More Good News for Coffee Drinkers

When I first started practicing, fresh out of my internal medicine residency and board certification, we were taught that consuming more than five cups of coffee per day increased your chances of developing pancreatic cancer. Thankfully that theory has been proven to be false.

Last week I reviewed a publication in a peer reviewed journal which showed that if you infused the equivalent of four cups of coffee into the energy producing heart cell mitochondria of older rodents, those mitochondria behaved like the mitochondria found in very young healthy rats. The authors of that article made the great leap of faith by suggesting that four cups of caffeinated coffee per day was heart healthy.

This week’s Journal of the American Medical Association Internal Medicine published a study which said if you drank eight cups of coffee per day your mortality from all causes diminished inversely. Their study included individuals who were found to be fast and slow metabolizers of caffeine. It additionally made no distinction between ground coffee, instant coffee or decaffeinated coffee.

The research study investigated 498,134 adults who participated in the UK Biobank study. The mean age of the group was 57 years with 54% women and 78% coffee drinkers. The study participants filled out questionnaires detailing how much coffee they drank and what kind. During a 10 year follow-up there were 14,225 deaths with 58% due to cancer and 20% due to cardiovascular disease. As coffee consumption increased, the risk of death from all causes decreased. While instant coffee and decaffeinated coffee showed this trend, ground coffee showed the strongest trend of lowering the mortality risk.

This is an observational study and, by design, observational studies do not prove cause and effect. It is comforting to know however that having an extra cup or two seems to be protective rather than harmful. At some point a blinded study with true controls will need to be done to prove their point. If the caffeine doesn’t keep you up or make you too jittery, and the coffee itself dehydrate you or give you frequent stools, then drink away if you enjoy coffee in large volume.

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Coffee and the Healthy Heart

Two German biologists are stating there is sufficient data to claim that four cups of caffeinated coffee is the optimal daily dosage to maintain a healthy heart. Their findings were published in Plos Biology and summarized in Inverse Magazine. The scientists cite past warnings by public health officials of the danger of caffeine when given to people with heart conditions. Quite the contrary. They believe that up to four cups of coffee per day are actually therapeutic for the heart.

In their research they noted caffeine helps a protein called “p27” enter the energy producing mitochondria of heart cells making them function more efficiently. They experimented with rats comparing the mitochondrial function of old rats and young rats. When they injected the older rats with the caffeine equivalent of four cups of coffee, their aging mitochondria performed at the level of young rats’ mitochondria. They then experimentally caused the older rats to have a heart attack or myocardial infarction. Half of these heart damaged rats were injected with the equivalent of four cups of coffee and their heart cells repaired themselves at a far more rapid rate than those not exposed to that dose of coffee and caffeine.

The researchers conclude that four cups of coffee is probably the optimal daily dosage of coffee for a healthy heart. They caution that certain patients, especially those with malignant tumors, should probably avoid that much coffee because it may promote growth of blood vessels to the tumors. They additionally caution against using caffeine pills or energy drinks because their research was done with coffee.

Coffee in moderation is probably not harmful for any human adult.

Keep in mind, this biologic evidence was obtained in rats not human beings. Fortunately, I have not seen rats breaking into my local Dunkin Donuts and Starbucks craving a lifesaving nutrient.

Coffee has been associated with preventing cognitive dysfunction, preventing diabetes and now keeping your heart healthy. If you enjoy coffee, drinking it in moderation makes sense to me.

Fish, Fish Oils and Cardiovascular Disease

Years ago the scientific researcher responsible for the promotion of fish oils as an antioxidant and protector against vascular disease recommended we all eat two fleshy fish meals of cold water fish a week. He continued to endorse this dietary addition and included canned tuna fish and canned salmon in the types of fish that produced this positive effect.

Over the years I heard him lecture at a large annual medical conference held in Broward County and he fretted about the growth of the supplement industry encouraging taking fish oils rather than eating fish. He worried about the warnings against eating all fish to women of child bearing age because of the fear of heavy metal contamination and knew that the fish oils and omega 3 Fatty Acids played a developmental role in a growing fetus and child.

