heart attacks were twice as common (22 percent) among older patients as recognized heart attacks (10 percent). Five years after tests were administered, death rates for patients with both recognized and silent heart attacks were 23 percent, almost double the 12 percent death rate for older adults who'd never experienced a myocardial infarction, the technical name for this medical event.

Recognized heart attacks may be more serious in the short run, but silent heart attacks are equally dangerous in the long run because they don't receive medical attention, said Dr. Andrew E. Arai, the lead author and chief of the cardiovascular and pulmonary branch of division of intramural research at the U.S. National Heart, Lung and Blood Institute.

Indeed, seniors who had the silent version were less likely to get treatments for coronary artery disease — aspirin, beta blockers, and cholesterol-lowering statins. Yet tests documented they had higher-than-average risk factors: elevated blood pressure, high cholesterol, hardening of the arteries, and evidence of plaque buildup in blood vessels.

Results from Iceland may not be fully generalizable to the United States since more people smoke in Iceland, and there's greater diversity in the population here. But a key takeaway message is that heart attacks aren't always easy to detect, especially in older people.

"Not everyone has classic symptoms — chest pain, maybe radiating to the arm, nausea, sweating, shortness of breath," Dr. Arai said.

"In reality, many patients, have much less clear cut symptoms," he continued. "They may think it's a bad case of indigestion or the flu, or this may even occur during their sleep and they won't realize that anything happened."

If you're an older person and you've been feeling seriously unwell for a while, "go see your doctor, don't blow it off," Dr. Arai said.

That's not an invitation for people to run out and demand M.R.I.'s of the heart if they've been feeling flulike for several weeks. Although M.R.I.'s identified more silent heart attacks than EKGs in the JAMA report, these tests are expensive, not widely available, and stress echocardiograms, nuclear stress tests, and computerized tomography (CT) coronary angiograms are good alternatives, said Dr. Michael Shen, section head of cardiac imaging at the Cleveland Clinic in Florida.

Tests should be based on the patient's family history, personal history, symptoms like shortness of breath or tightness in the chest, and risk factors like cholesterol levels, high blood pressure, smoking and diabetes, Dr. Shen said.

In the JAMA study, 26 percent of patients with diabetes (266 altogether) had silent heart attacks, compared with 11 percent who had clinically recognized heart attacks.

"We don't really understand what causes one person to have chest pain and another person not to have chest pain," said Dr. LeRoy E. Rabbani, director of cardiac intensive care and the cardiac inpatient service at NewYork-Presbyterian Hospital/Columbia University Medical Center in New York. But diabetics, who are prone to nerve damage known as neuropathy, "may have impaired sensation that extends to chest wall."

To illustrate the point, Dr. Rabbani tells of an elderly patient who had undergone coronary artery bypass surgery and had stents implanted in his arteries to prop them open. Each time his heart gave him trouble over a period of a dozen years, he had felt chest pain.

But one day, after developing diabetes in his 80s, this patient felt a little dizzy, noticed a nose bleed and fainted after arriving at his ear nose and throat doctor's office. In the emergency room, tests showed that he had had a heart attack, with no symptoms this time, six hours before. "Even in a given individual, things can change," Dr. Rabbani said.

There's no opportunity to restore heart muscle damaged in a silent heart attack, but there is opportunity to intervene to prevent a second heart attack or heart failure.

"One has to look at (a silent heart attack) as a potential marker for coronary atherosclerosis and take a more detailed look to see if risk factors are being treated adequately," said Dr. Christopher O'Connor, chief of cardiology at Duke University School of Medicine.

If damage is relatively mild, "there are a whole host of medications we can use to prevent the occurrence of a second event," he said. If damage is more significant, bypass surgery, stents, and even devices like implantable defibrillators may be warranted.

Afterward, doctors monitor patients more frequently and "pay much more attention to ambiguous symptoms like prolonged fatigue, confusion or shortness of breath," Dr. O'Connor continued. "Before, we thought these silent events were less important. Now, we realize they're equally important as symptomatic heart attacks and deserving of careful follow-up."

