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Wednesday, December 29, 2010

Snow shoveling and heart attacks - Is shoveling really dangerous to the heart????

Here is Fairfield County, CT, we are still digging out from The Blizzard of 2010 just like the rest of the TriState Area and New England.
I spent the blizzard on-call covering our local hospital for Interventional Cardiology - that means I was the "heart attack" expert on-call.
Monday morning, not one but two middle aged men can in with large heart attacks that began when the went outside to try and shovel snow.
What makes shoveling more dangerous than other average tasks around the house is the temperature. Your heart rate and blood pressure increase during strenuous activity. That, coupled with the body's natural reflex to constrict arteries and blood vessels when exposed to the cold, is a recipe for a heart attack. Research has also shown that many people hold their breath while shoveling, which can lead to a sudden change in hear rate.
Snow shoveling in itself can be done safely by individuals in good shape, but can be very dangerous for those individuals who lead a most sedentary lifesytle. Unfortunately, many individuals do not have a choice - they must get out and clear the driveway. In these individuals, the body is not prepared to deal with going from 0 to 100 (the couch to the driveway) in the above mentioned conditions. This places individuals at a uniquely highrisk.
My recommendations:
  • Certain individuals should consult their doctor before shoveling snow:
    • People who have previously had a heart attack or other cardiovascular disease.
    • People with a history of chest pain or angina.
    • People with medical histories of high blood pressure, diabetes or high cholesterol levels.
    • People who smoke or who have other cardiovascular risk factors.
    • People who do not exercise regularly.
    Please be careful

    Tuesday, December 21, 2010

    Plavix and Proton Pump Inhibitors

    There has been much written in the press about a potential dangerous interaction between Plavix and a commonly used class of antacids called proton pump inhibitors. This class of medications includes drugs like: omeprazole (Prilosec), esomeprazole (Nexium), pantoprazole (Protonix) ...

    It is true that testing of platelets in a test tube have show that using PPI's can decrease the potency of Plavix (potentially leading to more MIs), this has not been in many observational studies. Strangely and in a surprise to most Cardiologists, the FDA forced the makers of Plavix to warn their patients about this test tube interaction.

    This potential interaction has only been tested in one randomized clinical trial. The COGENT randomized almost 4,000 patients and found NO increased signal for increased cardiovascular events. What it did show was a highly statistically significant decrease in gastrointestinal events (GI bleeding and ulcers) in the patients taking both omeprazole and Plavix.

    I have been using Plavix in conjunction with PPI's for years. I have never seen an increase in MI's or other cardiovascular events in these patients. The COGENT trial supports what I have seen clinically -- while there may be an interaction in the test tube, the concomitant use of Plavix and a PPI is not only safe but also possible helpful.

    Monday, December 20, 2010

    Our Obesity Problem

    I recently read to editorials on obesity. Both of these were written as thought pieces after the announcement of first new diet pill to be approved by the FDA in over ten years. I thought both were extremely poignant and I could not have written them better myself. I agree completely with their overwhelming sentiment that overcoming our obesity epidemic needs to be a concerted effort to change our eating habits and getting moving and not with a magic diet pill.

    The first piece is an editorial from the most recent Lancet

    New obesity pill: new hopes, old fears

    On Dec 7, 2010, the US Food and Drug Administration (FDA) Endocrinologic and Metabolic Drugs Advisory Committee gave a positive recommendation for the use of Contrave in the treatment of obesity and weight management, signalling a potentially major shift in attitude towards the disorder. Contrave, if finally approved by the FDA on Jan 31, 2011, will be the first new weight-loss drug to be approved for 10 years. The drug is a combination of bupropion, an antidepressant used to help patients to quit smoking, and naltrexone, an opioid antagonist prescribed for alcohol and drug addiction, thought to affect the reward pathway (system in which behaviour is regulated by induction of pleasure).