I then attended lectures, in particular one sponsored by the Cleveland Clinic, during which they promoted Krill oil as the chosen form of fish oil supplements because it remained liquid and viscous at body temperature of 98.6 while others solidified. I listened to this debate only to hear the father of the science speak again and this time advocate that one or two fleshy fish meals a month was adequate to obtain the protective effect of Omega 3 Fatty acids. He felt that the supplements did not actually provide a protective effect as eating real fish did. Since I love to eat fresh fish I had no problem with this message but others are not comfortable buying and preparing fish at home or eating it at a restaurant. Supplements to them were the answer.

Steve Kopecky, M.D. examined the question in an article published in JAMA Cardiology this week. He looked at 77,917 high risk individuals already diagnosed with coronary artery disease and vascular disease who were taking supplements to prevent a second event. His study concluded that taking these omega 3 supplements had no effect on the prevention of recurrent cardiovascular events. The study did not discuss primary prevention for those who have not yet had a vascular illness or event.

Once again it seems that eating fish in moderation, like most anything, is the best choice. I will continue to eat my fresh fish meals one or two times per week, not necessarily for the health benefit but because I enjoy eating fresh fish.

I advise those worried about preventing primary or secondary heart and vascular disease to find a form of fish they can enjoy if they want this benefit. If you really wish to reduce your risk of a cardiovascular event; I suggest you stop smoking, control your blood pressure and lipid profile, stay active and eat those fresh fish meals.

Emergencies and the Rational For Our Treatment Algorithm

We are a primary care medical office that tries to deliver personalized attentive care. We define emergencies as chest pain, significant breathing difficulty and loss of consciousness, uncontrolled bleeding or pain, sudden change in mental status and behavior or major trauma. In these situations, my office staff receiving a phone call interrupts me so I can speak with you and determine whether or not to advise you to call 911. We do this because we know with life threatening situations time is of the essence.

Emergency Medical Services at 911 can arrive within 5 minutes. They are all Advanced Cardiac Life Support (ACLS) trained and carry the equipment and medications to provide life sustaining care while you are transported to a hospital Emergency Department that has the staff, medications and equipment to keep you alive while we diagnose the problem and create a plan to rectify it.

The office staff is trained in Basic Cardiac Life Support. We do not have a defibrillator. We do not maintain and store medications to correct low blood pressure – cardiac arrhythmias. We do not have endotracheal tubes to intubate you and breathe for you. In the past, when we tried to maintain these supplies, they became outdated due to infrequent use and were expensive to replace. Since we do very few resuscitations day to day we are not as experienced or efficient as EMS and emergency department personnel are.

I realize the wait for care and institutional care settings are not pleasant. We sacrifice that for the best chance to keep you healthy. Trust me, it is no fun cancelling a scheduled patients to run to the ER and then return already behind. We do it for your comfort and security and safety.

In the recent past patients with chest pain resembling heart disease, trouble breathing and excessive bleeding have refused to call 911 and were upset when we did not bring them into the office. We do this for your health and safety not our convenience. If you would like to discuss this feel free to contact the office.

Inflammation as a Cause of Heart Attacks and Strokes

Years ago I attended a series of lectures sponsored by the Cleveland Clinic to promote its proprietary lab tests that were geared to detect previously undetectable causes of heart attacks and strokes. A cardiologist at Cleveland Clinic, along with a research nurse out of Emory University Hospital and Medical Center, noted that 50% of the men having heart attacks and strokes were within the recommended life and health guidelines. They didn’t smoke, their blood pressures were controlled, they had lipids within the recommended guidelines and their weight was appropriate – as was their activity level.

They unofficially dubbed it the Supermen study and showed that by reducing “inflammation” they could reduce the number of heart attacks and strokes. They concentrated on periodontal disease and rheumatologic diseases as sources of inflammation. They believed that angina and heart attacks and strokes did not occur because a blood vessel gradually narrowed much like a plumbing pipe clogged with hair and debris. They felt that soft lipid plaque under the surface in vehicles dubbed “foam cells” ruptured through the blood vessel wall into the lumen through the endothelial lining under the direction of inflammation in the body.

This breakthrough into the blood carrying portion of the blood vessel was perceived as a fresh cut or wound which was bleeding. The body’s natural response was to try and stop the bleeding by creating a clot. This clot occurred quickly in a small vessel and every living item downstream, not supplied by a collateral blood vessel, died from lack of oxygen and fuel to function. They treated the identifiable inflammation and felt that statin medications (Lipitor, Zocor, Pravachol, Crestor , Livalo and the generics) had an of- label quality that reduced inflammation as well as lowered the cholesterol.

