So... you didn't take care of your body when you were young, and now at middle age you're feeling out of shape and over the hill. You're motivated to make a lifestyle change if it would help, but will it actually do any good at this point?
The good news is that perhaps it will. According to a report in Circulation, just two years of high-intensity exercise improves heart health. In the study, sedentary middle-aged men (mean age 53 years) participated in either a moderate to high intensity aerobic exercise program for two years (the experimental group), or only non-aerobic exercise such as yoga or balance training (the control group). At the end of two years, those who had exercised showed signs of improved heart health, including improved oxygen uptake and a reduced stiffness of the left ventricle. It's as if the clock was turned back on the heart aging process.
Middle age may be the last time that one can improve heart function, however. According to an NPR article, the same improvement is not possible by the time one reaches seventy years of age. The time to get moving is now, not later.
Showing posts with label heart and circulation. Show all posts
Showing posts with label heart and circulation. Show all posts
Wednesday, March 21, 2018
Thursday, March 8, 2018
A New Risk Factor for Heart Attack and Stroke
Why is it that most patients who have had a stroke or a heart attack don't have any of the normal risk factors, such as high cholesterol or high blood pressure, that are generally associated with cardiovascular risk? The answer, it seems, may be a risk factor that has been missed until now; a condition called clonal hematopoiesis of indeterminate potential, or CHIP.
In essence, CHIP is a condition in which some of the stem cells in bone marrow that initiate the production of white blood cells (WBCs) begin to mutate, resulting in the increased production of white blood cells carrying the mutation. Patients with an increased number of these mutated WBCs in their blood are 40-50% more likely to die of a stroke or a heart attack within 10 years. Apparently, the risk of developing CHIP goes up sharply with age. Although only about 20% of 60-yr-olds have developed CHIP, half of all 80-yr-olds have the condition. It's almost as if CHIP is a normal consequence of aging.
And how might CHIP contribute to cardiovascular disease risk? Researchers have long speculated that chronic inflammation may contribute to the development of blood vessel-blocking atherosclerosis. And its possible that chronic inflammation is initiated by increased numbers of inflammatory WBCs in the blood.
Doctors are not advising their patients to be tested for CHIP yet, because at the moment there is nothing to be done about it even if you do test positive. At least not yet; perhaps some day there will be.
In essence, CHIP is a condition in which some of the stem cells in bone marrow that initiate the production of white blood cells (WBCs) begin to mutate, resulting in the increased production of white blood cells carrying the mutation. Patients with an increased number of these mutated WBCs in their blood are 40-50% more likely to die of a stroke or a heart attack within 10 years. Apparently, the risk of developing CHIP goes up sharply with age. Although only about 20% of 60-yr-olds have developed CHIP, half of all 80-yr-olds have the condition. It's almost as if CHIP is a normal consequence of aging.
And how might CHIP contribute to cardiovascular disease risk? Researchers have long speculated that chronic inflammation may contribute to the development of blood vessel-blocking atherosclerosis. And its possible that chronic inflammation is initiated by increased numbers of inflammatory WBCs in the blood.
Doctors are not advising their patients to be tested for CHIP yet, because at the moment there is nothing to be done about it even if you do test positive. At least not yet; perhaps some day there will be.
Sunday, February 18, 2018
Keeping Human Organs Alive Longer Before Transplantation
One of the practical limitations to transplantation of organs from a recently-deceased donor to a recipient is the length of time that human organs remain viable outside a human body. Even if the organ is immediately cooled on ice, it's only a matter of hours before it is no longer considered healthy enough for transplantation. Sometimes it would take too long to transport the organ from where it is harvested to where it is needed, even if pilots and planes were standing by to transport it.
That may be about to change. Several companies (OrganOx and Transmedics) are working to extend the time during which human organs can be kept alive outside the body for up to a full day. This is being accomplished not by cooling the organ, but by keeping it warm and perfused with blood throughout storage and transport so that the organ's metabolic requirements are met and it can continue to function. The techniques require some expensive equipment (much more expensive than just a cooler of ice!), but if lives can be saved the extra cost may just be worth it.
And if we are allowed to dream, if the time of organ storage outside a human body could be extended to weeks or even months, it might be possible to establish human organ banks in some distant future!
That may be about to change. Several companies (OrganOx and Transmedics) are working to extend the time during which human organs can be kept alive outside the body for up to a full day. This is being accomplished not by cooling the organ, but by keeping it warm and perfused with blood throughout storage and transport so that the organ's metabolic requirements are met and it can continue to function. The techniques require some expensive equipment (much more expensive than just a cooler of ice!), but if lives can be saved the extra cost may just be worth it.
And if we are allowed to dream, if the time of organ storage outside a human body could be extended to weeks or even months, it might be possible to establish human organ banks in some distant future!
Wednesday, January 3, 2018
Redefining High Blood Pressure is a Two-Edged Sword
Two months ago I highlighted the new American Heart Association guidelines for defining high blood pressure. I was a bit skeptical, as you may have noticed (see this blog Nov. 14, 2017).
A recent opinion piece by Aaron Carroll, a professor of pediatrics at Indiana University School of Medicine, does a better job than I of pointing out that while keeping blood pressure under control is important, the new guidelines could easily lead to over-treatment of patients who might not actually need treatment. That's because the new guidelines are based on a study of people who were at high risk of cardiovascular disease, either by virtue of their age or because they had another underlying cardiovascular or kidney condition. So technically, the new guidelines may not apply to people whose only symptom is high blood pressure. But will patients and their doctors be aware of that? In addition, some people whose blood pressures are usually normal have slightly elevated blood pressures when they are under the stress of being in a doctor's office - its called "white-coat hypertension".
Thank you, professor Carroll, for your thoughts on this issue.
