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Saturday, May 30, 2009

Does aspirin protect healthy patients from heart attacks?

A new large study published in the recent issue of the Lancet brings this into question.

I believe that the press is misreporting on the findings. What the researchers found that YES aspirin did prevent nonfatal heart attacks. However, patients who took aspirin were also more prone to develope gastrointestinal bleedings.

When aspirin is given to patients for primary prevention, it could be expected to prevent five nonfatal heart attacks but cause three extra gastrointestinal bleeds per 10,000 people treated per year.

In my experience as a Interventional Cardiologist ("heart attack doctor"), most patients that I meet having a heart attack are not on a daily aspirin. Even if they are on a daily aspirin, when they do have a heart attack, its never the "big one" but a small non-life treatening one.

Yes, patients on aspirin do blled more than patients not taking aspirin.

There is no doubt that a daily aspirin is highly protective in patients with established heart and vascular disease.

So what do I take from this.

  1. Asprin is highly effective in patients with established heart or vascular disease
  2. Aspirin does protect "healthy" patients from heart attacks
  3. Patients who take aspirin bleed more than patients who do not
  4. Therefore, the risk/benefit ratio needs to be analyzed very carefully for each patient. If a patient has a high risk of GI bleeding with low risk of heart disease, I would recommend staying away from aspirin. If a patient has a high risk of heart disease but low risk of bleeding, I would definitely recommend using aspirin. If the patient has a high risk of bleeding and a high risk of heart disease, I would recommend treating the patient with aspirin but ensure that the patient understands the increased risk of bleeding.

Very Cool!!!! Atherosclerosis Vaccine

A Vienna-based company, AFFiRiS AG, has recently announced it has secured funding for development of a vaccine that may help fight atherosclerosis.

For years, we have had medications (most notably statins - Zocor, Crestor, Lipitor, Pravacol) that are extremely efficacious in lowering the low density lipoproteins (LDLs - I call them the "lousy" ones) which dramatically reduces the incidence of heart attacks in primary and secondary prevention.

Yet, we still do not have a good medication to raise the high density lipoproteins (HDLs - I call them the "healthy" ones). The HDLs are responsible for bringing cholesterol from the tissue (plaque) back to the liver for processing.

This new vaccine would be aimed at the cholesteryl ester transfer protein (CETP), which is an enzyme responsible for transferring cholesterol esters from HDL to LDL - therefore reding the "healthy" HDL. Over time, the vaccine should reduce the activity of this enzyme.

This is very cool.

It is still totally unproven and previous such vaccines have failed. Yet this current company successfully bio-engineered vaccines for Alzheimer's and Parkinson's disease already.

I look forward to hearing how this program progresses.

Thursday, May 28, 2009


You can now follow me on twitter (http://twitter.com/drportnay). I have placed a permanent link on right of the blog. I look forward to tweeting with you

Safety of non inflammatory drugs in patients with heart disease

For some time now, there has been concern regarding the safety of non inflammatory drugs (NSAIDS) in patient with heart disease. Some of the medications seemed to lead to increased incidence of heart disease (Vioxx and Celebrex) and some NSAIDS seem to interfere with aspirin (ibuprofen).

Now, reasearchers are reporting in the May 2009 issue of Circulation: Cardiovascular Quality and Outcomes, that naproxen (Alleve) is clearly safer than the other NSAIDS with fewer heart attacks, strokes and cardiac related deaths.

For now, I encourage all my patients to try and see if they can control their pain with acetaminophen (Tylenol). If this does not control their pain, I recommend Alleve for pain control.

So Scary - where are we heading!!!!!

A new study published in the American Journal of Medicine reveals that less Americans are engaging in "healthy lifestyle" as compared with 2 decades ago.

The researchers are reporting the only 8% of today's patients engage in all five healthy behaviors -- maintaining a healthy weight, eating fruits and vegetables, drinking alcohol in moderation, exercising, and not smoking -- compared with 15% in 1988.

Enough said!!!!!