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A Possible Price to Pay if Doctors Spurn Insurance - NYTimes.com

http://well.blogs.nytimes.com/2012/10/01/when-doctors-stop-taking-insurance/

When Doctors Stop Taking Insurance

By RONI CARYN RABIN

Tim Bower

Private health insurance used to be the ticket to a doctor's appointment. But that's no longer the case in some affluent metropolitan enclaves, where many physicians no longer accept insurance and require upfront payment from patients — cash, checks and credit cards accepted.

On Manhattan's Upper East Side, it's not unusual for a pregnant woman to pay $13,000 out of pocket in advance for childbirth and prenatal care to a physician who does not participate in any health plan. Some gynecologists are charging $650 for an annual checkup. And for pediatricians who shun insurance, parents on the Upper East Side are shelling out $150 to $250 whenever a child falls or runs a high fever.

Efforts by insurers to rein in health care costs by holding down physician fees — especially for primary care doctors, who play a critical role in health care though they are among the lowest paid doctors — appear to be accelerating the trend, and some patients say it's getting harder to find an in-network physician.

Orlene Paxson, 33, a stay-at-home mom on Manhattan's Upper East Side, was unable to find an obstetrician she liked who would accept her insurance. Many were not accepting new patients, and one highly recommended doctor did not return her call for five days and did not want to see her until 12 weeks into the pregnancy. It was Mrs. Paxson's first pregnancy and she did not want to wait, so even though her policy does not cover any out-of-network services, she and her husband chose a doctor who doesn't take insurance and paid the entire $13,000 fee themselves.

Once their daughter was born 20 months ago, Mrs. Paxson needed a pediatrician but could not find one who was in her plan, accepting new patients and within walking distance. So she again chose an out-of-network doctor.

"We stayed with her for a year and a half because we loved her," Mrs. Paxson said. At her first scheduled visit after the baby was born, the doctor "talked to me for almost three hours. She knew it was our first baby."

But three months ago, Mrs. Paxson switched to an in-network pediatrician, largely because of the cost of the vaccines. "They didn't cover a dime of it," Mrs. Paxson said of her insurance, adding that she was not complaining. "I made informed decisions."

Though data on private practices is scanty, a new survey of 13,575 doctors from around the country by The Physicians Foundation found that over the next one to three years, more than 50 percent plan to take steps that reduce patient access to their services, and nearly 7 percent plan to switch to cash-only or concierge practices, in which patients pay an annual fee or retainer in addition to other fees.

When doctors stop taking regular insurance or drop a health plan, patients are free to take their business elsewhere. If they have health plans that cover out-of-network expenses, these patients may be reimbursed for fees they pay in cash, but probably not for the entire sum.

The cash-upfront trend raises an uncomfortable question. Can the Affordable Care Act, intended to widen access to health care, succeed by expanding insurance coverage if primary-care doctors are walking away from insurance?

"If all it means is that doctors who serve the wealthy are figuring out ways to avoid the hassles of insurance, I'm not sure it's a public policy problem," said Marsha Gold, a senior fellow at Mathematica Policy Research in Washington and an expert on health care financing. "The real problem comes in if it really restricts the choices people have and makes it worse than it is now. We don't really have the data to know."

The country is already facing a shortage of physicians, according to the Association of American Medical Colleges. By 2025, the nation will have 100,000 fewer doctors than needed, according to the association. With fewer medical students choosing to go into primary care, shortages in this area are expected to become especially acute.

Physicians are increasingly feeling shortchanged by insurance companies, said Dr. Bob Hughes, an otolaryngologist in Saratoga Springs who is president of the Medical Society of the State of New York. "Insurance companies do not negotiate with physicians. It's all take-it-or-leave-it contracts," he said.