A recent opinion piece by Aaron Carroll, a professor of pediatrics at Indiana University School of Medicine, does a better job than I of pointing out that while keeping blood pressure under control is important, the new guidelines could easily lead to over-treatment of patients who might not actually need treatment. That's because the new guidelines are based on a study of people who were at high risk of cardiovascular disease, either by virtue of their age or because they had another underlying cardiovascular or kidney condition. So technically, the new guidelines may not apply to people whose only symptom is high blood pressure. But will patients and their doctors be aware of that? In addition, some people whose blood pressures are usually normal have slightly elevated blood pressures when they are under the stress of being in a doctor's office - its called "white-coat hypertension".
Thank you, professor Carroll, for your thoughts on this issue.
Tuesday, December 19, 2017
A New Method for Treating Ventricular Tachycardia
One of the consequences of the damage to a heart caused by infection or a heart attack is scarring of cardiac muscle tissue. In some cases the scarring leads to a type of arrhythmia called ventricular tachycardia, in which the patient suffers from a rapid and uncontrolled heart rate and a feeling of dizziness and lightheadedness. The standard treatment is generally a surgical procedure, in which the scarred region is burned off via a catheter inserted into the heart. But the surgical procedure carries some risk, and in some patients it just doesn't work.
An experimental non-invasive technique offers hope to these patients. Borrowing a technique used to treat cancer patients, the new procedure uses targeted radiation to ablate the offending tissue. During the procedure the patient wears a vest that incorporates 256 electrocardiogram leads as opposed to the usual 10, allowing precise targeting of the region to be ablated.
The procedure seems to work well - the first five patients went from more than 6,500 episodes of tachycardia in three months to just four episodes in a year, according to an article in The New York Times. Further research will be needed to determine the long-term consequences and safety of the procedure, but some day, targeted radiation could become the method of choice for patients suffering from ventricular tachycardia.
An experimental non-invasive technique offers hope to these patients. Borrowing a technique used to treat cancer patients, the new procedure uses targeted radiation to ablate the offending tissue. During the procedure the patient wears a vest that incorporates 256 electrocardiogram leads as opposed to the usual 10, allowing precise targeting of the region to be ablated.
The procedure seems to work well - the first five patients went from more than 6,500 episodes of tachycardia in three months to just four episodes in a year, according to an article in The New York Times. Further research will be needed to determine the long-term consequences and safety of the procedure, but some day, targeted radiation could become the method of choice for patients suffering from ventricular tachycardia.
Tuesday, November 14, 2017
The American Heart Association Redefines High Blood Pressure
The popular press (an NBC News report is an example) was full of the news yesterday that the American Heart Association (AHA) has come out with new recommendations for the treatment of high blood pressure (hypertension). According to the AHA, hypertension should now be defined as blood pressure above 130/80 mmHg. I'm sure the AHA has its reasons, but I'd be more comfortable with their recommendation if it wasn't the AHA's members (heart doctors) who stand to gain the most from the recommendations. The new recommendations summarily define nearly half the adult population as potential patients!
The new AHA recommendations are different from the recommendations of the Eighth Joint National Committee (JNC 8), an independent, unbiased group chosen from over 400 experts to examine the evidence and provide guidance to clinicians concerning the treatment of hypertension. The JNC 8 recommendations came only after an exhaustive review of the literature and were submitted to peer review by additional experts not on the panel before they were published. JNC 8 recommends treatment of hypertension to the goal of lowering pressure to below 140/90, not 130/80.
The AHA argues that blood pressure above 130/80 doubles your relative risk of heart disease, compared to pressures below that level. That may be so, but there's a big difference between relative risk and absolute risk. A doubling of relative risk can be as little as an increase in absolute risk from one in a million to two in a million. Think about that before you commit yourself to a lifetime of antihypertensive medication.
The new AHA recommendations are different from the recommendations of the Eighth Joint National Committee (JNC 8), an independent, unbiased group chosen from over 400 experts to examine the evidence and provide guidance to clinicians concerning the treatment of hypertension. The JNC 8 recommendations came only after an exhaustive review of the literature and were submitted to peer review by additional experts not on the panel before they were published. JNC 8 recommends treatment of hypertension to the goal of lowering pressure to below 140/90, not 130/80.
The AHA argues that blood pressure above 130/80 doubles your relative risk of heart disease, compared to pressures below that level. That may be so, but there's a big difference between relative risk and absolute risk. A doubling of relative risk can be as little as an increase in absolute risk from one in a million to two in a million. Think about that before you commit yourself to a lifetime of antihypertensive medication.
Monday, November 6, 2017
Coronary Artery Stents Don't Reduce Angina Pain
For decades, cardiologists have been inserting stents into their patients' partially blocked coronary arteries in order to improve blood flow to the heart. Stents are particularly effective in patients who have already suffered a heart attack. But stents are also used to improve coronary blood flow in patients who have not had a heart attack but are suffering from angina, the chest pain that some patients feel when coronary blood flow is compromised. It makes sense, right? It's always a good idea to improve coronary blood flow.....isn't it?
Cardiologists generally think so. And it's a big business for them; more than 500,000 stents are performed every year at $14,000 - $40,000 a pop, according to some estimates. But now a new study by British researchers questions whether the patients are actually improved by the procedure.
The study is unusual in that it is a true double-blind study with a control group. Two hundred patients suffering from angina due to a severely blocked coronary artery were recruited. Half of them got a stent, and the other half underwent the same surgical procedure, but the stent was just inserted and then removed. It's hard to get approval for this kind of study in humans, because if you can show that a treatment works, you can't ethically withhold it from some patients just to prove a point! In fact, the stents did improve coronary blood flow in the patients that received them. But more to the point, there were no differences between the two groups in the ability to do exercise six weeks later or in their self-reported pain.
Cardiologists are busy assessing what it all means, according to an article in The New York Times. In all likelihood the clinical guidelines for the use of stents in patients with angina will have to be revised, or at least re-examined. And additional studies will probably be needed to try to determine whether there might be some other benefit of the stents, such as a reduced risk of heart attacks further down the road.