    The use of such a drug to tackle a complex problem like obesity is worrying, especially when the benefits seem modest (a decrease in bodyweight of 5%) compared with the potential risks. Albeit no serious side-effects were recorded in the four phase-3 trials for Contrave (one of which was published in this journal), there are indices of serious risks associated with bupropion, such as suicidal thoughts, seizures, and serious cardiovascular effects. The FDA committee and the drug's manufacturer, Orexigen, agreed that a large trial to assess the risk of major cardiac events associated with Contrave was needed, but that this study could wait until after the approval.
    Research into obesity has been fraught with difficulty, with many drugs having been withdrawn from the market in the past for safety reasons. The flexibility shown by the FDA in its ruling on Contrave may be motivated by a desire to encourage pharmaceutical companies to commit more funding into obesity research, as rates of obesity continue to soar. More than a third of the US population is obese, and two-thirds are either obese or overweight. But this drug showed weight loss only when combined with lifestyle modification, and should not be seen as a magic bullet. Governments should address the obesity epidemic through a comprehensive approach, focusing on the underlying causes of obesity, and not promoting medication of a disorder that should be treated with modifications of lifestyle, diet, and exercise.

    The second piece I read this morning on kevinmd.com

    Is it the doctor's fault if an obese patient cannot lose weight?

    By John Mandrola, MD

    I need help.  In dealing with obesity as a medical problem, that is.

    I am pretty solid at arrhythmia management, but as an obesity doctor, not so much.  If I was the teacher, and my obese patients were the students, I would surely be fired for poor student test performance. At least, if the core measure was the patient's BMI.

    If a student does poorly on an achievement test, is it the student's or the teacher's fault? If the obese patient does not lose weight, is it the doctor's or the patient's fault?

    Recently in the NEJM, I read about Arena pharmaceutical's attempt at creating the new "wonder pill" for obesity.  Lorcaserin is a novel serotonin re-uptake inhibitor which acts primarily in the brain centers that control hunger and satiety.  Theoretically, it provides a patient with the good sense not to eat too often, and as the skinny farmer advises, leave the table before you are stuffed.

    Although, Locarserin had no major adverse effects, the weight loss was modest, up to 5-10% of body weight.  Thirty pounds is only the prologue for the 300 pound patient.

    So, now we may have another pill for fatness.  Like we do for tiredness, and the low sex drive of male middle-agedness.

    The study conclusion is worded with scientific precision.  The researchers say, in conjunction with behavioral modification, the drug was effective in weight loss  What people hear, though, and the drug manufacturer are really saying is: take this pill and be thin.

    Cynicism is knocking at my door, and I am trying to ignore it.

    It is clearly true that obesity is one of the developed world's most important medical problems.  Paradoxically, while the fury of modern medicine has lowered death rates from heart disease and cancer, the obesity epidemic continues unabated.  The more sophisticated we become as a society, the fatter we get.

    As a doctor of the heart, it is crystal clear that lifestyle choices lie at the heart of health. No disease is more preventable by lifestyle choices than heart disease.  And these same lifestyle choices work on obesity as well.  Call it being on "the program."  Not a diet, the program is a simple concept: finding the groove of enough exercise, wise food choices and adequate rest.

    I own only one belt.  It is thick leather.  At times, as I am human, the white-chocolate-chip brownies in the doctor's lounge get the best of me.  If this behavior persists with any regularity the belt feels tighter.  Thick leather belts do not stretch. The tighter belt says, pedal a little longer and cut smaller pieces of brownie. Doing so restores equilibrium.  But if I deny too much the result is grumpiness. The pattern is repetitive.

    This simple formula is the problem.

    However, the notion that obesity is simply an imbalance of the equation, calories-in, calories-burned, is not in vogue.  It seems, by saying to the patient, eat less (really, it is sadly amazing how few calories a sedentary middle-aged human needs) and move more, you are at risk of being perceived as judgmental, incurious and even aloof.

    If on the other hand you talk about enhanced receptor sensitivities in hunger centers that may be inhibited by sophisticated chemicals, you are smart, and a sensitive doctor.  The obese patient may conclude that poor lifestyle choices are not their fault, rather a chemical imbalance in the brain.  (And maybe this will be proven so.)

