Archive for the ‘coronary artery disease’ Category

Should I be taking aspirin?

Wednesday, January 30th, 2013

I take a dose equivalent to 1/4 tablet of aspirin

One of our friends recently told my wife she’d stopped taking aspirin after a news report linked regular use of the medication to macular degeneration. We’ve both taken 81 mg of aspirin a day and, after I’d heard that people may not absorb the enteric coated form well (and I couldn’t find any other form in that size at the local drugstore), I’d ordered ten bottles of chewable orange-flavored aspirin online from Amazon.

Then I decided to read the medical reports that our friend’s recommendation had been based on. She doesn’t have a medical background and hadn’t looked at the original data, but instead had seen a warning in a newspaper article. Let’s start at The New York Times blog. On Dec 12, 2012 they published an article by Anahad O’Conner titled “Aspirin Tied To Rare Eye Disorder.”

It’s a very well-worded article written by a 31-year-old, Yale-educated Times reporter who writes a weekly science column and has published two books He notes the article he based his piece on was from JAMA with the lead author, Dr. Barbara Klein, being a professor of ophthalmology at the University of Wisconsin, Madison. Since I’m a UW graduate (BS 1963, MD 1966), I was particularly interested in her study.

It used data from the Beaver Dam Eye Study, started in 1988-1990 and concluded in 2010. O’Connor very appropriately noted this was an observational study, not a prospective, controlled research project. In other words a group of ~5,000, aged 43 to 84, agreed to have regular eye exams and reports were published after the 5-, 10-, 15- and 20-year followups.More than 300 publications have resulted from this project with data supporting a relationship of cataracts and age-related macular degeneration (AMD) to cigarette smoking.

Klein’s paper stated that an estimated 19.3% of US adults take aspirin on a regular basis. It’s commonly recommended for anyone who has had a heart attack (secondary prevention), but many   of us who’ve never had evidence of coronary vascular disease also take aspirin. This is primary prevention and is controversial with some data suggesting reduction of heart attacks in men over 45, but not women, although they may have a 17% reduction in stroke incidence.

A senior who has AMD may need a magnifying glass.

A January 21,2013 article from an Australian group reported a two-fold increase in AMD of a particular type, independent of smoking habits. Nearly a quarter of regular long-term aspirin users developed neovascular AMD, two and a half times the percentage of those who did not regularly take aspirin.

A 2001 paper in the Archives of Ophthalmology reported a randomized, double-masked, placebo-controlled study of low dose aspirin (one adult tablet every other day) plus 50 milligrams of beta carotene (a vitamin A precursor rated possibly effective in treating advanced AMD) among over 20,000 US male physicians aged 30 to 84 in 1982. The study was stopped after ~5 years due to a statistically extreme reduction (44%) in first heart attacks. There were fewer cases of AMD in those taking low-dose aspirin than in those who got the placebo.

There’s also some data supporting aspirin’s role in cancer prevention, especially in malignancies of the colon. Here the benefit was unrelated to aspirin dose (75 mg/day and up), but increased with age.

So let me look at my own risks: my dad had a large polyp in the earliest part of the colon, an area hard to see even on colonoscopy. It was initially felt to be benign, but later had some areas of low-grade malignancy. He also had macular degeneration in his remaining eye  diagnosed at age 90+ (the other eye having been removed nearly sixty years previously after a bad cut and a subsequent infection). My brother died of a heart attack at age 57 and my mother had a heart attack at age 74 with a cardiac arrest; (Dad resuscitated her and she lived to age 90).

The editorial that accompanied the recent JAMA article is thoughtful and impressive. Its title was “Relationship of Aspirin Use With Age-Related Macular Degeneration: Association or Causation?” and it concludes “From a purely science-of-medicine perspective, the strength of evidence is not sufficiently robust to be clinically directive.” It then switches to a different viewpoint, the art-of-medicine perspective, saying maintaining the status quo is currently the most prudent approach, especially in secondary prevention (someone who has already had a cardiovascular event). For those of us who haven’t, the risks versus benefits should be individualized based on our own medical history and value judgement.

I’m going to discuss this with my own physician but not stop taking a chewable 81 mg aspirin daily until I do.