Wednesday, May 27, 2009

"subscribe to"

I've added the ability to subscribe to my blog. If you chose to do so, you will be emailed every time I make a new blog posting. Right now, the sign up is at the bottom of the blog. I'm hoping I can find someone who can write HTML and help me move this to the left side of the blog to make it more convenient.

Tuesday, May 26, 2009

Safety of Acid Reflux Drugs

Today's New York Times is reporting on a new study where patients who take proton pump inhibitors to prevent acid reflux are at higher risk for pneumonia than those who do not.

Proton Pump Inhibitors (PPIs) are amazing drugs that dramatically reduce the acid content of the stomach. This therapy has proven vital in the treatment of gastric and duodenal ulcers as well as severe cases of gastroesophageal reflux disease (GERD).

However, there have been more and more recent data regarding the safety of this medication. Not only for higher rates of pneumonia but also for cardiac reasons. There is some data that these medications have the potential to counteract the effects of plavix and there is data that patients taken both plavix and PPIs have higher rates of heart attacks than patients taking plavix without PPIs.

This raises to two important issues.
  1. All the data so far on safety of PPI and plavix is retrospective. This means that researchers go back and look to see what happens in different groups of patients. This form of research is excellent for hypothesis generating but is unable to prove causality. For tis we need prospective randomized controlled trials. I have a hunch that what researchers have seen so far is that compared with patients on just plavix, patients on both Plavix and PPIs are sicker at baseline and therefore more prone to have heart attacks because of their overall health status not because of their PPI use. In my practice, I have not seen PPIs leading to heart attacks.
  2. PPI are probably being used too much. They work so well, it is easier for a physician to just got to the most potent medication instead of trying a less potent medication to see if this works first.

Until this all plays out, I will be following the recommendations of the Society of Angiography and Intervention: "SCAI believes more research is needed on this topic. However, given the thousands of patients who receive stents each year, coupled with the significant risks demonstrated in this study, SCAI recommends the use of alternative medications for GI symptoms in patients with stents when appropriate. Other effective treatments for heartburn and ulcers include histaminergic (H2) blockers (Zantac [ranitidine, Boehringer Ingelheim], Tagamet [cimetidine, GlaxoSmithKline]) or antacids. In some patients the use of PPIs may still be warranted, based on the patient's medical problems, and should be taken at the direction of the patient's cardiologist, gastroenterologist, or primary physician."

I recommend you talk to your physician if you are on a PPI and plavix prior to stopping or changing your therapy based on this discussion.

Wednesday, May 20, 2009

More on the Swine Flu

On my way into work this am, I heard a report on NPR about the swine flu.

California has published some data on their documented cases. The majority of the patients with documented swine flu had mild symptoms. However, 30 patients have been hospitalized. 5 of them required intubation (placement on a mechanical breathing machine) and 1 may not survive. Of the patients hospitalized many had known established risk factors severe flu symptoms including pregnancy, heart diease, diabetes and asmthma.

However, of the patients that we considered "previously healthy", many of them were obese. This has not been reported with seasonal flu. Might it be that the swine flu will be more likely to lead to serious disease in obese patients. Given what we Americans look like, think of how many patients could be at risk for a serious case of swine flu.

I do take issue with this report though. I would NOT call an obsese patient HEALTHY. It has been shown over and over again that obesity leads to multiple health related issues. In fact, as I commented in my April 28th posting, obesity is the 3rd most frequent risk factor in America that may be responsible for 216,000 preventable deaths yearly.

In my opinion, obesity is a disease state and, if left untreated, will lead towards markedly increased rates of morbidity and mortality.

Tuesday, May 19, 2009

Swine Flu vaccine - tough decisions

While not exactly a cardiology issue, I find the current outbreak of swine flu fascinating. It is an opportunity to learn about the seasonal flu too.

The World Health Organization (WHO) estimates that 1/2 million people die every year from seasonal flu.

For drug makers to make enough vaccine to prevent us all from the swine flu, drug makers would need to stop making regular flu vaccine to make enough vaccine to handle pandemic swine flu.

