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.

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.

Vitamin D & Cardiovascular Health

The online journal Practice Update reviewed a publication in the Journal of the American College of Cardiology which basically says excessive calcium supplementation may harm your healthy heart. It was published at a pertinent time because it came while I was trying to convince my post-menopausal wife that between her Vitamin D pearls, calcium, Vitamin D pills and her multivitamin she was taking too much Vitamin D. Her measured 25-hydroxy Vitamin D level came back at 63.

Vitamin D is a fat-soluble vitamin like vitamins A and K. Extra doses of fat-soluble vitamins are stored in the body’s cells and can reach harmful and toxic levels. The normal level of Vitamin D measured by a standard blood test is considered to be 20 or greater by the World Health Organization. In North America it was originally higher at 28 then raised to 30. The Covid-19 Pandemic has raised issues about low levels of Vitamin D being a risk for catching the disease, and developing complications, but no one has defined what levels are considered unsafe.

The National Academy of Medicine, after reviewing this data, has set these limits and levels:

  1. Deficiency is less than or equal to 12ng/ml
  2. Inadequacy is 12-20 ng/ml
  3. Adequate is 20-50 ng/ml
  4. Risk of Adverse Effects occurs at > 50ng/ml

The data suggest avoiding supplementation unless the 25-hydroxy Vitamin D level is <20 and probably best reserved for <12 ng/ml.

Calcium is best absorbed when accompanied by Vitamin D .  Taking smaller doses like 500 mg plus 1000 of Vitamin D3 works. For osteoporotic patients they suggest 600mg of Calcium plus 1000 IU of Vitamin D3 daily. They want you to eat a diet that supplies another 600 mg of calcium a day plus walk for weight bearing exercise and get 15 or more minutes of sunlight daily. Of interest was the statement that calcium supplements may harm your heart, but any calcium obtained naturally through foods does not.

The article was reviewed and commented on by David Rakel, MD, FAAFP with the take home message being, “Eat a high-fiber, plant-based diet with some fish and go outside and play.”

Blood pressure measurement, its importance in reducing vascular disease & remote patient monitoring

An article published in the prestigious journal Hypertension looked at following blood pressure over a decade and the reduction in heart attacks, strokes and deaths if you were able to keep blood pressure under control. It talked about extending your life by over four years and the preventing vascular disease from developing for at least five years.

The authors looked at multiple blood pressure trials and noted the difficulty in relying on one office visit measurement periodically. They too noticed that certain patients were always higher in the office than at home and noted the problems with home blood pressure monitors including trying to decide if they were accurate and being recorded correctly. The result was that whatever reading they obtained at your visit, when looked at over a 10-year period, influenced your survival and cardiac events.

We too have struggled with this issue in our office. We ask patients to bring in their home blood pressure equipment so we can correlate the readings they get in our office on our equipment and their equipment. Just last night a patient with no symptoms and feeling well took his blood pressure and found it elevated. Rather than contact me or his cardiologist he ran to the Emergency Room. He waited hours, had multiple tests and by that time his blood pressure lowered they referred him to his doctors without intervening at all.

When needed, we have a patient use a 24-hour ambulatory blood pressure monitor. They wear it on their arm like a blood pressure cuff and it inflates six times per hour during daytime and four times per hour during sleep while measuring their pressure. There is a small recording device worn on their belt. After 24 hours, it is returned to our office and we print out the readings and obtain averages to help us determine just what your blood pressure really is. The equipment has a diary so the patient can note when stressful events occur and we can correlate it with the readings. The minor drawbacks to the equipment are its bulkiness, the need to keep it dry and the disturbance to sleep it causes as the cuff inflates and deflates.

To improve measurements, as well as capture other health metrics, we are introducing a remote monitoring smart wristband. We have identified a vendor who will supply you with the high-tech wrist band at no out-of-pocket expense to you. The wristband interacts with your iPhone or android phone.

