Deep Breathing to Lower Blood Pressure

A new breathing device called Resperate is being marketed to slow your breathing rate, stimulate your parasympathetic nervous system and ultimately lower your blood pressure. The device sells for $330 and has been discussed in numerous health letters the last few weeks including the Harvard Health Newsletter.

The sympathetic nervous system controls involuntary functions such as breathing, digestion, heart rate. The parasympathetic division of it can slow your heart rate, dilate blood vessels and ultimately lower your blood pressure. The Resperate device uses sensors on your chest connected to a belt device to create a slow melody for you to listen to and breathe to. You synchronize your breathing to the melody slowing your breathing with prolonged exhalations. The slow breathing stimulates your parasympathetic nervous system slowing your heart rate, dilating blood vessels and lowering your blood pressure.

The device is used four times per week for 10-15 minutes sessions and should lower your diastolic and systolic blood pressure over a few weeks. How much and for how long does the effect work is currently unknown.

Medicare does not yet cover the cost of the device but some private insurers do.  After reading about slow breathing lowering blood pressure I looked for information on breathing techniques to lower your blood pressure without requiring a breathing machine. A website viitalheartandbrain.com offered several options:

Thirty Second Method: Sit in a quiet place and relax. Set a timer for thirty seconds and begin. Take six slow deep breaths through your nose and exhale slowly through your mouth during the 30 second period. Repeat the process as often as you can. This method studied with 20,000 Japanese adults lowered BP.

Equal Breath Length Method: Begin by sitting or lying down in a quiet area and close your eyes. Inhale through your nose counting to 4. Pause and feel the air in your lungs. Exhale thorough your mouth to the count of four. Feel the emptiness of your lungs. Repeat as often as you can

4-7-8 Breathing Technique: Sit in a quiet place. Place the tip of your tongue behind your teeth. Inhale through your nose slowly counting to four. Hold this breath for a count of seven. Exhale through your mouth to a count of eight making a gentle whooshing sound. Repeat four times per session

Diaphragmatic Breathing: Lie flat on your back. Place a pillow under your neck and bend your knees up. Place one hand on your chest and one under your rib cage (diaphragm). Inhale slowly through your nose and watch the hand placed under your rib cage rise while the hand on your chest remains still. Exhale through your pursed lips while watching the hand under your rib cage descend and the hand on your chest remaining still. Repeat the process several times.

Give these relaxation techniques and slow breathing techniques an opportunity to relieve your stress and lower your BP and heart rate. In a previous post I discussed tea both green and regular tea lowering blood pressure. Try a cup after the breathing exercises for further relaxation. If tea isn’t your drink, then consider unsalted tomato juice, beet juice, prune juice, pomegranate juice or skim milk. These drinks all had a similar blood pressure lowering effect.

The COVID-19 Pandemic Continues Due to Citizen Dysfunction

Last night on the national news coverage of the Sars 2 Coronavirus Pandemic a major story dealt with the large number of children infected with the Delta variant of the virus and the severity of their illness. These children are too young to receive the vaccine.

At best, Pfizer and Moderna hope to have approval to start vaccinating young children by the end of September. These children are dependent on their parents, teachers and counselors keeping them masked, keeping them distanced and keeping them safe. This story dealt with an outbreak in Missouri and Mississippi with 10 youngsters currently on life support systems.

It is a dilemma for parents, especially working parents, about what activities to allow their children to engage in. With previous COVID-19 surges and outbreaks, experts have discussed how mild the illness is in children and how infrequently long-term and life-threatening complications occur. They stress the need for children this age to socialize and go to school and camp but that was prior to the Delta variant and other mutations and variants becoming the dominant source of infection in the USA. It is hard to tell whether the news coverage is sensationalized to promote viewership or is the Delta variant a threat to young unvaccinated children different and more severe than it was 90 days ago?

It’s time for our federal government to take a hard line with health care workers and health care facilities. All employees without a valid health reason for being vaccinated must be vaccinated or face termination. This would include hospitals, outpatient facilities, senior centers, childcare centers, etc. If the result is the facility is understaffed resulting in delays in elective profitable procedures, then so be it until the pandemic is controlled!