Cardiologists generally think so. And it's a big business for them; more than 500,000 stents are performed every year at $14,000 - $40,000 a pop, according to some estimates. But now a new study by British researchers questions whether the patients are actually improved by the procedure.
The study is unusual in that it is a true double-blind study with a control group. Two hundred patients suffering from angina due to a severely blocked coronary artery were recruited. Half of them got a stent, and the other half underwent the same surgical procedure, but the stent was just inserted and then removed. It's hard to get approval for this kind of study in humans, because if you can show that a treatment works, you can't ethically withhold it from some patients just to prove a point! In fact, the stents did improve coronary blood flow in the patients that received them. But more to the point, there were no differences between the two groups in the ability to do exercise six weeks later or in their self-reported pain.
Cardiologists are busy assessing what it all means, according to an article in The New York Times. In all likelihood the clinical guidelines for the use of stents in patients with angina will have to be revised, or at least re-examined. And additional studies will probably be needed to try to determine whether there might be some other benefit of the stents, such as a reduced risk of heart attacks further down the road.
Tuesday, August 22, 2017
High Blood Pressure in Children
So, you thought that hypertension (high blood pressure) was a problem primarily for older adults, right? Think again. Although fewer than 5% of children and teens currently have been diagnosed with hypertension, soon you may hear about a startling increase in hypertension in these groups.
Why is this likely to happen? It used to be that guidelines for pediatricians suggested that they look closely at blood pressures in teens and children who were overweight or obese because these children were considered to be at risk for hypertension. Overweight children were considered to have hypertension if their pressures were elevated above the norm for their weight. But now, new guidelines published by the American Academy of Pediatrics encourage pediatricians to check pressures in all children, relying on data tables that include blood pressures for children of normal weight. No doubt, some normal weight children will now be diagnosed with hypertension as well. Furthermore, blood pressures of overweight and obese children will now look even worse, because normal weight childrenwho tend to have lower pressures on average. Add it all up and more children of all weights are likely to be diagnosed with (and probably treated for) hypertension.
Early diagnosis and treatment is good, right? Well, yes, if it decreases morbidity and/or mortality in these children later in life. The justification for treatment in children is the assumption that high blood pressure in a child will lead to high blood pressure and increased risk of morbidity/mortality as an adult. And that we can't know just yet, and probably won't for at least 20 years. Meanwhile, parents will stress out and health care costs will continue to rise....
It's an interesting risk/benefit conundrum. At least we know where pediatricians stand on this one.
Early diagnosis and treatment is good, right? Well, yes, if it decreases morbidity and/or mortality in these children later in life. The justification for treatment in children is the assumption that high blood pressure in a child will lead to high blood pressure and increased risk of morbidity/mortality as an adult. And that we can't know just yet, and probably won't for at least 20 years. Meanwhile, parents will stress out and health care costs will continue to rise....
It's an interesting risk/benefit conundrum. At least we know where pediatricians stand on this one.
Wednesday, May 4, 2016
Stent Retrievers Improve the Odds of Recovery From a Stroke
A device called a stent retriever can improve the odds of recovery from an ischemic stroke, brought on by a clot that blocks blood flow in an artery in the brain. The stent retriever is a tube-shaped wire mesh device similar to the stents that are used to open blocked arteries in the heart. In the case of a stroke, however, the device is inserted into the blocked artery in the brain, where it enmeshes and entraps the clot so that it can be pulled out.
Stent retrievers (and the surgeons trained to use them) have been available for a while now in hospitals with state-of-the-the art endovascular treatment units. Generally that does not include your local clinic or small hospital; more likely it's a large regional hospitals. That may prove to be important, because new findings show that the stent retriever technique is highly effective IF it is done soon after the stroke. Using "functional independence" as the definition of recovery from a stroke, 91% of stroke patients recover if the stent retriever technique is performed within 2 1/2 hours of the onset of stroke symptoms. However, recovery percentages decline rapidly if treatment is delayed. The recovery percentage declines an additional 10% if treatment is delayed another hour, and another 20% for each additional hour after that. By 5 1/2 hours after the stroke, recovery after the stent retrieval procedure is only about 40%.
Stent retrievers are shaping up to be a lifesaver for stroke victims with quick access to a well-equipped health care center. But burn this into your brain; in the case of a stroke, getting to treatment (any treatment) quickly is absolutely essential. Like the stent retrieval procedure, clot-dissolving drugs also are more effective when they are administered soon after a stroke.
Stent retrievers (and the surgeons trained to use them) have been available for a while now in hospitals with state-of-the-the art endovascular treatment units. Generally that does not include your local clinic or small hospital; more likely it's a large regional hospitals. That may prove to be important, because new findings show that the stent retriever technique is highly effective IF it is done soon after the stroke. Using "functional independence" as the definition of recovery from a stroke, 91% of stroke patients recover if the stent retriever technique is performed within 2 1/2 hours of the onset of stroke symptoms. However, recovery percentages decline rapidly if treatment is delayed. The recovery percentage declines an additional 10% if treatment is delayed another hour, and another 20% for each additional hour after that. By 5 1/2 hours after the stroke, recovery after the stent retrieval procedure is only about 40%.
Stent retrievers are shaping up to be a lifesaver for stroke victims with quick access to a well-equipped health care center. But burn this into your brain; in the case of a stroke, getting to treatment (any treatment) quickly is absolutely essential. Like the stent retrieval procedure, clot-dissolving drugs also are more effective when they are administered soon after a stroke.
Monday, April 25, 2016
Determining Who Can't Tolerate Statins
For years now, a class of drugs called statins have been the treatment of choice for lowering LDL cholesterol levels. They're cheap (pennies a day), effective, and safe. The problem is that 5-20% of patients say they can't tolerate the statins because of muscle-related side effects, including muscle pain and weakness.
