Sleep and Cardiovascular Health

Several recent publications and presentations of data on the relationship between sleep patterns and vascular disease occurred at the recent meeting of the European Society of Cardiology. The PESA (Progression of Early Subclinical Atherosclerosis) study performed by Dr Fernando Dominguez, MD, of the Spanish National Center for Cardiovascular Research in Madrid talked about the dangers of too little or too much sleep.

The principal researcher, Valentin Fuster, MD PhD, looked at 3,974 middle-aged bank employees known to be free of heart disease and stroke. They wore a monitor to measure sleep and activity. Interestingly, while only about 11% reported sleeping six or fewer hours per night, the monitor showed the true figure was closer to 27%. They found those who slept less than six hours per night had more plaque in their arteries than those people who slept six to eight hours. They additionally looked at people who slept an average of greater than eight hours.

Sleeping longer had little effect on men’s progression of atherosclerosis but had a marked effect of increasing atherosclerosis in women. Researchers then adjusted the data for family history, smoking, hypertension, hyperlipidemia, diabetes and other known cardiovascular risk factors. They found that there was an 11% increase in the risk of diagnosis of fatal or non-fatal cardiovascular disease in people who slept less than six hours per night compared to people who slept 6-8 hours per night. For people who slept an average of greater than eight hours per night they bore a 32% increased risk as compared to persons who slept 6-8 hours on average. Their conclusion was distilled down into this belief: “Sleep well, not too long, nor too short and be active.”

In a related study, Moa Bengtsson, an MD PhD student at the University of Gothenburg in Sweden presented data on 798 men who were 50 years old in 1993 when they were given a physical exam and a lifestyle questionnaire including sleep habits. Twenty one years later 759 of those men were still alive and they were examined and questioned. Those reporting sleeping five hours or less per night were 93% more likely to have suffered an MI by age 71 or had a stroke, cardiac surgery, and admission to a hospital for heart failure or died than those who averaged 7-8 hours per night.

While neither study proved a direct cause and effect between length of sleep and development of vascular disease, there was enough evidence to begin to believe that altering sleep habits may be a way to reduce future cardiovascular disease.

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Inflammation and Increased Risk of Cardiovascular Disease

For years, experts have noted that up to 50% of men who have a heart attack do not have diabetes, high blood pressure, high cholesterol, do not smoke and are active. This has led to an exploration of other causes and risk factors of cardiac and cerebrovascular disease.

In recent years, studies have shown an increased risk of cardiovascular disease in patients with rheumatoid arthritis, in untreated psoriatic arthritis and in severe psoriasis. We can also add atopic eczema to the list of cardiovascular risk factors.

In a publication in the British Medical Journal, investigators noted that patients with severe atopic eczema had a 20% increase risk in stroke, 40 – 50% increase risk of a heart attack, unstable angina, atrial fibrillation and cardiovascular death. There was a 70% increased risk of heart failure. The longer the skin condition remained active the higher their risks.

The study looked at almost 380,000 patients over at least a 5 year period and their outcomes were compared to almost 1.5 million controls without the skin conditions. Data came from a review of medical records and insurance information in the United Kingdom.

It’s clear that severe inflammatory conditions including skin conditions put patients at increased risk. It remains to be seen whether aggressive treatment of the skin conditions with immune modulators and medications to reduce inflammation will reduce the risks?

It will be additionally interesting to see what modalities cardiologists on each side of the Atlantic suggest we should employ for detection and with what frequency? Will it be exercise stress testing or checking coronary artery calcification or even CT coronary artery angiograms? Statins have been used to reduce inflammation by some cardiologists even in patients with reasonable lipid levels? Should we be prescribing statins in men and women with these inflammatory skin and joint conditions but normal lipid patterns?

The correlation of inflammatory situations with increased risk of vascular disease currently raises more questions with few answers at the present time.

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.

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.