    I don't think we should persecute the obese. Malfeasance is bad for the heart.  Nor am I against novel pharmaceuticals or innovative surgery.  But taking a pill or having surgery (that someone else pays for) will always be easier than saying no to white-chocolate-chip brownies.

    As we advance in medical technology, the simplicity of making a series of good choices should not be overshadowed by the science of receptor inhibition in the brain.

    Surely, doctors should emphasize the program more.

    John Mandrola is a cardiologist who blogs at Dr John M.

    Friday, December 17, 2010

    Stamford Hospital featured on NBC's "Today Show" this morning

    Stamford Hospital was on the Today Show this morning.

    The CT woman, Charla Nash, who was severely mauled by her friend's chimpanzee made an return to Stamford Hospital.

    It was a very positive story about the staff and hospital.

    I'm proud to be a part of the staff at this hospital.

    From the BlackBerry

    Death from heart disease continues to decline but burden remains huge

    Every year, I read the AHA's Heart and Stroke stats with one eye closed. I read wanting justification that my hard work is paying off. Yet, I am consistently humbled by how much work needs to be done. So, how did we do this year.

    The good news: from 1997-2007
    - death rates from heart disease have declined 27.8%
    - death rates from stroke have declined 44.8%

    Now the bad news:
    - In 2007, the total cost of heart disease and stoke was $286 billion. All cancers and benign tumors only cost $228 billion
    - 1/3 of Americans have high blood pressure
    - > 67% of adults are overweight
    - during the past 30 years, the prevalence of obesity in kids 6-11 years increased from 4 to more than 20%
    - 15% of adults have total cholesterol levels of 240md/dL or greater
    - 8% of adults have diabetes
    - 36.8% of adults have pre-diabetes

    My take: I agree with what my colleagues have been writing. We are doing really well at keeping our patients from dying. Emergency angioplasty, automated defibrillators and thrombolytic therapy has changed the acute death risk from heart attacks and strokes. Yet, the burden of disease is HUGE. I expect that at some point, we will begin the see the decline in death rates plateau as the overall burden of disease becomes overwhelming. The increasing rate of obesity in this country is scary. It will hamper our ability to continue to lower the rates of heart disease and stroke.

    If the AHA is to reach is 2020 impact goal "to improve the cardiovascular health of all Americans by 20% while reducing deaths by 20% - drastic changing in the rate of obesity will need to occur. I believe this must start with our children and young adults.

    We all must eat better and exercise more if we ever want to reach a time when heart disease and stroke is not the largest killer and most expensive disease of Americans.

    Thursday, December 16, 2010

    Isn't Coumadin supposed to be dead?

    Coumadin - the drug Cardiologists love to hate.

    Ever since I was a medical student, I've be amazed what patients requiring Coumadin have to go through. Coumadin (warfarin) is a blood thinner, ie it keeps the blood from clotting. It is used for many conditions - atrial fibrillation, after placement of metallic heart valves, blood clots in the legs or lungs and many other conditions.

    Its action is very dependent on diet, its very effected by the amount of vitamin K ingested. Therefore, patients must have frequent blood tests to ensure the level of their blood thinnest is safe (level of anti-coagulation). We use the INR to measure this. An INR of 1 is normal. For atrial fibrillation, we aim for an INR 2-3. For other conditions, we aim for an INR of 2.5-3.5. Keeping patients within this narrow therapeutic window can be difficult. Too low, patients blood and clot - in atrial fibrillation this increases the risk of a stroke. Too high, patients can spontaneously bleed. Therefore, patients need to have their blood tested at least one a month. If the levels are off and adjustments in dosage need to be made, patients may need weekly blood tests. This is a big deal for patients who need this medication indefinitely.

    For years, I've been looking forward to a new medication for patient with atrial fibrillation to take Coumadin's place. I envisioned that all my patients would be immediately switched to this drug. I thought we would be able to close the Coumadin Clinic which we run in my office (15-25 patients come through this clinic on a daily basis).