A new class of class cholesterol-lowering drugs, called PCSK-9 inhibitors, avoids the muscle-related side effects. However, the big downside to the PCSK-9 inhibitors is that they are very expensive - approximately $14,000 a year. For that reason, insurance companies would like the PCSK-9 inhibitors to be used only by the few people who are truly intolerant of the statins. But how is intolerance to the statins to be defined, other than by the patients and their physicians?
A recent study showed how big a problem this is. Researchers wanted to explore the effectiveness of several newer LDL cholesterol-lowering drugs in statin-intolerant patients with very high cholesterol levels. To find such patients, they recruited more than 500 patients who had tried two or more statins and claimed that they could not tolerate them because of muscle pain or weakness. The patients were randomly assigned to take a statin (atorvastatin) or a placebo for ten weeks. Then the drugs were switched for an additional 10 weeks. It turned out that only 43% of the patients could be defined as statin-intolerant; that is, they reported muscle-related symptoms while they were on the statins but not while they were on the placebo. 26% of the patients reported muscle pain only while on the placebo, 17% never experienced muscle-related symptoms on either the statin or the placebo, and 10% complained of pain on both the statins and the placebo.
The bottom line is that fewer than half of all patients who say they are statin-intolerant actually are statin-intolerant. Because the PCSK-9 inhibitors are so expensive, some insurance companies are suggesting that patients who request them should be tested for statin intolerance (as the patients in the above study were) before insurance will pay for the new drugs.
What do you think? Should patients be required to submit to several months of testing before their (and your) insurance company agrees to pay for a $14,000-a-year drug for them?
A new class of class cholesterol-lowering drugs, called PCSK-9 inhibitors, avoids the muscle-related side effects. However, the big downside to the PCSK-9 inhibitors is that they are very expensive - approximately $14,000 a year. For that reason, insurance companies would like the PCSK-9 inhibitors to be used only by the few people who are truly intolerant of the statins. But how is intolerance to the statins to be defined, other than by the patients and their physicians?
A recent study showed how big a problem this is. Researchers wanted to explore the effectiveness of several newer LDL cholesterol-lowering drugs in statin-intolerant patients with very high cholesterol levels. To find such patients, they recruited more than 500 patients who had tried two or more statins and claimed that they could not tolerate them because of muscle pain or weakness. The patients were randomly assigned to take a statin (atorvastatin) or a placebo for ten weeks. Then the drugs were switched for an additional 10 weeks. It turned out that only 43% of the patients could be defined as statin-intolerant; that is, they reported muscle-related symptoms while they were on the statins but not while they were on the placebo. 26% of the patients reported muscle pain only while on the placebo, 17% never experienced muscle-related symptoms on either the statin or the placebo, and 10% complained of pain on both the statins and the placebo.
The bottom line is that fewer than half of all patients who say they are statin-intolerant actually are statin-intolerant. Because the PCSK-9 inhibitors are so expensive, some insurance companies are suggesting that patients who request them should be tested for statin intolerance (as the patients in the above study were) before insurance will pay for the new drugs.
What do you think? Should patients be required to submit to several months of testing before their (and your) insurance company agrees to pay for a $14,000-a-year drug for them?
Wednesday, December 9, 2015
Survival Rates After a Cardiac Arrest
If you're going to experience a cardiac arrest (complete cessation of a heartbeat), it's best to do it in Seattle.
Cardiopulmonary resuscitation (CPR) always seems to work on the medical TV shows. But in truth, the chances of recovering from a cardiac arrest aren't all that good. Outside a hospital the average survival rate of patients eventually treated by an emergency medical service (EMS) is less than 10%; even in a hospital it's only about 20%. Survival rates vary considerably depending on where the patient undergoes a cardiac arrest. In Detroit the survival rate is only 3%; in Seattle it's 20%, according to an article in the New York Times.
The four components of CPR are chest compression, ventilation (breathing for the patient), defibrillation (shocking the heart to get it started again), and epinephrine. The first two can be done by amateurs (passers-by) and can be fairly effective as a stopgap measure if done right. The latter two require EMS staff. And the key to improved survival seems to be better education of amateurs and training and monitoring of EMS staff. Seattle, for example, has a long history of an emphasis on CPR awareness and education of amateurs, combined with continual training and monitoring of the success of EMS staff.
Keys to good CPR are that it should be done vigorously and for longer than most people think. If you ever are in a position to try to save a patient while waiting for the EMS, don't stop chest compressions for longer than 10 seconds at a time while searching for a pulse, and don't give up too soon. Cardiac compression can be tiring for the resuscitator, but an hour of compression rather than just 15 minutes can sometimes save a patient.
If you're not trained in CPR yet, you might consider taking a basic CPR training class. The Red Cross and the American Heart Association offer them on a regular basis.
Cardiopulmonary resuscitation (CPR) always seems to work on the medical TV shows. But in truth, the chances of recovering from a cardiac arrest aren't all that good. Outside a hospital the average survival rate of patients eventually treated by an emergency medical service (EMS) is less than 10%; even in a hospital it's only about 20%. Survival rates vary considerably depending on where the patient undergoes a cardiac arrest. In Detroit the survival rate is only 3%; in Seattle it's 20%, according to an article in the New York Times.
The four components of CPR are chest compression, ventilation (breathing for the patient), defibrillation (shocking the heart to get it started again), and epinephrine. The first two can be done by amateurs (passers-by) and can be fairly effective as a stopgap measure if done right. The latter two require EMS staff. And the key to improved survival seems to be better education of amateurs and training and monitoring of EMS staff. Seattle, for example, has a long history of an emphasis on CPR awareness and education of amateurs, combined with continual training and monitoring of the success of EMS staff.
Keys to good CPR are that it should be done vigorously and for longer than most people think. If you ever are in a position to try to save a patient while waiting for the EMS, don't stop chest compressions for longer than 10 seconds at a time while searching for a pulse, and don't give up too soon. Cardiac compression can be tiring for the resuscitator, but an hour of compression rather than just 15 minutes can sometimes save a patient.