A June report by the Medicare Payment Advisory Commission, which advises Congress and focuses primarily on the government plan for seniors, suggests adults ages 50 to 64 are having more trouble getting an appointment with a new physician. Some 30 percent of privately insured individuals who were looking for a new primary care doctor in 2011 reported problems finding one, compared with 26 percent in 2008. (Only 14 percent had a problem finding a specialist in 2011.)

Cash-only practices may exacerbate the access problem. Since her doctor stopped accepting her insurance, Kathryn Vanasek, 43, a mother of two in Manhattan, hasn't been back for a checkup or preventive screenings, relying on a new walk-in clinic for urgent problems like an ear infection.

Her annual physical would cost at least $250 out of pocket, Ms. Vanasek said, but she would not get any money back from her insurer until she met the deductible.

"You are making a decision between preventive medicine and reactive medicine," she said.

If you choose to see a physician who will not accept insurance, experts advise a few precautions:

¶Read the fine print on your health insurance policy. Though many plans provide out-of-network coverage, the reimbursement may cover only a fraction of your costs.

¶Try to estimate your out-of-pocket costs in advance so you can pay the physician with money saved in a flexible spending account, which is sheltered from taxes.

¶Ask yourself whether you really must see a doctor who does not take insurance. Is the care really better? Ask acquaintances outside your regular circle for references. If you are willing to travel, you may find a highly recommended physician who takes your insurance.

¶Keep track of your expenses and receipts, file out-of-network claims promptly and keep copies for yourself. Call your insurer to follow up; it is not unusual for an insurance company to lose paperwork.

¶Watch for expenses that will not be reimbursed. Children's vaccines, for instance, may not be reimbursed even if you have out-of-network coverage. The global fee quoted by an obstetrician for childbirth should encompass all care required unless you have complications, need to see another specialist or require a last-minute Caesarean section.

¶Doctors who don't take insurance are likely to refer to others who don't. Make every effort to ensure that expensive services, such as hospitalizations and surgery, are with network providers and that you have the required approvals from your insurer.

A version of this article appeared in print on 10/02/2012, on page D5 of the NewYork edition with the headline: A Possible Price to Pay if Doctors Spurn Insurance.

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Vitamin D does not prevent colds, study says - latimes.com

http://www.latimes.com/health/boostershots/la-heb-vitamin-d-does-not-prevent-colds-infections-study-20121002,0,377309.story?track=rss&utm_source=dlvr.it&utm_medium=twitter&dlvrit=53001

Vitamin D does not prevent colds or infections, study finds

If you're trying to ward off the sniffles, you can take vitamin D supplements out of your shopping cart: A new study reports that dosing with the vitamin does nothing to prevent colds or other forms of upper respiratory tract infections (URTI).

The effect of vitamin D on the immune system has been debated for a long time. Controlled laboratory research has shown that vitamin D has several beneficial effects on the immune system, and some studies conducted in the past have suggested that people with low levels of the vitamin are at higher risk for URTIs. But the authors of the new study, published Tuesday in the Journal of the American Medical Assn., point out that the previous studies were poorly controlled and results have been mixed, calling into question whether the vitamin does anything at all for URTIs.

To answer the question, the researchers, who are based in New Zealand, conducted a randomized trial nicknamed VIDARIS, for "Vitamin D and Acute Respiratory Infection Study." They gave 161 subjects doses of vitamin D once a month for 18 months, and another group of 161 people a placebo. The doses used were those that appeared to have been the most effective against colds in previous studies.

Over the 18-month period, the vitamin D group reported 593 URTI episodes, while the placebo group reported 611 -- an insignificant difference that is likely due to chance, the authors wrote. There were also no differences between groups in days of work missed, or severity of symptoms. In healthy adults at these recommended doses, Vitamin D appeared to have absolutely no ability to reduce the impact of colds.

In an accompanying editorial, Dr. Jeffrey Linder of Harvard Medical School says the study is well-conducted and its results should be trusted. "The VIDARIS trial, which assessed upper respiratory tract infections as they actually occur in the real world, demonstrated that vitamin D supplementation does not reduce the incidence of respiratory tract infections in adults," he wrote.