The device measures and captures pulse, heart rhythm, blood pressure, blood oxygen level, and steps.  It even has built-in fall detection. The 2021 model, which will be introduced in a few months, has an EKG component to help us follow patients who get dizzy, faint or have documented heart issues. It will also capture body temperature. There is an optional blood glucose sensor monitoring device. The wristband is water resistant so you may shower with it.

Due to the Pandemic, and development of tele-health, Medicare pays for the monitoring if you wear the device a minimum of 16 days each month. Patients are asked to identify emergency contacts so that if you fall or if you have an arrhythmia, abnormal blood pressure, abnormal blood sugar, the monitoring call center contacts your emergency contact on record.

Your physician can view all the data on our computers. Certain private insurances pay for these services as well as Medicare. I will start wearing one and my wife will as well.

I will personally discuss this with each of you whom I feel will benefit from wearing the wristband as remote monitoring is proven to reduce hospital admissions and ER visits. If you have a chronic condition, disease or certain risk factors; it’s likely I will encourage you to wear the band.

Some patients have asked if the band has a panic button for you to push if you feel you need to such as after a fall. The technology senses if you fell and have not gotten up or if you are ill and calls your emergency contacts but it does not have a unique panic button to push.

We look forward to introducing this new remote high technology to improve your health, safety and peace of mind.

Chocolate and the Risk of Coronary Artery Disease

Chayakrit Krittanawong, MD, of the Baylor College of Medicine, was part of a group of physician scientists conducting an observational study involving regular chocolate consumption and the risk of developing coronary artery disease. Their research was recently published in the European Journal of Preventive Cardiology. In what was called “a systematic review and meta-analysis” they analyzed data from 336, 289 participants, participating in six studies, looking at chocolate consumption, coronary artery disease, acute coronary syndrome and acute myocardial infarction.

If you consumed chocolate 3.5 times or more a month, or more than one time per week, you were considered a high chocolate consumer. High chocolate consumers turned out to have a lower risk of coronary artery disease of about 8%.

This is great news for chocolate lovers. However, readers must remember this is an observational study and cannot link cause and effect. It did not factor in obesity, lipid levels, presence of diabetes, cigarette smoking history, activity level, family history of premature coronary artery disease or other dietary habits.

Is it possible that chocolate lovers eat more fruits and vegetables than non-chocolate consumers? Could it be that chocolate lovers eat a healthy Mediterranean Diet more frequently than non-chocolate consumers?

This study clearly didn’t answer those questions. What it does say to me is that if you reduce your cardiovascular risk factors, as best you can, eating chocolate occasionally may not hurt.

Collusion or Conspiracy?

A 67 year-old woman with a high stress job had a vigorous disagreement with her neighbors last week. She developed severe substernal chest pain and called 911 fearing a heart attack. She is thin, has never smoked, has normal blood pressure and normal cholesterol. She is not a diabetic and runs on a treadmill for two hours at five miles per hour with an elevation for two hours four times a week. She has few risks for developing heart disease.

The ER staff was quick and efficient. An EKG revealed changes consistent with a multivessel involved heart attack. Her cardiac isoenzymes were elevated and abnormal confirming muscle injury. The ER doctor called her PCP and the cardiologist on call. This experienced interventional heart specialists on call, has worked with and cared for many of the PCPs patients. He came right over, explained the options to the patient and, with her agreement and the PCPs blessing, took her to the heart catheterization lab to perform an angiogram to find the blockages and restore blood flow to the heart muscles.

To his surprise her arteries were perfectly normal with no blockages. The heart muscle was pumping weakly exhibiting the appearance of an octopus swimming through the sea proclaiming the unusual heartbreak stress syndrome known as Takotsubos cardiomyopathy. With rest, time and reduction of stress; she was projected to recover fully in days to weeks.