If you're not trained in CPR yet, you might consider taking a basic CPR training class. The Red Cross and the American Heart Association offer them on a regular basis.
Thursday, October 15, 2015
Express Scripts Will Cover the Newest (Expensive) Cholesterol-Lowering Drugs
I posted a blog recently about the two newest cholesterol-lowering drugs, made by Amgen and Sanofi SA (See this blog, Oct. 6, 2015). The new drugs will be very expensive; approximately $14,000 per year, compared to just a few dollars a month for the statins. I raised the question about whether insurers should cover the new drugs just because patients say they want them.
When the prices of the new drugs were announced, it seemed that the intent was to limit the use of the drugs to those patients who couldn't achieve adequate cholesterol reduction with the statins. According to FoxNews, insurers planned to "aggressively challenge" claims of statin intolerance before agreeing to pay for them. But how will insurers respond when physicians write prescriptions for the new drugs for their patients? I'm betting that patients will demand the new drugs once the drug companies start their ad campaigns, and that insurers will be pressured into paying the exorbitant bill.
At least one pharmacy benefits management company, Express Scripts, has included the new drugs in its 2016 list of approved drugs, but the company added that there would be "restrictions" on who could use them. Good luck with that! It will be interesting to see whether they actually do manage to restrict their use, or whether the costs to insurers will spiral out of control.
If you think it doesn't matter, consider this; high health insurance expenses by other insured individuals ultimately affects your insurance rates.
When the prices of the new drugs were announced, it seemed that the intent was to limit the use of the drugs to those patients who couldn't achieve adequate cholesterol reduction with the statins. According to FoxNews, insurers planned to "aggressively challenge" claims of statin intolerance before agreeing to pay for them. But how will insurers respond when physicians write prescriptions for the new drugs for their patients? I'm betting that patients will demand the new drugs once the drug companies start their ad campaigns, and that insurers will be pressured into paying the exorbitant bill.
At least one pharmacy benefits management company, Express Scripts, has included the new drugs in its 2016 list of approved drugs, but the company added that there would be "restrictions" on who could use them. Good luck with that! It will be interesting to see whether they actually do manage to restrict their use, or whether the costs to insurers will spiral out of control.
If you think it doesn't matter, consider this; high health insurance expenses by other insured individuals ultimately affects your insurance rates.
Tuesday, October 6, 2015
New Drugs For Lowering Cholesterol
The Food and Drug Administration (FDA) recently approved two new drugs for lowering LDL, the "bad" cholesterol. The new drugs work by an entirely different mechanism from the current gold-standard cholesterol lowering drugs, the statins. The new drugs mimic the effect of a genetic mutation, described in two patients several years ago, that results in very low LDL levels (see this blog July 18, 2013). The two drugs, Praluent, made by Sanofi Regeneron, and Repatha, made by Amgen, should be available soon.
Now for the bad news; the new drugs will cost upwards of $14,000 a year. For most patients who need of a cholesterol-lowering drug, there will be no reason to switch from a statin to one of the new drugs. But some patients say (rightly or wrongly) that the statins cause them to have muscle pain, hazy memory, and problems sleeping.
Should health insurers pay for the new (expensive) drugs just become some patients say they can't tolerate the statins? Double blind studies have shown that patients taking statins have no more muscle pains than patients taking a placebo. Muscle pain is such a common complaint in the age group of patients likely to be taking cholesterol-lowering drugs that it's hard to pinpoint the source.
I guess the question is, should patients' perceptions trump good science? Or should the insurance companies just say "no"?
Now for the bad news; the new drugs will cost upwards of $14,000 a year. For most patients who need of a cholesterol-lowering drug, there will be no reason to switch from a statin to one of the new drugs. But some patients say (rightly or wrongly) that the statins cause them to have muscle pain, hazy memory, and problems sleeping.
Should health insurers pay for the new (expensive) drugs just become some patients say they can't tolerate the statins? Double blind studies have shown that patients taking statins have no more muscle pains than patients taking a placebo. Muscle pain is such a common complaint in the age group of patients likely to be taking cholesterol-lowering drugs that it's hard to pinpoint the source.
I guess the question is, should patients' perceptions trump good science? Or should the insurance companies just say "no"?
Tuesday, September 29, 2015
What is the "Ideal" Systolic Blood Pressure?
Current guidelines for treating high blood pressure are that anyone with systolic blood pressures of 140 mmHg or above (or diastolic pressures above 90mmHg) should be treated to lower their blood pressures below those numbers. But the guidelines beg the question; is there an ideal systolic pressure that is even lower than 140?
According to a recent article in the New York Times, a major new research study shows that lowering systolic pressure to 120 or below reduces the risk of heart attacks, heart failure and strokes by a quarter and reduces the risk of death by a third, compared to just lowering systolic pressure to 140 or below. The findings imply that treatment of high blood pressure should be much more aggressive than the current guidelines suggest.
However, a closer reading of the actual study design reveals an important point: the study examined only patients who are already at risk for heart disease. These were not normal healthy people who just happened to have systolic pressures of 130 mmHg; they were all subjects with systolic blood pressures above 130 mmHg who also had evidence of cardiovascular disease, chronic kidney disease, cardiovascular disease risk factors, or were older than 75.
The results are clear; patients at high risk of cardiovascular disease should be treated more aggressively than in the past, with a goal of lowering their systolic pressures to 120 mmHg or less. But what about normal people who just happen to have a systolic pressure of greater than 120 mmHg? Cardiologists may begin recommending that they be treated, too (to the delight of the companies selling antihypertensive drugs.) But I'm not so sure. All drugs have side effects: when drugs are recommended, the potential benefits should outweigh the risks. And we just don't know whether lowering systolic blood pressure to below 120 in otherwise healthy people is a good idea.