Surviving, or better still, preventing heart attacks: Part 1: After it happens

Friday, May 18th, 2012

Heart attacks frequently cause sudden cardiac arrest

The April 17, 2012 edition of The Wall Street Journal had an article titled “The Guide to Beating a Heart Attack.” It had both good news and bad: since the 1970s the annual number of American deaths from heart attacks (the “med-speak” term is myocardial infarction or MI) has diminished by three fourths; on the other hand nearly a million of us will have an MI this year and many of those will die.The National Vital Statistics Reports estimate for 2010 was 595,000 deaths from heart disease (of all kinds)  and the Seattle-King County 2012 estimate is 480,000 adults dying from an MI or its complications.

A quarter million die from sudden cardiac arrest (SCA) and the majority of those happen in a non-hospital location. Only 7.6% of people who  have an SCA outside a hospital survive to be discharged to home. This figure varies markedly according to where you live. If you happen to reside in Rochester, NY, your odds are much better. Bystander-witnessed cardiac arrest victims there who have the typical heart rhythm disorder that leads to sudden cardiac arrest (it’s usually due to a chaotic quivering called ventricular fibrillation{VF}), have a 50% chance of survival to discharge from the hospital.

My mother, as I’ve mentioned before, was one of the fortunate ones. She didn’t live in Rochester or in the Seattle area which also has a superb track record.  But she had a bystander-witnessed event, got prompt CPR and a rapid response from a trained Advanced Cardiac Life Support (ACLS) team, and lived another 16 years.

The Seattle-King County concept is termed “Community Responder CPR-AED.” They knew that most people who die from SCA have VF and the only “cure” was to use a defibrillator. Most non-medical people wouldn’t be able to operate the complex gadgets used in hospitals. The answer was the AED, an automated external defibrillator developed nearly twenty years ago.

The American Heart Association” Science Advisory commentary on AED use by non-medical people has a four-point program for out-of-hospital SCA: early recognition followed by a 911 call; early bystander-performed CPR; early AED use and then early ACLS.

look for this sign

They included several extra points I hadn’t thought about, having always performed CPR-defibrillation & ACLS in hospital settings. Early CPR increase the possibility that defibrillation will stop VF and the heart will then resume its normal rhythm; it does so while providing blood flow to the brain as well as the to heart. And all the AED does is stop the VF abnormal heart rhythm enabling the heart to restart normal beating, but the heart rate may be slow to begin with, so CPR may be necessary for several more minutes.

Early CPR also increases overall survival rates; if it’s not being provided, every minute between the patient’s collapse and defibrillation lowered that rate by 4-6%.

Given all that, one of the first things the state of Washington did was to pass a law granting immunity from civil liability for any person (or entity) who acquires a defibrillator. Then they started wide-spread CPR and AED training (learning to use an AED is easier than learning CPR) and markedly increased their paramedic numbers.

The life-saving results have been very impressive. My question now is whether to buy an AED for our home.

 

Medical Waste: Part two

Sunday, April 15th, 2012

this ECG is normal

In my last post, about trying to decrease the incredible expense of US health care, I gave a link to the ideas Dr. Donald Berwick had outlined in the April 11th edition of JAMA. He thinks we could save huge amounts in six areas: failure of care delivery; failure of care coordination; overtreatment; administrative complexity; pricing failures and fraud & abuse.

Now I’d like to look at a few specific examples.

The same JAMA edition had a research article titled “Association of Major and Minor ECG Abnormalities with Coronary Heart Disease Events” It detailed the followup of nearly 2,200 people in my age range and up (they were 70 to 79) who were in the Health, Aging and Body Composition Study. Thirteen percent had electrocardiograms with minor changes when the study started; twenty-three percent had more significant changes. Both kinds of ECG changes were associated with an increased likelihood of having coronary artery disease (CHD) during the subsequent years.

Now ECGs are relatively cheap and can be done in many settings. But the senior author, Dr. Reto Auer, said in an interview for a publication called heartwire ”Our data do not permit one to say anything about clinical practice.” The article itself concluded, “Whether ECG should be incorporated in routine screening of older adults should be evaluated in randomized, controlled trials.”

In the same edition of JAMA a Northwestern University Preventive Medicine professor, Dr. Philip Greenland, commenting on Auer’s research, mentioned a 1989 summary of the value of the “resting ECG,” which said additional study was needed. Dr.Greenland said the major finding in Auer’s work was a relatively new measurement called the net reclassification index (NRI). As opposed to diagnostic studies (e.g., does this patient have heart disease), this study hoped to be prognostic, telling what the chances were of a major heart event occurring in the future to a particular study subject. In this case the NRI helped most in reclassifying people into a lower CHD risk group, not a higher one.

