Archive for the ‘coronary heart disease’ Category

Heart attacks Part 2: Prevention: risk factors & our kids

Wednesday, May 23rd, 2012

Here's a risk factor you can eliminate

This post pings off the April 17, 2012 article in The Wall Street Journal, "The Guide to Beating a Heart Attack." I initially wrote about surviving a heart attack (myocardial infarction {MI} is the medical term). Next I wanted to turn toward the prevention side.

I first found the Interheart study's article from 2004, "Nine modifiable risk factors predict 90% of acute MI." The study followed 29,000 people from 262 sites in 52 countries and concluded that the common belief that half of heart attacks can be predicted was clearly an underestimate.

The research group found the same impact of the nine variables everywhere in the world: abnormal blood lipids (fats, like cholesterol) and smoking were at the top of their list. Then came diabetes, high blood pressure, abdominal obesity, stress & depression, exercise, diet and alcohol intake.

I was used to measuring cholesterol and its HDL (so-called good cholesterol)  and LDL (bad cholesterol) components. This study actually used a more sophisticated lipid approach.

They measured the ratios of  the proteins that bind to and carry fats, apolipoproteins A and B. APOA is associated with HDL lipids while APOB is said to unlock the door to cells and in doing so acts as an unwelcome delivery van for cholesterol. When present in high levels, APOB can lead to plaque formation in blood vessels and an increased risk of coronary heart disease (CHD).

They also found some good news: as expected, eating fruits and vegetables daily, exercising and perhaps moderate alcohol intake were associated with lower risks of CHD. Again this was true everywhere in the world.

The WSJ article mentioned that hospital admissions for heart attacks had actually decreased among the elderly; these nine factors were better predictors in younger groups. What can be done to stop the looming specter of CHD among our younger population?

The CDC examined the parameters in a recent online article titled "A Growing Problem." One issue was "screen time." Our kids eight to eighteen average four an a half hours a day watching TV and three more on cell phones, movies, computers and video games. I even read an article about a two-year-old whose parents think learns a lot from their iPad. Maybe so, but how much exercise does that kid (and his older compatriots) get?

The CDC feels there is a dearth of quality physical activity in our schools; as of 2009 only a third of them provided daily PE for our kids. And after they leave school or when they're on vacation, many don't have safe access to biking, hiking, running, playing areas and trails.

Somerville chose healthier food in their schools

One Massachusetts community, Somerville, has gotten attention for their anti-obesity integrated program, "Shape Up Sommerville"  (You can watch the thirteen minute PBS special on their community-wide progress). The Robert Wood Johnson Foundation is attempting to help similar programs get started across the country, especially focusing on childhood obesity.

Recently I heard a NPR comment that caught my attention. If we don't do something to stop the epidemic of childhood obesity, we'll soon be seeing CHD rates soar in people in their 20s and 30s and maybe even younger.

A French researcher said, "Mankind is doing a good job of killing himself."

We need to try new approaches to help our kids. The Somerville plan sound like a good place to start.

 

 

 

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,