She was monitored overnight and observed until her heart enzymes were normalizing, her heart rhythm was normal, and; she could walk around the room easily. She was medicated with a low dose aspirin, a low dose of a beta blocker to blunt the stress induced surge of chemicals that caused the heart damage and mild antianxiety medicines. She was advised to cancel her work schedule for two weeks, cancel a cruise scheduled for the upcoming weekend and see a psychologist for stress reduction.

She opposed each of these suggestions and demanded that I call her relative’s cardiologist for a second opinion. The very type A characteristics that led to her stress, anxiety and illness was creating the request for a second opinion. The diagnosis and treatment were straight forward.

I called her cardiologist to explain the request never expecting the reaction I received. He is successful and experienced but when I brought it up he became anxious, angry and defensive. Why? He said he was leaving the case! I begged him not to and called the cardiologist she requested for a second opinion.

“We do not do in-hospital second opinions because we wish to maintain collegiality. Let her call my office when she is home and we will see her as an outpatient.” She called that office for an appointment and was told the next appointment is in six months. I called three other groups and received the same answer of no second opinions on inpatients to maintain collegiality.

As a primary care, physician my decisions are questioned and second guessed daily. Dr Google, Dr Cousin in NY or Boston, retired neighbor doctor offer opinions on my care regularly. It comes with the territory.

An anxious fit senior citizen suffering a frightening and unexpected heart malady should be able to obtain a second opinion without threatening the egos or collegiality of professionals. I called the medical staff office and hospital administration for help and was told to work it out with my colleagues.

As we examine our dysfunctional health system, we are quick to blame insurers, big pharmacy and government interference. Medical doctors are not without blame.

Is TMAO the New LDL CHOLESTEROL?

Prevention of heart disease has centered on smoking cessation, controlling blood pressure, achieving an appropriate weight, regular exercise, control of blood sugar and control of your cholesterol.  Despite addressing and controlling these items individuals still have heart attacks and strokes and vascular events. Researchers are now directing their attention to a dietary metabolite of red meat called trimethlamine N-oxide or TMAO.

Recent peer reviewed and published studies have shown an association between high blood levels of TMAO and increased risk of all-cause mortality and cardiovascular disease.  A 2017 study published in the Journal of the American Heart Association found a 60% increased risk of a major cardiovascular event and death from all causes in individuals with elevated TMAO.  Other research has linked high TMAO levels to heart failure and chronic kidney disease.

Our bodies make TMAO when choline and L-carnitine are metabolized by our gut bacteria in the microbiome. Red meat is particularly high in L-carnitine.  A study group at the Cleveland Clinic found that red meat raised the TMAO levels more than white meats or non-meat protein. They also discovered that red meat allowed more bacteria in the gut microbiome to be switched to producing TMAO. Of interest was the fact that the amount of fat in the food, particularly saturated fat, made no difference on the TMAO levels obtained.   Stanley Hazen, M.D. PhD, section head of preventive cardiology at the Cleveland Clinic, feels the TMAO pathway is “independent of the saturated fat story.”  The important issue to Dr Hazen is the presence of the gut bacteria to produce the TMAO from foods eaten.

Not all scientists buy into the TMAO theory of cardiovascular disease because of the relatively high level of TMAO found in many fish.  Some experts believe the beneficial effects of omega 3 fatty acids in fish offset the negative effects of TMAO. The leading researcher on TMAO says it is an evolving study and he is supported by experts who believe TMAO is “atherogenic, prothrombotic and inflammatory” per Kim Williams, M.D., chief of cardiology at Rush University Medical Center in Chicago.

There is even a blood test to measure TMAO levels developed by the Cleveland Clinic and available through Quest Labs.  Do not get too excited about asking your physician to order it on your blood because it requires eliminating meat, poultry and fish plus other food items for several days in advance of the test.

For many years researchers at the Cleveland Clinic and Emory University recognized that 50% or more of heart attacks occurred in men who followed all the risk reduction guidelines including stopping smoking, controlling blood pressure and lipids, losing weight and getting active. Perhaps the answer as to why will be in the TMAO research and the solution will be changing the gut bacteria or their ability to convert L-carnitine to TMAO.

