Cocoa Flavonoids & Avocados May Protect Against Cardiovascular Death

The COSMOS study, sponsored by Pfizer and Mars Candies, looked at the effect of Cocoa flavonoids on cardiovascular events such as a heart attack, cardiovascular deaths and consumption of cocoa flavonoids and green tea. There were 21,442 U.S. adults in the study followed for 3.6 years.

The experimental group received cocoa and green tea. While there were just as many cardiovascular events in the study group as in the control group, the number of deaths dropped by 27%. The study was published in the American Journal of Clinical Nutrition and was commented on by David Rakel, MD, FAAFP in the online medical journal Primary Care.

Flavonoids are found in dark colored grapes and berries, apples, pears, green tea and dark chocolate. If you eat 1/4 of a dark chocolate bar you are getting the same dosage the experimental group was given in this study.

Dr. Rakel suggested that Flavonoids maintain the flexibility of the blood vessels as we age. Recent related studies indicate a handful of blueberries or cranberries daily have similar effects. A glass of red wine with a square of dark chocolate and some dark berries suddenly sounds like a healthy snack!

Avocados apparently convey cardiovascular protection as well. In a study published in the March 30, 2022 Journal of the American Heart Association researchers followed 110,00 adults for 30 plus years and found that those who consumed two or more servings of avocado a week had a much lower risk of developing cardiovascular disease then non consumers.

Multivitamins Do Not Reduce Invasive Cancer in Older Adults

Several years ago, a research study published in a peer reviewed journal claimed that taking a multivitamin daily (Centrum Silver) had positive benefits on the health of women health care workers taking part in the Women’s Health Initiative. A similar study hinted at positive benefits in reducing certain cancers in men including prostate cancer.

Since every male in the last two generations of my family had prostate cancer, I have been taking a Centrum Silver for men for years. I have blissfully been ingesting it daily with no ill effects I can remember.

It was with personal interest that I saw a synopsis of an article in the American Journal of Clinical Nutrition, March 16th edition in which Howard D. Sesso, ScD., MPH, from Brigham and Women’s Hospital in Boston, and associates looked at daily multivitamin use and invasive cancers. They randomly assigned 21,442 US adults, free of cancer and cardiovascular disease, to receive a multivitamin. They then followed them for 3.6 years. These study participants were all 65 years of age or older – 1,266 were women and 8,776 were men.

Over the 3.6 years they were observed, there were 518 invasive cancers detected in the daily multivitamin group and 535 invasive cancers in the placebo group. In this group of senior citizens, taking the vitamin for less than 4 years, there was no clear-cut benefit in preventing invasive cancers.

 I am not sure what to make of this publication other than in seniors who start a multivitamin at age 65 or older daily you will not prevent invasive cancers. If they started it at 45 or 55 years old would the results be different?  For now, the recommendation remains the same to eat a healthy balanced diet filled with fresh fruits and vegetables, limited in fats, simple sugars, and sodium chloride and have regular checkups. My multivitamin bottle is still filled to the brim. I think I will continue to take them because no ill effects were reported in this study,

An Extra Tablespoon of Olive Oil Per Day May Keep Death Away

Dr. Marta Guash-Ferre’ and team at Harvard T. H. Chan School of Public Health evaluated whether substituting a teaspoon of olive oil daily to replace margarine, butter, mayonnaise and dairy fat led to a drop in the likelihood of death from cardiovascular disease, cancer, dementia and respiratory diseases.

Her team looked at 92,00 participants who were free of cancer and cardiovascular disease in 1990. Every four years, for the next 28 years of follow-up, the researchers assessed each person’s diet through a detailed questionnaire. Olive oil consumption was determined from olive oil used on salads, cooking, or used on breads and foods.