Commercial air traffic from regions of the country and world with low vaccination rates and vaccine hesitancy battling large outbreaks of COVID-19 should be halted until their outbreaks are under control. Vaccine passports should be encouraged – not legislated against. When an individual’s actions and decisions threaten others around them by increasing the likelihood of spread of a disease, and its accompanying economic devastation, then the issue is not about loss of freedom. It is about public health and the governments’ sworn duty to protect its citizens.

It’s time to end this Pandemic and the way to achieve that is through mandatory vaccination.

Aerobic Training Helps Blood Pressure Medications Do Their Job

We are always looking for ways to stay healthy with less medicine.  Miguel Ramirez-Jiminez, PhD of the  University of Castilla-La Mancha, Toledo, Spain presented a paper to the American College of Sports Medicine recently week and addressed this topic.

His group looked at 36 obese and overweight adults who normally did less than 120-minutes of physical activity per week. Ages ranged from 53 – 65 years with 22% postmenopausal women. They had all been taking blood pressure medications for at least eight years and all met the criteria for having the metabolic syndrome which includes hypertension, elevated blood glucose, elevated triglycerides and a large waist.

The group was randomly divided into a placebo group whose medication was stopped or a trial group who continued their antihypertensive medications for the next three days. All participants then underwent 24-hour ambulatory blood pressure monitoring. All the participants were then entered into a four-month cycling program three times a week. 

After completing the four months of cycling training the placebo group again did not receive their medications for three days while the trial group did.  Twenty-four-hour ambulatory blood pressure was then checked in both groups.

The group exercising plus taking their medications saw an average drop in blood pressure of 3-5 mm Hg in addition to the 5mm Hg noted just from the medication’s pre-exercise training. When the exercise program stopped, the extra drop in blood pressure additionally dropped. There is a phenomenon known as “post exercise hypotension” that can reduce your blood pressure for up to 24 hours after training. This is the reason experts advise 3-5 exercise sessions per week.  

The study also revealed that if you exercise aggressively, and hope to permanently stop your blood pressure medications, your pressure usually rises above acceptable levels.  Exercise is not a substitute for prescribed blood pressure medicines. The article can be found at www.medscape.com  

Eggs Are Safe & Delicious

A few years ago, while visiting my pug’s veterinarian to try and find a way to get the dog to eat while undergoing radiation therapy, he suggested, “Why don’t you scramble him some eggs? It’s a great protein source and doesn’t contribute to cardiovascular disease in canines.” I have to admit I was a bit jealous since I was avoiding eggs, using egg whites and Egg Beaters instead. Two recent studies suggest eggs are safe for humans too.,

The American Journal of Medicine, in the January 2021 edition, published a research paper by C. Krittanwong, MD and associates which looked at 23 prospective studies covering a median of 12.8 years and 1,415,839 patients. There were 157,324 cardiovascular events during the study period. “Compared with the consumption of no egg or 1 egg per day, higher consumption was not associated with significantly increased risk of cardiovascular disease events. Higher egg consumption (>1 egg per day) was associated with a significantly decreased risk of coronary artery disease compared to no egg or one egg per day.

A study with similar results was published in the March 2020 edition of the British Medical Journal in a study involving 14,806 patients over 32 years. “Moderate egg consumption is not associated with increased cardiovascular risk overall.”

The message is clear, eggs are a fine source of protein in moderation.

Nonsteroidal Anti-inflammatory Drugs Can Injure Your Kidneys

When I awaken and first get out of bed, I feel my seventy-one years of age.  Decades of weight bearing exercise including running, jogging and walking, in addition to basketball and tennis on hard surfaces, has contributed to wear and tear arthritic discomfort.  I think all the time about popping naproxen, ibuprofen or some other medicine for pain but the risk of an adverse event results in me sucking it up and working through it. 