    Well, that time is here. But, the reality of American medicine is keeping my above dream from becoming a reality. Dabigatran (Pradaxa) has been released. It is a new class of medications called factor Xa inhibitors). Clinical trials have shown that it works better than Coumadin. It reduces strokes and other embolic and reduces significant major bleeding events. Also, its absorption is consistent and not effected by diet. Therefore, as long as it is taken morning and night, NO blood tests are required.

    So, why are so few of my patients jumping on the dabagatran bandwagon? $$$$$ Coumadin, specifically generic warfarin, cost pennies. Depending on my patients insurance plan, Pradaxa costs $90-300/month.

    So we have a medication that works better and is safer but is not being used because insurance companies will not pay for it.

    My hope for 2011 is that more of my patients will be able to be afford this new Rx. As more and more Factor Xa inhibitors come to the market (at least 3-4 are in the works), market forces will push down the price making each Rx cheaper.

    If you are interested about leaning more about this new Rx, please talk to your physician.

    Wednesday, December 15, 2010

    Exercise before eating - another way to combat holiday season weight gain

    I'm not the only one writing about weight gain over this holiday season.

    The New York Times is running an article today describing new research which shows that under controlled conditions exercising prior to eating leads no significant weight gain and no development on insulin resistance compared to eating prior to exercising or not exercising at all. While not eating prior to exercise will not be able to improve your performance during exercise (think competitive athletics who "carbo load" prior to a big event), it is a strategy that is helpful for those considering weight-loss).

    All of this evidence is presented in the subtext of overeating around the holidays.

    The article goes on to describe research from Australia where scientists have "found that after only three days, an extremely high-fat, high-calorie diet can lead to increased blood sugar and insulin resistance, potentially increasing the risk for Type 2 diabetes."

    So, to avoid overeating and gaining weight this holiday season, consider my recommendations and try exercising on an empty stomach.

    Tuesday, December 14, 2010

    Fwd: Absolutely Amazing

    Written yesterday --
    Today started out in a frenzy. The entire house overslept. I'm usually up between 5:30 and 6:00am. If not, at least my wife and I can usually depend on one of our 3 children to wake us up by 6:30. Not today! Today, I awoke at 7:20!! Ahhhhh. I had to be at work (30 minutes away) to supervise a colleague performing a cardiac cath at 8am.
    So, I'm in my car stressing out about going to work when I hear a segment on npr that totally floors me.  

    This was a fascinating segment contained two stories on the treatment of  hypoplastic left heart syndrome, or HLHS for short. "In utero, the left side of the heart does not develop properly. The mitral and aortic valves, the first part of the aorta itself, and the left ventricle of the heart are small, underdeveloped or nonexistent."
    While the first story was about the amazing success of pioneering physicians performing corrective congenital heart surgery on a newborn. The second story was the one that really got me. Now I'm a balloon guy. I spend my day in the cath lab ballooning open patients coronary arteries. Nevertheless, I was absolutely humbled by the amazing balloon work these docs in Boston were performing. They are sticking a catheter through the moms uterus, into the heart of the fetus and performing balloon valvuloplasty. Oh My Gosh! When successful, they were preventing these kids from being born with HPLH.

    After listening to this segment, I totally forgot about being late to work.

    Please listen - I think you too will be amazed

    Monday, December 13, 2010

    Be smart and healthy this season

    I'm always amazed at how much I see people overeating during the holiday season. I read recently that the average American can gain ~ 5lbs over the holiday season. While this seams exaggerated - the New England Journal Of Medicine has reported that the average American can gain 1-2lbs over this season. The really bad news is that many Americans never lose this weight.

    What to do? So many of my patients are constantly reminded of just how hard it is to lose the weight once it has been gained. Therefore, any strategy to keep the weight off in the first place seems to me to be the smartest.

    Here are some ideas that I have come across to help my patients during this season of temptation.
    1. Eat smaller portions of food
    2. Eat slowly
    3. Go for a walk after a meal
    4. Off to bring a low calorie dish to the party
    5. Go ahead and mingle - get away from the food
    6. Say "no" to fast food
    7. Be realistic - now is not the time to diet but to maintain