That means you can probably stash away your vitamin D pills wherever you put your Airborne.

Return to the Booster Shots blog.

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Do Exercise Programs Help Children Stay Fit? - NYTimes.com

http://well.blogs.nytimes.com/2012/10/03/do-exercise-programs-help-children-stay-fit/?smid=tw-nytimeswell&seid=auto

Do Exercise Programs Help Children Stay Fit?

By GRETCHEN REYNOLDS

Thor Swift

Getting children to be more physically active seems as if it should be so simple. Just enroll them in classes and programs during school or afterward that are filled with games, sports and other activities.

But an important new review of the outcomes of a wide range of different physical activity interventions for young people finds that the programs almost never increase overall daily physical activity. The youngsters run around during the intervention period, then remain stubbornly sedentary during the rest of the day.

For the review, which was published last week in the British medical journal BMJ, researchers from the Peninsula College of Medicine and Dentistry in England collected data from 30 studies related to exercise interventions in children that had been published worldwide between January 1990 and March 2012.

To be included in the review, the studies had to have involved children younger than 16, lasted for at least four weeks, and reported objectively measured levels of physical fitness, like wearing motion sensors that tracked how much they moved, not just during the exercise classes but throughout the rest of the day. The studies included an American program in which elementary school-age students were led through a 90-minute session of vigorous running and playing after school, three times a week. Another program involved Scottish preschool youngsters and 30 minutes of moderate physical playtime during school hours, three times a week.

In each case, the investigators had expected that the programs would increase the children's overall daily physical activity.

That didn't happen, as the review's authors found when they carefully parsed outcomes. The American students, for instance, increased their overall daily physical activity by about five minutes per day. But only during the first few weeks of the program; by the end, their overall daily physical activity had returned to about where it had been before the program began. The wee Scottish participants actually became less physically active over all on the days when they had the 30-minute play sessions.

The review authors found similar results for the rest of the studies that they perused. In general, well-designed, well-implemented and obviously very well-meaning physical activity interventions, including ones lasting for up to 90 minutes, added at best about four minutes of additional walking or running to most youngsters' overall daily physical activity levels.

The programs "just didn't work," at least in terms of getting young people to move more, said Brad Metcalf, a research fellow and medical statistician at Peninsula College, who led the review.

Why the programs, no matter their length, intensity or content, led to so little additional daily activity is hard to understand, Dr. Metcalf said, although he and his co-authors suspect that many children unconsciously compensate for the energy expended during structured activity sessions by plopping themselves in front of a television or otherwise being extra sedentary afterward. It is also possible, he said, that on a practical level, the new sessions, especially those taking place after school, simply replace time that the youngsters already devoted to running around, so the overall additive benefit of the programs was nil.

But the broader and more pressing question that the new review raises is, as the title of an accompanying editorial asks, "Are interventions to promote physical activity in children a waste of time?"

Thankfully, the editorial's authors answer with an immediate and emphatic "no." If existing exercise programs aren't working, finding new approaches that do work is essential, they say.

They point out that active children are much more likely to be active adults and that physically active children also are far less likely to be overweight. A convincing, if separate body of scientific evidence has shown that the most physically active and fit children are generally the least heavy.

So if structured classes and programs are not getting children to move more, what, if anything, can be done to increase physical activity in the young? "It's a really difficult problem," said Frank Booth, a professor of physiology at the University of Missouri-Columbia, who was not involved with the review.

Determining the most effective placement of classes and programs, so that they don't substitute for time already spent running around and instead augment it, would help, he said.

But a more vital element, he said, "involves mothers and fathers," who can encourage children to leave the couch, subverting their drive to compensate for energy expended earlier by sitting now.

A welcoming setting may also be key, the authors of the accompanying editorial wrote, pointing to a 2011 study of same-sex twins, ages 9 to 11. In that study, the most important determinant of how much the youngsters moved — or didn't — was their local built environment. Children with more opportunities to be outside, in a safe, well-designed space, were more likely to be outside, romping.