According to a recent article in the New York Times, a major new research study shows that lowering systolic pressure to 120 or below reduces the risk of heart attacks, heart failure and strokes by a quarter and reduces the risk of death by a third, compared to just lowering systolic pressure to 140 or below. The findings imply that treatment of high blood pressure should be much more aggressive than the current guidelines suggest.
However, a closer reading of the actual study design reveals an important point: the study examined only patients who are already at risk for heart disease. These were not normal healthy people who just happened to have systolic pressures of 130 mmHg; they were all subjects with systolic blood pressures above 130 mmHg who also had evidence of cardiovascular disease, chronic kidney disease, cardiovascular disease risk factors, or were older than 75.
The results are clear; patients at high risk of cardiovascular disease should be treated more aggressively than in the past, with a goal of lowering their systolic pressures to 120 mmHg or less. But what about normal people who just happen to have a systolic pressure of greater than 120 mmHg? Cardiologists may begin recommending that they be treated, too (to the delight of the companies selling antihypertensive drugs.) But I'm not so sure. All drugs have side effects: when drugs are recommended, the potential benefits should outweigh the risks. And we just don't know whether lowering systolic blood pressure to below 120 in otherwise healthy people is a good idea.
Tuesday, July 21, 2015
Replacing a Heart Valve Without Major Surgery
Replacing a failing aortic heart valve is actually pretty routine. However, the normal procedure requires cracking the chest, stopping the heart, and cutting into the heart to get to the damaged valve. Because of the traumatic nature of the surgery itself, full recovery is more likely if the patient is relatively young and healthy except for the needed valve. As a result, the surgery is not recommended for patients over about 80 years of age.
Now those older patients have a viable option. Federal regulators recently approved a new technique called TAVR (transcatheter aortic valve replacement) for replacing aortic heart valves in patients who are deemed at high risk from open-heart surgery. In TAVR, surgeons attach a folded-up artificial valve to a catheter, insert it into a main artery and thread it up to the heart, and then open it like an umbrella. The catheter lodges in place, pushing the old damaged valve out of the way. The procedure can be done in minutes with the patient awake and only lightly sedated. Recovery time is minimal.
The TAVR technique is likely to be a lifesaver for the estimated 100,000 patients who are too old or sick for open-heart surgery. One patient it has helped is former Secretary of State Henry Kissinger, age 92. Right now TAVR is only recommended for older and sicker patients because there are only 5 years of data on how long the new valves will last. But if you're 80 and need an aortic valve replacement just to get through the next year, do you really care whether the valve lasts 20-30 years?
Some surgeons think that TAVR will eventually replace open-heart surgery as the method of choice for younger patients as well. That will depend on how long valves replaced by the TAVR procedure last. It matters to someone who is closer to age 50 than 80.
Now those older patients have a viable option. Federal regulators recently approved a new technique called TAVR (transcatheter aortic valve replacement) for replacing aortic heart valves in patients who are deemed at high risk from open-heart surgery. In TAVR, surgeons attach a folded-up artificial valve to a catheter, insert it into a main artery and thread it up to the heart, and then open it like an umbrella. The catheter lodges in place, pushing the old damaged valve out of the way. The procedure can be done in minutes with the patient awake and only lightly sedated. Recovery time is minimal.
The TAVR technique is likely to be a lifesaver for the estimated 100,000 patients who are too old or sick for open-heart surgery. One patient it has helped is former Secretary of State Henry Kissinger, age 92. Right now TAVR is only recommended for older and sicker patients because there are only 5 years of data on how long the new valves will last. But if you're 80 and need an aortic valve replacement just to get through the next year, do you really care whether the valve lasts 20-30 years?
Some surgeons think that TAVR will eventually replace open-heart surgery as the method of choice for younger patients as well. That will depend on how long valves replaced by the TAVR procedure last. It matters to someone who is closer to age 50 than 80.
Friday, May 22, 2015
Grip Strength and Cardiovascular Disease Risk
An interesting new study published in The Lancet adds additional evidence to the hypothesis that reduced muscular strength is associated with an increased risk of cardiovascular disease. The study determined the grip strength of nearly 140,000 men between the ages of 35 and 70 years, in 17 countries. Then they followed them for a median of four years, during which time 3,379 of the men (2%) died.
After controlling for other variables such as age, there was a positive association between grip strength and death from cardiovascular disease, including both myocardial infarction (heart attack) and stroke. Specifically, every 11-lb reduction in grip strength was associated with a 17% increase in death from cardiovascular disease. Grip strength was even a stronger predictor of death from cardiovascular disease than was systolic blood pressure. There was no association between grip strength and the risks of diabetes, hospital admissions for respiratory disease, or accidents.
The authors suggest that grip strength may be a simple, inexpensive, and quick way to categorize (in very general terms) a person's risk of death from cardiovascular disease. But don't read too much into this. An association between grip strength and risk of cardiovascular disease does not mean that reduced grip strength is the cause of the increased cardiovascular risk. It's just a useful predictive tool, nothing more.
After controlling for other variables such as age, there was a positive association between grip strength and death from cardiovascular disease, including both myocardial infarction (heart attack) and stroke. Specifically, every 11-lb reduction in grip strength was associated with a 17% increase in death from cardiovascular disease. Grip strength was even a stronger predictor of death from cardiovascular disease than was systolic blood pressure. There was no association between grip strength and the risks of diabetes, hospital admissions for respiratory disease, or accidents.
The authors suggest that grip strength may be a simple, inexpensive, and quick way to categorize (in very general terms) a person's risk of death from cardiovascular disease. But don't read too much into this. An association between grip strength and risk of cardiovascular disease does not mean that reduced grip strength is the cause of the increased cardiovascular risk. It's just a useful predictive tool, nothing more.
Tuesday, March 17, 2015
Bacon and Eggs are Back!