These wonderful pain medications work by inhibiting prostaglandins involved in the inflammatory response. One of those prostaglandins also keeps the coronary arteries open. The NSAIDS can inhibit the mucous covering of the stomach leading to stomach inflammation and bleeding. 

As a physician caring for senior adults these incredible pain killers can injure the kidneys. By the time we reach 70 years of age most of us have naturally lost 70% of our functioning kidney cells. We do very well with the remaining 25% if we do not stress the kidney asking it to call on reserves it no longer possesses.

A study on the kidney effects of these drugs was published in the Clinical Journal of the American Society of Nephrology in April 2021 by physicians working in Hong Kong. They performed a retrospective analysis of kidney function in almost 2 million Chinese individuals in Hong Kong – all over 18 and with normal kidney function. The study looked at those individuals with a prescription for a NSAID for a minimum of 28 days and found a marked decrease in their Glomerular Filtration Rate (GFR) and a 94% increased risk of a decline of GFR of 30% or greater.

The study looked at ibuprofen, celecoxib, diclofenac, indomethacin, naproxen, piroxicam, sulindac and mefenamic acid. The average patient was 55 years old and 53% were women.  Their results showed that ibuprofen was the least likely to lower GFR indicating kidney injury but even it conferred a risk of 12% on GFR declining to less than 60%.

The findings of this study reinforce what we already know. A steady diet of NSAIDs will injure your kidneys.  An occasional dosage is probably still safe if you take it with food in your stomach and remain well hydrated.

We live in a society where physical exercise and activity are encouraged for health.  Long-term activity will lead to morning stiffness and aches and pains. Traditional opioid pain medications are addictive and clearly not the answer. NSAIDs were hoped to be safer but apparently not so on a long-term steady basis.

Sugary Drinks & Increased Colon Cancer

The Nurses Health Study II followed 95,464 nurses’ health from 1991- 2015. Principal researcher Yin Cao, ScD, MPH, of Washington University in St. Louis and co-researchers found that those women consuming two sugar sweetened beverages a day in adulthood had more than double the early onset colorectal cancer risk as those consuming less than one serving a week. The risk rose by 16% with each additional serving per day.

In adolescents aged 13-18, each serving per day increment was accompanied by a 32 % higher risk of early onset colorectal cancer. As adolescents reach adulthood, replacing these sugar sweetened beverages with artificially sweetened beverages, coffee or milk was associated with a 17-36% lower risk.

The diagnosis of colorectal cancer in those born around 1990, and risk of developing it, is twice as much risk of developing colon cancer and four times the risk of developing rectal cancer as in adults born around 1950. Cao and associates offered several theoretical reasons for the findings including the use of fructose corn syrup as a sweetener instead of real sugar. Fructose corn syrup is known to make changes to the intestinal wall making it more susceptible to carcinogens. And, it has been shown to cause intestinal tumors in mice.

The message is clear. Obstetricians, family practitioners, pediatricians and internists need to start asking about sugar sweetened beverages in our patient histories. Screening for colon and rectal cancer at a younger age with fecal globulin tests, Cologuard fecal genetic testing and fiber optic exams in a younger group is essential. Most importantly, we must educate teenagers and young adults about the dangers of these sugar sweetened beverages so they don’t give them to their friends and eventually their own children.

New Device Helps Stroke Victims with Hand Function Difficulties

Stroke victims often lose function of a hand. The road back to recovery involves months of physical therapy and work.

Last month the FDA approved the Neurolutions IpsiHand Upper Extremity Rehabilitation System for survivors of stroke trying to regain hand, wrist or arm function.  The system uses EEG electrodes to record your brain activity and then uses these messages to move an electronic hand brace according to the intended muscle movement. It essentially delivers your brain’s intended electrical message to the brace to retrain your limb to work.

This is a sophisticated device which will need to be fitted by stroke rehab professionals and then tailored for individual patient needs so it can be successfully used.

Making Sense of the New CDC Guidelines Here in Florida

There were almost 6,000 new cases of Coronavirus illness in Florida yesterday with the positivity rate of those tested being well above 5%. Fewer and fewer people are showing up for testing or to receive vaccine here in the Sunshine State.