I bought into that theory and incorporated these blood tests into the patient population most at risk and the appropriate age where prevention would make a major difference. Tests like hsCRP, Myeloperoxidase, Apo-B and others were used for screening. Finding the inflammation and treating it for men who met the definition for entry into the Supermen study was far more difficult. The whole theory of inflammation causing acute cardiac and cerebrovascular events was treated much like climate change, genetically modified foods and even vaccinations with a large degree of community doubt.

Last week at a major European Cardiology meeting the CANTOS (Canakinumab Anti-inflammatory Thrombosis Outcomes Study) showed that by administering an anti- inflammatory medicine for three plus years at an appropriate dosage, we could reduce the number of heart attacks and strokes significantly. Using a monoclonal antibody, “Canakinumab” at 150 mg every third month they treated inflammation and reduced the number of events. The downside was the annual cost of this medicine currently stands at about $200,000 per year making it unavailable for most of us.

The surprising and startling finding was that it reduced lung cancers by 70% and other malignancies as well. The true finding in this study may be its use as a cancer weapon in the future. The study truly opened the door for research into new and less expensive approaches to treating inflammation. It validated inflammation as a pathway to vascular disease. Now we need to find a way to make that treatment affordable to all.

Red Meat May Not Increase The Risk For Vascular Disease But Is It Healthy?

A study published in the online version of Consultant 360 magazine looked at the relationship between eating red meat and cardiovascular risk factors. The study was performed at the Department of Nutrition Science at Purdue University. Researchers reviewed 24 studies on the topic listed on PubMed, Cocrane Library and Scopus databases. These studies examined individuals 19 years old or older who consumed at least 35 grams of red meat per day and whom listed at least 1 cardiovascular risk factor. They then examined the study participants blood total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides plus systolic and diastolic blood pressures.

They found that red meat at these quantities did not increase lipids, lipoproteins or blood pressure. This led them to conclude that the risk for cardiovascular disease did not increase in individuals consuming more than the recommended daily amount of red meat.

While this study gives hope to meat lovers, cardiovascular disease is not the only cause of illness or death. High consumption of red meat has been implicated in a greater risk of developing colon cancer, breast cancer, diabetes and an overall increased risk of death from all other causes. Some individuals seem to believe that you can counteract this negative effect of red meat by eating large quantities of fresh fruits and vegetables. Unfortunately a Swedish study published this year in the American Journal of Clinical Nutrition disproved this theory. For men, the more red meat they ate the more likely they were to develop diabetes. For both women and men, those who ate the most red meat had a 21% greater risk of all – cause mortality than those who ate the least. This higher risk did not change when the authors took into account fruit and vegetable intake. Interestingly it was processed meat that caused the rise in health risk with unprocessed meats only being associated with a slightly increased death risk even at high consumption levels.

I believe the take home advice is that consumption of unprocessed red meat in moderation with plenty of fresh fruits and vegetables doesn’t impair your risk of dying. Processed meats are to be avoided if you wish to avoid multiple illnesses and disease. Give up the bologna and salami and other processed meat products except on limited occasions.

FDA Approves Coronary Artery Disease Screening Test

FDA - Steven Reznick, MDMedPage Today, the online medical journal of the University of Pennsylvania School of Medicine, announced that the FDA has ” cleared a blood test ” to screen for heart disease known as Lp-PLA2 or lipoprotein associated phospholipase A2. This test is an individual marker of vascular inflammation produced within atherosclerotic plaques. Its use was cleared for screening in all adults with no history of coronary artery disease.

In a National Institute of Health study, known as Reasons for Geographic and Racial Differences in Stroke, it was shown in a review of 4,598 people, aged 45 – 92, that individuals above the threshold level for Lp-PLA2 were more than twice as likely as others to have an event, heart attack or stroke, 7% versus 3.3 %. The study was particularly helpful when looking at black women as a group. An Lp-PLA2 level > 225nmol/min/mL is considered elevated.

This test has been available to patients in our practice through the Cleveland Heart Labs screening panel. It plus the myeloperoxidase level, CRP and other markers have been felt by the Cleveland Clinic cardiology division to have predictive value. These tests are currently available but in many cases require private pay because Medicare and private insurers do not yet cover them all.