But none of these suggestions will be easy to put in place, Dr. Booth said, or inexpensive, and all will require scientific validation. No one expected, after all, that well-designed exercise interventions for children would prove to be so ineffective.

Ultimately, he continued, the best use of resources in this field may be to direct them toward unearthing the roots of childhood inactivity. "Kids naturally love to run around and play," Dr. Booth said. "But they're just not doing it as much now. And we don't know why. So what we really need to understand is, what's happening to our kids that makes them quit wanting to play?"

Phys Ed

Gretchen Reynolds on the science of fitness.

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Beta-Blockers Might Not Reduce CV Events in Patients with Stable Heart Disease - Physician's First Watch

http://firstwatch.jwatch.org/cgi/content/short/2012/1003/3?rss=1&utm_source=twitterfeed&utm_medium=twitter&utm_campaign=Feed%3A+PhysiciansFirstWatch+%28Physician%27s+First+Watch%3A+Current+Issue%29

Beta-Blockers Might Not Reduce CV Events in Patients with Stable Heart Disease

Beta-blockers might not lower the risk for major cardiovascular events in patients with — or at risk for — stable coronary artery disease (CAD), according to a JAMA study.

Investigators compared outcomes with and without beta-blocker therapy in about 22,000 participants in the REACH (Reduction of Atherothrombosis for Continued Health) registry who had prior myocardial infarction, CAD without MI, or CAD risk factors only. Patients were followed for roughly 44 months.

In both cohorts with CAD, risk for the primary outcome — a composite of cardiovascular death, MI, or stroke — did not differ significantly between beta-blocker recipients and nonrecipients. In the risk-factor-only group, the primary outcome occurred more often among beta-blocker recipients (14% vs. 12% among nonrecipients).

The authors note that their findings support recent changes in secondary prevention guidelines, giving class I status only to the short-term use of beta-blockers after MI.

LINK(S):

JAMA article (Free abstract)

Journal Watch Cardiology summary (Free)

Background: Journal Watch Cardiology coverage of recent secondary prevention guidelines (Free)

Published in Physician's First Watch October 3, 2012

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http://mobile.reuters.com/article/idUSBRE89118020121002?irpc=932

Fish linked to heart failure risk, omega-3 results mixed

By Andrew M. Seaman

NEW YORK (Reuters Health) - For people conscious about their heart health, a new study suggests it may be best to eat fish instead of taking individual omega-3 fatty acids in supplement form.

After reviewing information on the habits and fatty-acid blood levels of more than 20,000 male doctors, researchers found mixed results when it came to omega-3 supplements and the men's likelihood of heart failure, but eating fish regularly was linked to a lower risk.

According to the study's senior researcher, the results are consistent with the American Heart Association's (AHA) recommendations.

"Our findings showed a lower risk of heart failure in men consuming any amount of fish per week," Dr. Luc Djoussé, a professor at Harvard Medical School in Boston said in an email. "Given current AHA recommendations, we do not believe that any change should be made based on our findings."

The current recommendations are for people to eat two servings of fatty fish per week. Salmon, herring, sardines and albacore tuna are some of the fish considered the most beneficial, according to the AHA.

Some people, however, may prefer to take omega-3 fatty acid supplements that are available over the counter, but their benefits for heart health remain unclear.

One recent study, for instance, analyzed data from multiple past studies and found no link between omega-3 supplements and overall death rates (see Reuters Health story from September 11, 2012).

For the new study, published in the American Journal of Clinical Nutrition, Djoussé's group wanted to see if there was any connection between taking individual omega-3 fatty acids and one's risk of heart failure.

They used information from the Physicians' Health Study, an ongoing study of male doctors that began in 1982.

The researchers analyzed how much omega-3 fatty acid the doctors had in their bodies based on blood samples and food questionnaires, which also indicated how much fish the doctors ate.