The Center for Disease Control (CDC) has issued new less restrictive activity guidelines last week which suggest outdoor activities in low population densities do not require a mask. This makes great sense and I am in complete agreement. They go further and say small indoor gatherings with vaccinated individuals do not require a mask. This makes great scientific sense as well. What they do not want is thousands of individuals, whose vaccination or immunity status is unknown to be packed into a venue indoors or out without being masked. They additionally don’t recommend large private gatherings indoors of individuals whose immune status is unknown. This makes sense to me as well in Florida where the infectious positivity rate remains greater than 5%.

We know vaccinated individuals have a low probability of catching COVID if exposed. If they are unlucky enough to catch it (about 6,000 breakthrough cases are known in the USA with about 150 million already receiving vaccine) there is an even smaller chance of getting sick enough to require hospitalization or dying. They still are not sure if those infected can transmit it to those unvaccinated or those frail, immunosuppressed and vulnerable.

The Governor of Florida and his Attorney General have sued the CDC, NIH and Federal government demanding that they allow cruise ships to begin sailing again from Florida ports. My daughter and grandchildren depend on cruise industry revenue to pay their mortgage, feed and clothe the family and live. The cruise industry has gone to great expense to vaccinate its crews and restrict passenger access to those who can prove they have been vaccinated or prove they are not COVID Positive. They wanted a “vaccine passport” for passengers.

Florida responds by having its Surgeon General, pediatrician friend and political ally of the Governor with zero public health or infectious disease background declare if you are vaccinated you are not required to wear a mask anywhere anytime. The legislature, composed primarily of members of the Governors party, passes legislation forbidding businesses from barring individuals from their business based on their vaccine status. This comes well after they supported the Governor with legislation forbidding local municipalities from enforcing local ordinances requiring masks.

I want the ships to sail so my son-in-law keeps his job! The last thing we need is for Florida politics to permit a ship to go out to sea and become a center of infection, illness and death because Florida elected officials watered down the sensible guidelines the cruise industry developed to begin sailing again safely.

Florida is a gateway state encouraging visitors from Latin and Central America as well as US tourists. Brazil is embroiled in a COVID surge of infection and death . The poverty in Central America and the islands prevent knowing exactly what their status is. I am more concerned about the disease entering and leaving Florida via visitors and no rules than I am concerned with illegal immigrants bringing it in at the Texas and Arizona borders as the media and certain elements of the U S seem to be.

Vaccines have brought us so close to controlling the Pandemic. Why can’t we mask up and be patient for a few weeks more?

In my office we will continue to follow the CDC guidelines. We will wait to see if the relaxed mask recommendations of the CDC, plus the vaccine program, keep the infection rate down. Florida Surgeon General Scott Rivkes’ no mask for the vaccinated anywhere may be interpreted as no masks anywhere for everyone. It will take three to four weeks for the consequences of these announcements to make an impact. If the number of infected decreases, my physician associate and I will sit down and alter our approach based on the science. Until that time, we will require masks in our office!

I Was Wrong Regarding Athletes Post COVID-19 & Inflammatory Heart Disease

In a January 2021 blog post, I criticized college athletic departments for allowing their athletes who were infected with SARS-CoV-2  to resume training and competing in their sport without taking a cardiac MRI scan first. This was based on an article early in the pandemic from Italy citing the large number of inflammatory heart issues seen in 100 relatively mildly symptomatic COVID patients.  There was unexpected heart inflammation found in over 50% of these older nonathletic individuals.

The Big Ten Intercollegiate Athletic Conference published an article from the University of Wisconsin Department of Athletics a few months later. All their athletes recovering from COVID (182) received a cardiac MRI at the three-week mark and only two students had MRI evidence of myocarditis.  Based on this small study, other institutions decided that a history session, physical exam, electrocardiogram, echocardiogram and laboratory measurement of the athletes’ cardiac muscle troponin levels would be sufficient. Athletes with abnormalities on any of those tests were referred for a cardiac MRI which could cost $1500- $7500 per study.  I was extremely critical of that decision citing the large amount of income these athletes generated for their university and the potential cost in terms of long-term medical care, potential lawsuits and negative publicity from an athlete becoming seriously ill.  