Keep Moving for Cardiovascular Benefits

We keep extolling the benefits and virtues of regular exercise and fitness. Some research studies have documented the intensity and duration of exercise programs with cardiovascular events and mortality. Those who do more and are fitter apparently do much better which surprises few of us.

It comes down to the “which came first the chicken or egg “question?  Are people genetically able to exercise at a high level living longer and healthier because they exercise at a high intensity and duration or vice versa?

It is quite comforting to read the recent study in JAMA by Andrea LaCroix, PhD, MPH and colleagues from the University of California, San Diego that shows the benefits of even modest movement and exercise.  The study was conducted under the umbrella of the Women’s Health Initiative and put pedometers and accelerometers on women to measure activity during waking hours.  Light physical activity was defined as less than 3 metabolic equivalents (Walking one mile in about 22 minutes expends about 3 Metabolic Equivalents of Activity).  They noted that for each hour per day increment in light activity there was a 14% lower risk of Coronary Heart Disease and 8% lower risk of cardiovascular disease.

The researchers evaluated 5,861 women with a mean age of 78.5 years. Average follow-up spanned 3.5 years with study members having 570 cardiovascular disease events and 143 coronary heart disease events. The study group was diverse with there being 48.8% Caucasian women, 33.5 % Black women and 17.6% Hispanic women.

The study’s results and message was clear. Keep moving. Even modest exercise is beneficial in reducing heart attack and stroke risk.

Scientific Reports, Media Reports and Ambiguity

Last week I read an article in a peer reviewed journal citing the benefits of a few eggs per week as part of a low carbohydrate dietary intervention for Type II Diabetes.  The information was so meaningful about a controversial food source of protein that I decided to write about it in my blog and pass it along to my patients.  Three days later the American Heart Association and American College of Cardiology discussed the increased risk of cardiovascular events and mortality in individuals consuming three or more eggs regularly. They talked about the detrimental cholesterol being concentrated in the yolk making egg white omelets look healthier than traditional omelets.

In the early 1970’s a VA study was published showing that veterans over 45 years of age who took an aspirin a day had fewer heart attacks and strokes and survived them better than those who don’t.  Fast forward almost 50 years and we have different recommendations for people who have never had an MI or CVA or evidence of cardiovascular disease compared to secondary prevention in individuals who have known coronary artery disease, cerebrovascular disease or diabetes. Throw in the controversial discussions of aspirin preventing colorectal adenomas from developing, aspirin preventing certain types of skin cancers and today’s report that suggests it may prevent liver cancer. Now three studies suggest that in older individuals (70 or greater) the risk of bleeding negates the benefits of cardio and cerebrovascular protection and aspirin may not actually prevent heart attacks and strokes in that age group.

We then turn to statins and prevention of heart attacks and numerous articles about not prescribing them to older Americans.  I saw articles on this topic covered by CNN, the Wall Street Journal, ARP Journal, AAA magazine and in several newsletters published by major national medical centers.  In each piece they caution you to talk to your doctor before stopping that medicine.

I am that seventy year old patient they all talk about.  I have never smoked. I exercise modestly on a regular basis, getting my 10,000 or more steps five or more days a week.  I battle to keep my weight down and find it difficult to give up sweets and bread when so many other of life’s pleasures are no longer available due to age and health related suggestions.

There are clearly no studies that look at patients who took a statin for 15 years and aspirins for over 20 years, stopped them and then were followed for the remainder of their lives.   How will they fare compared to patients who never took them?

I have this discussion every day with my patient’s pointing out the current guidelines and trying to individualize the suggestions to their unique lifestyle and issues. On a personal level, I still have no idea what the correct thing is to do even after discussing it with my doctors.  How can I expect my patients to feel any differently?

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.