All of that is fascinating and the Auer article is a superb example of carefully performed research. But, my fear is that many physicians won’t read the caveats. If you ignore the last paragraph, skip the editorial and never get to “theheart.org’s” take on the work, you may well decide that every older adult should have an ECG done on a regular basis.

What should we do if your cholesterol is high?

In the same edition of the journal is a pair of short articles deliberately set up to examine a medical controversy, in this case whether a middle-aged man with an elevated cholesterol, but no personal or family history of coronary heart disease should be given statin drugs to lower his cholesterol. This is a new feature of the journal, and the accompanying editorial, with the intriguing title, “The Debut of Dueling Viewpoints,” explains this will be a continuing series of discussions and debates.

What a wonderful idea.

 

 

 

 

The the online publication, theheart.org actually had a nice summary of the two pieces,

Exercise counts most for kids

Saturday, February 18th, 2012

thumbs up on this activity

In a previous post I mentioned former neighbors whose two boys had to run around outside for an hour a day (and they did spend most of that hour literally running), before they got any “screen time.” I thought that was admirable and noted both kids were slender.

Now I found an article in the February 15, 2102 issue of JAMA that confirms the wisdom of the approach my friends took toward this issue. A sextet of authors from the UK, Norway, Sweden and Canada published results for the International Children’s Accelerometry Database Collaborators (ICAD).

First I had to make sure what accelerometry meant in this context. The dictionary definition was only somewhat useful. It obviously refers to a gadget for measuring acceleration, but when I returned to a prior study  of 1,862 British children aged 9 or 10 published in 2009 in the American Journal of Clinical Nutrition, I learned it’s a very expensive and sophisticated gadget. My wife has a step counter that our local hospital seniors’ organization, the Aspen Club, gave her free. The device used in the large-scale research project, sold by a Florida firm, does lots more than just count steps. Among other thing it also monitors how much energy you expend and what your activity intensity has been. Of course the current model I found online costs $1,249, but there is a volume discount.

That earlier study concluded we need to get our youngsters really moving in order to “curb the growing obesity epidemic.”

The current paper offers a more nuanced viewpoint. It has a daunting title: “Moderate to Vigorous Physical Activity and Sedentary Time and Cardiometabolic Risk Factors in Children and Adolescents.”  The study looked at exercise levels and screen time in over 20,000 kids ages 4 to 18. Overall those who got more exercise improved all the risk factors measured: waist size, blood pressure, insulin levels, triglycerides and HDL cholesterol.

thumbs down on this one

Once levels of physical activity were factored in, sedentary time seemed relatively unimportant. But a smaller group, 6413 kids, was followed  for a little over two years and neither screen time nor exercise seemed important in changes in waist size, while kids who, at the start of the various studies, had bigger bellies, also had them later. I’d bet most of those were quite TV-addicted, since the paper warns that activity (or lack of activity actually) is often a clue to snacking and soft drinks.

I may show the short form of this paper to the principal of the nearby grade school I’ve mentioned previously. All those kids, starting in kindergarden, have a one-hour exercise period mostly spent running. I think it’s a school-district-wide program and just confirms what to me is common sense.

Lots of our youngsters are spending their days sitting in front of a screen of some sort instead of playing active games outdoors. Even in the age group followed in the recent article, a quarter of the kids were at least overweight; 7% were already obese. The average time for active play was a half an hour a day and the average for screen time was close to six hours a day.

I doubt we can totally reverse those numbers, but it’s a good idea.

Adults, obese and otherwise

Sunday, February 12th, 2012

PIck well and cut back your waste/waist

In my last post I explained the concept and the math behind the body mass index (BMI) approach to evaluating if your weight was normal or not (your BMI is very  well in synch with the most scientific methods of determining body fat percentages). Now I want to expand on that a bit  with some recent statistics and some thoughts on how we can lose weight if we need to. Unfortunately, some of us have lots of extra pounds we should shed if we want to have our best shot at leading long, healthy lives.

The Feb 1, 2012 issue of JAMA had a number of interesting articles on obesity. I’ve previously mentioned several on childhood and adolescent obesity; today I’d like to zero in on two whose focus is American adults.

Four CDC staffers, led by Katherine Flegal, PhD, published the most recent statistics from a recurring national survey with the daunting acronym NHANES. This national health and nutrition survey (the E stands for examination) started in 1971, but from 1999 on has been released results in two-year cycles. The current article from the National Center for Health Statistics, looking at the 2009-2010 NHANES data had a little good news and lots of bad news.