Their long-term calculations showed that olive oil consumption increased in the study participants during the test period while consumption of margarine decreased, and other fats stayed the same. Participants with higher olive oil consumption were more likely to be physically active, less likely to smoke, consumed more fruits and vegetables than lower olive oil consumers. When the researchers compared those with little olive oil consumption to those with the highest consumption, the high consumers had a 19% lower risk of death from cardiovascular disease, a 17%lower risk of cancer death, a 29% lower risk of death from dementia and an 18% lower risk of respiratory disease death. The study also concluded that substituting ten grams of olive oil per day (a bit less than one tablespoon) for other fats such as butter, margarine, mayonnaise, and dairy fat their death risk dropped by 8-34% from all causes.

In reviewing the data, its seems that their study group represented an extremely well-educated health-conscious group of individuals. Substituting olive oil for other fats is certainly a worthy goal based on these numbers and I will certainly aim to try it.

Aspirin & Heart Disease Prevention Recommendations

In the 1950’s a research paper based on work done at a Veterans Administration Hospital found that men 45 years of age who took a daily aspirin tended to have fewer heart attacks and strokes. The VA patients were mostly male WWII and Korean War Veterans. That was the basis for most of the men in my Baby Boomer generation to take a daily aspirin.

Yes, we knew that aspirin gives us an increased risk of bleeding from our stomach and intestine. And we knew that if we hit our head while on aspirin the amount of bleeding on the brain would be much greater. It was a tradeoff – benefits versus risks.

Over the years the science has advanced to now distinguish those taking aspirin to prevent developing heart disease, cerebrovascular disease or primary prevention and those seeking to prevent an additional health event such as a second heart attack or stroke. To my knowledge there are no studies that examine what happens to someone in their 60a or 70s who has been taking an aspirin for 40 plus years daily and suddenly stops. It’s a question that should be answered before electively stopping daily aspirin.

Over the last few years researchers have hinted that the daily aspirin may protect against developing colorectal cancer and certain aggressive skin cancers. The downside to taking the aspirin has always been the bleeding risk. This data is now being questioned by the USPTF looking for more “evidence.”

The US Preventive Services Task Force was formed in 1984 with the encouragement of employers, private insurers selling managed health care plans and members of Congress to try and save money in healthcare. It is comprised of volunteer physicians and researchers who are supposed to match evidence with medical procedures to ensure that we are receiving high value procedures only.

In 1998 Congress mandated that they convene annually. Under their direction, recommendations were made to stop taking routine chest x rays on adult smokers because it didn’t save or prolong life and it took $200,000 of X Rays to save one life. They reversed their opinion decades later deciding that the math on that study wasn’t quite right and now recommend CT scans on smokers of a certain age and duration of tobacco use. I point this out to emphasize why I am not quite as excited today about their change in aspirin guidelines as the newspaper and media outlet stations seem to be.

I am a never smoker, frequently exercising adult with high blood pressure controlled with medication, high cholesterol controlled with medication and recently diagnosed non obstructive coronary artery disease. What does that mean? At age 45 my CT Scan of my coronary arteries showed almost no calcium in the walls. 26 years later there is enough Calcium seen to increase my risk of a cardiac event to > 10% over the next ten years. I took a nuclear stress test and ran at level 5 with no evidence of a blockage on EKG or films. The calcium in the walls of the arteries however indicates that cholesterol laden foam cells living in the walls of my coronary arteries and moving towards the lumen to rupture and cause a heart attack were thwarted and calcified preventing that heart attack or stroke. I am certainly not going to stop my aspirin.

My thin healthy friend who works out harder than I do told me he doesn’t have heart disease and is going to stop his baby aspirin. I asked him what about his three stents keeping several coronary arteries open? He told me he had heart disease before he got the stents but now he doesn’t. I suggested he talk to his internist or cardiologist prior to stopping the aspirin.

I may take a different path in starting adults on aspirin for cardiovascular and cerebrovascular event protection. I am certainly not going to withdraw aspirin from patients taking it for years unless they are high risk for falls and head trauma or bleeding. I suggest you ask your doctor before considering changing any of your medications.

Try an exercise by writing down all the prescription medicines and next to them list what condition you take them for. Once you have established that information, set up an appointment and talk about it with your physician. The decision-making is much more complicated than the USPTF and headline hungry media discussed and reported.

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.