Since the 1960s we've known that high blood cholesterol is a risk factor for atherosclerosis, a disease in which coronary arteries become narrowed by sticky deposits of cholesterol. And so, in an effort to try to keep blood cholesterol within healthy limits, since 1961 the government's dietary guidelines have advised us to avoid high-cholesterol foods such as (bacon and eggs).
That's about to change. In February an influential federal panel of experts that advises the secretaries of Agriculture and Health and Human Services announced that even though high cholesterol is indeed a risk for coronary artery disease, cholesterol derived from dietary sources is not really a significant health risk after all. The panel recommends that cholesterol no longer be called a "nutrient of concern" in the newest version of Dietary Guidelines for Americans, due out later this year.
How did such a complete switch come about? It turns out that the more nutritionists learned about cholesterol, the more they realized that cholesterol is actually an essential nutrient. It is a component of cell membranes, for example. Furthermore, approximately 80% of the cholesterol in your body is synthesized within the body, primarily by the liver. Because only about 20% comes from dietary intake, restricting dietary cholesterol intake is just not a very effective way to lower blood cholesterol levels.
Another significant change in the last fifty years has been the development of effective cholesterol-lowering drug such as Lipitor. Taking a cholesterol-lowering drug is a far more effective way to lower cholesterol than any change in diet.
Finally, experience has shown that when people are asked reduce their intake of one energy-rich food (saturated fats and cholesterol-rich foods, for example), they naturally tend to substitute something else, and oftentimes that something else is sugar. After all, the only three basic choices are fats, sugars, and proteins! And too much sugar isn't good for us, either.
And so once again we can include bacon and eggs in our diet, guilt-free. All things in moderation, of course.
That's about to change. In February an influential federal panel of experts that advises the secretaries of Agriculture and Health and Human Services announced that even though high cholesterol is indeed a risk for coronary artery disease, cholesterol derived from dietary sources is not really a significant health risk after all. The panel recommends that cholesterol no longer be called a "nutrient of concern" in the newest version of Dietary Guidelines for Americans, due out later this year.
How did such a complete switch come about? It turns out that the more nutritionists learned about cholesterol, the more they realized that cholesterol is actually an essential nutrient. It is a component of cell membranes, for example. Furthermore, approximately 80% of the cholesterol in your body is synthesized within the body, primarily by the liver. Because only about 20% comes from dietary intake, restricting dietary cholesterol intake is just not a very effective way to lower blood cholesterol levels.
Another significant change in the last fifty years has been the development of effective cholesterol-lowering drug such as Lipitor. Taking a cholesterol-lowering drug is a far more effective way to lower cholesterol than any change in diet.
Finally, experience has shown that when people are asked reduce their intake of one energy-rich food (saturated fats and cholesterol-rich foods, for example), they naturally tend to substitute something else, and oftentimes that something else is sugar. After all, the only three basic choices are fats, sugars, and proteins! And too much sugar isn't good for us, either.
And so once again we can include bacon and eggs in our diet, guilt-free. All things in moderation, of course.
Monday, April 7, 2014
Omega-3 Fatty Acids Don’t Protect Against Heart Disease?
Do an Internet search on “omega-3 fatty acids” and you’ll find that omega-3s, as they are called, are a type of polyunsaturated fat. They’re a minor component of cell membranes and they have effects in blood clotting. And since your body doesn’t make them, some omega-3s in your diet are considered essential to good health. Eating fatty fish (such as sardines or salmon), nuts, or certain plant oils (canola or soybean oil) occasionally should be sufficient.
Dig a little deeper and you’ll undoubtedly read that omega-3s protect against heart disease and stroke. That claim has spawned a huge omega-3 supplements industry, which encourages you to take an omega-3 supplement pill every day to ward off heart disease. This claim is often backed by at least one research study to support the claim. But is it true?
A recent meta-analysis* of the role of various fats in cardiovascular disease questions the cardiovascular protective effect of omega-3s. To understand why this particular analysis is so important, you need to know what a “meta-analysis” is. Basically, a meta-analysis is a study of many previous studies. In a meta-analysis, each previous study is a single data point. That makes meta-analysis an exceedingly powerful tool to tease out small effects, when one paper may say one thing and another says something quite different.
This particular meta-analysis examined 72 previous research studies, involving over 500,000 people overall. Some of the studies were observational, meaning that they examined the relationship between measured specific fatty acid biomarkers and heart disease risk. Others studies were randomized, controlled experiments of fatty acid supplementation. Overall, there was not a statistically lower risk of cardiovascular disease among participants in the high omega-3 groups, in either kind of study.
Bottom line: You probably get enough of the minimum amounts of omega-3s required for good health in your normal diet. I, for one, won’t be taking an omega-3 pill every day just to avoid heart disease. (For those of you will still choose to take omega-3s “just to be sure”, rest easy; there was no evidence presented in this meta-study that they harm you, either.)
* The complete manuscript is only available by subscription.
Dig a little deeper and you’ll undoubtedly read that omega-3s protect against heart disease and stroke. That claim has spawned a huge omega-3 supplements industry, which encourages you to take an omega-3 supplement pill every day to ward off heart disease. This claim is often backed by at least one research study to support the claim. But is it true?
A recent meta-analysis* of the role of various fats in cardiovascular disease questions the cardiovascular protective effect of omega-3s. To understand why this particular analysis is so important, you need to know what a “meta-analysis” is. Basically, a meta-analysis is a study of many previous studies. In a meta-analysis, each previous study is a single data point. That makes meta-analysis an exceedingly powerful tool to tease out small effects, when one paper may say one thing and another says something quite different.
This particular meta-analysis examined 72 previous research studies, involving over 500,000 people overall. Some of the studies were observational, meaning that they examined the relationship between measured specific fatty acid biomarkers and heart disease risk. Others studies were randomized, controlled experiments of fatty acid supplementation. Overall, there was not a statistically lower risk of cardiovascular disease among participants in the high omega-3 groups, in either kind of study.