Like most information regarding this pandemic over time, we learn more about the disease and how to diagnose and treat it. The more familiar we become with Sars2 coronavirus the more previous beliefs change.

This week researchers reported in the Journal of the American Medical Association Cardiology that very few elite athletes recovering from COVID-19 develop myocarditis.  They pooled medical data from May 2020 until October 2020 from Major League Baseball, Major League Soccer, the National Hockey League, the National Football League and the Men’s and Women’s National Basketball Association.

789 professional athletes tested positive for SARS-CoV-2 and entered the return to play protocol (RTP). Athletes who tested positive had a cardiac screening 19 days after their positive test without cardiac MRI imaging. From this group, only 30 athletes had abnormal results and were sent for additional screening. Cardiac MRI was performed on 27 of the 30 and inflammatory heart disease was found in 5 of them. This represents 0.6% of the original screened group. Three of the athletes had confirmed myocarditis and two had pericarditis. These athletes were held out of training and competition. The other 25 returned to training and competition.  None of those athletes who returned to competition had a cardiac illness related event as of December 2020.

In my blog I  tried to provide the ultimate safety evaluation and recommendation for athletes. My patients are older – not elite and anxious to resume their grueling workouts with their local personal trainers.  Given the knowledge base at the time I would make the same choice leaning towards safety, but the data proved me wrong. 

As we learn more about this disease previously held beliefs will be disproved. We have learned that hydroxychloroquine does not work in the treatment of the disease even though initial expectations were that it would. We learned that the virus does not last exceptionally long on surfaces but in the beginning a published article about the cleansing process on the cruise ship Yokahama Princess showed the virus survived 17 days on the ship’s surfaces. We learned that convalescent plasma does not save lives in severely ill patients. This is what happens in the field of science. The CDC and Dr Fauci do not flip flop and are not wrong. As information becomes available, they review the data and try and explain it to the rest of us. As the data changes over time, and the picture changes over time, they adjust their recommendations to be consistent with the facts. They tend to err on the side of caution and safety, as will I, as we move through this tragic pandemic.

Safety & Efficacy of Lowering Lipids in the Elderly

I am bombarded regularly by older patients, their adult children and various elements of the media with complaints that elderly are taking too many medicines. Poly pharmacy is the word they use and the first prescription medications they want eliminated are their cholesterol lowering drugs – either a statin (Lipitor, Zocor, Pravachol, Crestor , Livalo or their generic form), Zetia ( Eztimebe) or the newer injectable PCSK9 inhibitors Repatha and Praluent. Is there an age that we should stop these medications? Is there benefit in the elderly to continue taking them? Should we start these medications in the elderly if we discover they have high cholesterol and vascular disease?

A recent study was published in the prestigious Lancet medical journal. The authors looked at 29 trials with 244,090 patients. From this pool there were 21,492 patients who were at least 75 years old. Half of them were on oral statin drugs and the others were on Eztimebe or PCSK9 inhibitors. They were followed from 2 – 6 years.

The results showed that for every reduction of LDL cholesterol of 1mmol/L there was a 26% reduction of in major adverse vascular events. These numbers were similar to those in younger patients. The data also pointed out that these patients had a significant reduction in cardiovascular deaths, myocardial infarction (heart attacks), strokes and the need for heart surgical revascularizations. It was extremely clear that if you are on a cholesterol lowering drug you should stay on that medication despite your age!

A study in JAMA internal medicine, authored by LC Yourman, answered the question of whether you are too old to start on a cholesterol lowering drug. They found that it took 2.5 years before the cholesterol lowering medicine reduced your risk of a major cardiovascular event. Their conclusion was that if you are 70 or older, and your lifespan appears to be greater than 2.5 years, you should start the medicine.