They found that about 7 in 1,000 men who reported eating fish less than once per month suffered heart failure. That's compared to about 4 in 1,000 men who reported eating more than one serving of fish per month.

Djoussé said that works out to be "about 30 percent lower risk of heart failure than that of men not consuming fish."

DHA, EPA, DPA

As for the individual omega-3 fatty acids, things were a little more complicated.

Specifically, the researchers looked at eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and docosapentaenoic acid (DPA) in the men's diets and bloodstreams.

Overall, the researchers did not see an effect for blood levels of EPA or DHA, which are the two fatty acids thought to be responsible for fish's benefits and most often sold in the form of "fish oil" supplements.

There was a link between lowered heart failure risk and DPA, which is made in the body from EPA and can then be converted into DHA, according to Djoussé.

He told Reuters Health that their findings suggest DPA acts differently than the other fatty acids, but that needs to be confirmed by more research.

Also, while the researchers did see a link between eating fish and a lower heart failure risk, the study cannot prove whether or not the fish caused the lower risk.

Alice Lichtenstein, director of the Cardiovascular Nutrition Laboratory at Tufts University in Boston, told Reuters Health the study shows that the hope for a "quick fix" is fading.

"What we need to do - and I think this maybe reinforces it - is to put more effort on modifying the diet of people who are at an increased risk," she said.

For example, eating fish may not be just beneficial thanks to the omega-3 fatty acids, but also because it displaces less healthy foods from a person's diet.

Djoussé said until more studies are done, people should not change their diets as long as they're already following the AHA's guidelines.

SOURCE: http://bit.ly/UDVpOA American Journal of Clinical Nutrition, online September 5, 2012.

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Eating yogurt may prevent high blood pressure

http://www.medicalnewstoday.com/printerfriendlynews.php?newsid=250513

Eating Yogurt May Protect Against High Blood Pressure

21 Sep 2012   

A new study has suggested that adding low calorie yogurt to your diet may help lower your risk of high blood pressure.

The new information presented at the American Heart Association's High Blood Pressure Research 2012 Scientific Sessions, has found that long-term yogurt eaters had a lower systolic blood pressure, as well as a diminished risk of developing high blood pressure.

Systolic blood pressure is the measure of how powerful the blood is against the walls of your arteries when your heart is beating. It is the top number in a blood pressure reading.

Hypertension can be a commonly misunderstood condition. According to the American Heart Association,untreated high blood pressure damages and scars your arteries. Tears and scars in the arteries can act like a net catching debris traveling through the bloodstream, such as cholesterol and plaque, which can then lead to build ups or blockages. It is important to be aware of blood pressure measurements, because symptoms are many times non-existent.

Past studies have established various health benefits of yogurt. Frequent consumption has been associated with healthier body weight and lower body mass index.

Adding a low calorie yogurt to your daily diet may reduce your risk of high blood pressure.

Yogurt contains calcium, many needed daily nutrients and is easy to add to a meal or have as a snack. A great source of protein, yogurt keeps you feeling full slightly longer and also has liquid that provides hydration.

These researchers conducted a study lasting 15 years following more than 2,000 volunteers who did not have high blood pressure at the beginning of the study. Over the study period, participants filled out questionnaires three different times to measure yogurt intake.

Results showed that 31 percent of volunteers were less likely to develop high blood pressure when at least 2 percent of their daily caloric intake was yogurt, equivalent to at least one six-ounce cup of low-fat yogurt every three days. Their systolic blood pressure also increased significantly less than those who did not eat yogurt. These findings support a common belief that low-fat dairy products reduce blood pressure.

A healthy diet including low-fat yogurt, paired with physical activity, can help prevent chronic diseases such as hypertension and manage your health.

It should be noted that this study was presented at a conference and published as an abstract. It has not yet been published in a peer-reviewed journal.

Written by Kelly Fitzgerald
Copyright: Medical News Today
Not to be reproduced without permission of Medical News Today

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