Bottom line: You probably get enough of the minimum amounts of omega-3s required for good health in your normal diet. I, for one, won’t be taking an omega-3 pill every day just to avoid heart disease. (For those of you will still choose to take omega-3s “just to be sure”, rest easy; there was no evidence presented in this meta-study that they harm you, either.)
* The complete manuscript is only available by subscription.
Wednesday, January 1, 2014
New Recommendations for Treating High Blood Pressure
A panel of experts appointed by the Heart, Lung and Blood Institute has issued new evidence-based guidelines for the treatment of hypertension (high blood pressure). Consistent with the previous guidelines published in 2003, the goal of treatment for most people should be to achieve blood pressures of 140/90 mmHg or less. The only significant change is that for people over 60 years of age, treatment need only achieve a blood pressure of 150/90, rather than 140/90. The new guideline reflects the fact that there is no clear evidence that lowering systolic blood pressure in older persons to 140 achieves any additional benefit over lowering it to just 150.
The new guidelines make a lot of sense. With age, arteries get stiffer and less elastic. Systolic pressure (the peak pressure in the arteries as a result of the ejection of blood from the heart after a heartbeat) would be expected to be higher in stiff arteries than it would be in more elastic arteries. So a slight increase in systolic pressure is just a normal consequence of the aging process.
The new guidelines are just that; guidelines, based on the best available evidence. The panel fully expects that the recommendations will be discussed and debated by physicians. It will be interesting to see whether the American Heart Association eventually adopts the new guidelines; currently it still recommends that blood pressures be lowered to 140/90 in all hypertensive patients.
The new guidelines make a lot of sense. With age, arteries get stiffer and less elastic. Systolic pressure (the peak pressure in the arteries as a result of the ejection of blood from the heart after a heartbeat) would be expected to be higher in stiff arteries than it would be in more elastic arteries. So a slight increase in systolic pressure is just a normal consequence of the aging process.
The new guidelines are just that; guidelines, based on the best available evidence. The panel fully expects that the recommendations will be discussed and debated by physicians. It will be interesting to see whether the American Heart Association eventually adopts the new guidelines; currently it still recommends that blood pressures be lowered to 140/90 in all hypertensive patients.
Monday, September 9, 2013
Sloppy Science Reporting
It concerns me when reporters get sloppy when reporting science news, or try to make the news personal in order to attract readers (do they teach that in journalism school?). Consider the article on The Weather Channel’s website entitled “Which state is the worst for your heart?” The obvious implication is that some states are better than others for my heart. I clicked on the article just in case there really were some states I should avoid (no, not really!) I’m sorry to say I came away disappointed, and here’s why.
The article ranks the 50 states from best or worst in terms of deaths from heart disease, based on statistics from the U.S. Centers for Disease Control (the CDC). The data are legitimate, but the the title of the article is misleading. The number of deaths from heart disease in a particular state does not necessarily mean that I would have that same risk if I were to live there. For the most part, my risk factors are my own, regardless of which state I reside in or am traveling through at the moment. Statewide differences in deaths from heart disease are a complex mix of factors, including genetics of the state’s population, differences in local diets, job stresses, environmental pollutants, and other as yet unknown factors, spread out over an entire lifetime. The differences between states are interesting in that they may help us identify these risk factors, but they have almost nothing to do with me personally.
The article also makes no distinction between the past and the future. Take for example, the following statement about the best state, Minnesota; “In this state, 36.3 residents out of every 100,000 will die of a preventable heart condition this year, according to the most recent CDC data available.” Wrong! First, a fraction of a person cannot die (Thirty six point three people will die?). And second, the CDC is not in the habit of trying to predict future deaths; it simply reports deaths that have already happened. A correct statement about Minnesota would have read, “In this state, between 2001 and 2010 an average of 36.3 residents out of every 100,000 died of a preventable heart condition each year, according to the most recent CDC data available.” See the difference?
These may seem like minor errors, but if we’re going to report on science, why not try to get it right? I, for one, will not worry if I ever move to Mississippi (the state with the most deaths from preventable heart disease, at 95 residents per 100,000). My risk factors, whatever they are, are already pretty well set.
For more on this subject, go to a previous blog post titled "Journalistic Bias in Science Reporting."
The article ranks the 50 states from best or worst in terms of deaths from heart disease, based on statistics from the U.S. Centers for Disease Control (the CDC). The data are legitimate, but the the title of the article is misleading. The number of deaths from heart disease in a particular state does not necessarily mean that I would have that same risk if I were to live there. For the most part, my risk factors are my own, regardless of which state I reside in or am traveling through at the moment. Statewide differences in deaths from heart disease are a complex mix of factors, including genetics of the state’s population, differences in local diets, job stresses, environmental pollutants, and other as yet unknown factors, spread out over an entire lifetime. The differences between states are interesting in that they may help us identify these risk factors, but they have almost nothing to do with me personally.
The article also makes no distinction between the past and the future. Take for example, the following statement about the best state, Minnesota; “In this state, 36.3 residents out of every 100,000 will die of a preventable heart condition this year, according to the most recent CDC data available.” Wrong! First, a fraction of a person cannot die (Thirty six point three people will die?). And second, the CDC is not in the habit of trying to predict future deaths; it simply reports deaths that have already happened. A correct statement about Minnesota would have read, “In this state, between 2001 and 2010 an average of 36.3 residents out of every 100,000 died of a preventable heart condition each year, according to the most recent CDC data available.” See the difference?
These may seem like minor errors, but if we’re going to report on science, why not try to get it right? I, for one, will not worry if I ever move to Mississippi (the state with the most deaths from preventable heart disease, at 95 residents per 100,000). My risk factors, whatever they are, are already pretty well set.
For more on this subject, go to a previous blog post titled "Journalistic Bias in Science Reporting."
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