After 1980, until the turn of the 21st century, the prevalence (scientific term for percentage) of obesity in our population kept zooming up. Now it appears to have leveled off. I guess that’s something we should be happy about, except now over 35% of adults in this country are obese. Men and women have about equally high rates of obesity and men have caught up to women in this regard over the last twelve years. Some subsets, by sex and racial groups, are even more likely to be obese or very obese.

The worst news from this article was that no group–men, women, non-Hispanic whites, Hispanics or non-Hispanic blacks–had a decrease in the prevalence of obesity in this most recent data set.

So which exercise and diet should we try?

getting enough exercise is difficult when your joints hurt

Many adults report “No Leisure-Time Physical activity.” Overall, more of us are exercising, but the data vary from state to state. Those who have arthritis, fifty million in the US, need special attention or are even more likely to get no exercise. The CDC has worked with the Arthritis Foundation to develop ideas for this huge group. Going back to my review of articles on youngsters, I think for the rest of us, we could begin with simple steps, parking at the far end of the parking lot and substituting some walking for part of our screen time as two examples.

Harvard Medical School’s free online HEALTHbeat publication had a review of pros and cons of various diets in its Feb 7, 2012 edition. The bottom line still is if you want to lose weight, you must cut down on your calories. The Mediterranean-style emphasis on fruits and vegetables, unrefined carbohydrates, nuts, seeds and fish may be the most effective in reducing cardiovascular and diabetic risks.

My New Year’s Resolution is to keep my weight under 150 pounds. I have to work at it as I like to eat, but most of the time I’ve stayed away from splurges.

How about you?

 

JAMA

 

 

The very high-priced spread

Saturday, February 4th, 2012

This obese teenager could be headed for trouble

I’ve been concerned about our burgeoning problem of excessive weight, so when the Journal of the American Medical Association for February 1, 2012 arrived, I was intrigued by the variety of articles touching on the subject. Let me start with a disclaimer: I have no clear-cut special competence, no magic bullet for preventing or treating obesity in our children. I do think it’s a major threat to the upcoming generations here and elsewhere in the world. I am also very aware that its opposite numbers, hunger and even starvation, threaten whole populations around the globe.

But my own background, both as a physician and as someone who has successfully fought weight issues (I weighed 218 in 1969 and 148 this morning), has made me concentrate on the American epidemic of eating to excess as a major area of my interest.

The first article dealt with kids and adolescents. A group of CDC researchers reported an update on obesity in American kids, giving data from 199 to 2010. The newest statistics show nearly ten percent of our infants and toddlers are obese and close to 17% of our kids ages two to nineteen. As the kids got older, more boys than girls were obese in this survey with over 4,000 participants.

Then there was an article titled “Weight Loss Stratagies for Adolescents,” based on a Boston Children’s Hospital Conference roughly a year ago. The MD, PhD Harvard Professor of pediatrics who discussed the issue began with the case history of a particular obese girl, a fourteen-year-old who was five foot six and weighed nearly 250 pounds (giving her a body mass index,BMI, of 40). Her adoptive parents were overweight themselves, but had to learn to “back off” in their attempts to control her diet. There is some early data that suggests that parents can help by providing health food choices in the home and facilitating enjoyable physical activity throughout the day (versus a fixed “exercise time).

I had seen an example of that with some former neighbors whose boys, in order to have their one hour of “screen time,” had to be outside playing for several hours at a time. Both youngsters were lean.

One critical point to be made is avoiding focusing on obese kids only. A large Danish study, published in the New England Journal of Medicine in December, 2007,  followed over a quarter million children born in the 1930 to 1976 time period. Denmark established a national civil register of “vital statistics” in 1968 and enrolled everyone in the country, giving them a unique number, ironically termed their CPR number. Although that had nothing to do, I gather, with cardiopulmonary resuscitation, which is what I think CPR means, the study did look at risk factors for coronary heart disease.

When your heart's on fire, it may not be from love

The results are impressive and threatening: every one point increase in BMI across the spectrum was associated with an increased risk of coronary artery disease. A child didn’t have to be fat to be at risk later on. One calculation estimated that a 13-year-old boy weighing 25 pounds more than the average had a one-third increase in the likelihood of having a heart attack before the age of sixty.

It’s time to start helping our kids live leaner and longer, healthier lives.