We know that the seasonal flu vaccine saves millions of lives every year. We don't know how bad the swine flu pandemic will be and if the vaccine will work.

The decisions that will need to be made over the coming weeks will be difficult ones. Does the WHO and the Centers for Disease Control (CDC) instruct the drug companies to stop manufacting the seasonal flu vaccine and make swine flu vaccine instead?

I am a big proponent of the seasonal flu vaccine. I prescribe it to all my cardiac patients. I also encourage all my co-workers to get one since all health care workers are at increased risk. Even so, I'm not sure what the right answer is.

I would appreciate your comments on this issue.
Sent from my Verizon Wireless BlackBerry

"Walk often and walk far"

A new study in Circulation proposes a new approach to Cardiac Rehabilitation.

I often refer patients to cardiac rehab. Medicare pays for cardiac rehab for 5 distinct patient diagnoses: after bypass, after valve surgery, after heart attack, after percutanous intervention (angioplasty/stenting), chronic stable angina and after heart transplant.

There are multiple proven benefits of cardiac rehab. In all though, patients who participate in cardiac rehab have a roughly 30% reduction in major cardiovascular events (heart attack, cardiac death, stroke).  This is huge and compares very favorably to the best medicines I can prescribe to reduce risk.

In a typical cardiac rehab program, patients burn roughly 800 kcal per week, typically 3 days a week.

In this new program, patients walked at a moderate pace for 45-60 minutes per day, 5-6 days a week.

In the new program, patients lost much more weight and had marked reductions in insulin resistance. 

This study reinforces what I have been telling my patients for years. "Get off your butt and be active." The more you can do, the better -- 1 hour is better than 45 minutes, 45 minutes is better than 30 minutes. There is no better way to lose weight and be healthy than by being active and getting lots of exercise

Go out in the sun, get milk, eat oily fish

My wife has been telling me for some time about the benefits of Vitamin D. She has been keeping up to date with evidence that Vit D is beneficial to young children (important since we have 3 of them) -- turns out that the American Pediatric Association recommends at least 200-400IU of Vit D daily for children. The Flinstones vitamins we give our kids contains just that.

This got me interested in the data that exists with Vit D and heart disease.

There is a growing body of evidence that patients with Vit D deficiency have higher rates of heart disease. 

Vit D defiency is common and appears to affect as many as one-third to one-half of otherwise-healthy middle-aged to elderly adult world-wide. Increasing age, female gender, nonwhite race/ethnicity, diabetes, current smoking, and higher body-mass index (BMI) have all been shown to have higher rates of Vit D deficiency. 

It is NOT known yet if Vit D defiency causes heart disease or does the heart disease cause Vit D deficiency. There do appear to be biological reasons for why Vit D defiency may cause heart disease, including anti-inflammatory properties.

It is NOT yet known if patients with low levels of Vit D can dreduce their risk by taking viVit D supplementation.

The ARE some possible dangers in getting TOO MUCH Vit D.

The only way to know for sure if you are Vit D deficient is to test your blood levels. 

In the mean time, it appears 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).

Friday, May 1, 2009

I'll believe it when I see it

This sounds to good to be true --

HealthDay (4/29, Edelson) is reporting that according to reasearchers at an American Heart Association meeting "a urine test to detect coronary artery disease has worked well in a small trial." One researcher explained that "the test looks for fragments of the protein collagen, which plays a major role in blocking heart arteries." According to the researchers, "when the results were compared to coronary angiography...the urine tests were found to be 84 percent accurate."
More research is clearly needed but it sounds promising

Eat "oily" fish at least once a week

A new study out of Sweden has shown that compared with men who ate no fish, those that ate oily fish (herring, mackerel, salmon, whitefish, and char) once time a week were less likely to have heart failure. Interestingly, the authors found there was no benefit from eating 2 serving of fish compared with one serving.

For now, I will continue to tell my patient, following the recommendations of the AHA, that there appears to be a cardioprotective effect from eating oliy fish 1-2 x week. If you do this, there is probably no added benefit from taking Omega-3 supplements.

I will continue to update you on this as more data is available