Biphosphonates Raise the Risk of Atrial Fibrillation

Atrial FibBiphosphonate drugs such as Fosamax, Boniva and Actonel are used commonly to treat osteoporosis and to prevent the progression of bone disease from low mineralization or osteopenia to osteoporosis. The most common side effect we normally see is gastrointestinal upset with inflammation of the esophagus and stomach especially when the pill is not swallowed with sufficient liquids.  Patients receiving biphosphonates are cautioned to take the pill with sufficient liquid, while remaining upright for 45 minutes to an hour.  Biphosphonates have revolutionized the prevention of and treatment of osteoporotic bone disease.

In October’s issue of Chest Medical Journal Dr. Abhishek Sarma, MD, of Maimonides Medical Center in Brooklyn, N.Y. shows that biphosphonate use is associated with an increased risk of developing the arrhythmia atrial fibrillation.  Atrial fibrillation is a disorderly rhythm of the upper chambers of the heart leading to ineffective blood flow and increased risks of clots forming in the heart chambers and disseminating causing strokes. Older adults, the same patient population that is at risk for osteoporosis, is the patient group who when they develop atrial fibrillation require the use of blood thinners such as warfarin or xarelto or elliquis to prevent clot formation and strokes. Dr. Sharma performed a review of existing randomized controlled and observational studies.  He concluded there was a 27% increased risk of developing atrial fibrillation if you were taking biphosphonates. They looked at six observational studies with almost 150,000 participants and six randomized controlled trials with 41,000 patients. The increased risk occurred in patients taking the biphosphonates by mouth or by intravenous infusion. They postulated that biphosphonate use triggers an inflammatory protein that effects intracellular calcium and leads to arrhythmias.

The study clearly requires follow-up. If you stop the biphosphonates will the patient return to a normal rhythm on their own or if chemically or electrically shocked back into a normal rhythm?  It is clear that we need to prevent and treat osteoporosis but it is now important for us to determine what this new finding means to a person’s long term health. If you are taking biphosphonates speak to your physician about this new finding and how or if it relates to you.

Lipid Testing Continues After LDL Target Met

A study performed at a Veterans Affairs medical center in Houston, Texas claims that physicians are ordering too many lipid levels on patients with coronary artery disease who have met the LDL (low density lipoprotein) guidelines of <70mg/dl. They looked at 35,191 patients and found that 9200 of these patients had already achieved the desired lipid levels however their clinic physicians ordered a repeat lipid panel on subsequent tests. The researchers cited the Institute of Medicine guidelines which suggest testing your lipid levels only once a year once you have achieved goal levels. If that annual test reveals an elevation of your lipids outside guidelines and it leads to an intensification of your treatment, then they believe it is acceptable to recheck your cholesterol and its subtypes to assess the effectiveness of the treatment.

The study was published in the online edition of the Journal of the American Medical Association (JAMA) by Salim S. Virani, MD PhD of the Michael DeBakey VA and Baylor College of Medicine in Houston. They concluded and an accompanying editorial questioned whether this was an overuse of resources and wasteful spending that was not being discussed by health policy experts because this was low expense non procedural waste and not a big ticket item. They stressed the need to get this wasteful spending under control if we expect to reduce overall health care costs.

In my internal medicine practice, an individual who achieves goal levels of lipids by losing weight, or eating a different diet, or exercising more vigorously or by taking a medicine may in fact alter their habits over a 3-6 month period. They may gain back the weight they lost. They may reduce their exercise due to scheduling conflicts or physical injury and health problems. They may alter their medication regimens or be placed on medicines by other doctors that influence their lipid levels. There are very few patients in my practice that are static and have no changes from quarter to quarter of the calendar year. I make no money sending off blood tests. The lab makes a great deal of money. They have a very high fee schedule for uninsured patients. Their fee schedule for private insurances and Medicare is still far higher than the fee they will charge your doctor if the doctor charges the patient directly and pays the wholesale cost to the lab for that test. Maybe the researchers and cost effective analysts should be looking at the actual cost to the lab of performing the test and insuring that the profit they make is appropriate not price gouging instead of worrying about an additional two or three lipid panels per patient per year. When I send your blood to a reference lab I earn no money on it but do bear the responsibility for interpreting the result and conveying it to you. It seems to me some of the research on cost effectiveness is getting very penny wise and pound foolish.

Women and Cardiovascular Disease – There is A Difference Between Men and Women

Front view of woman holding seedlingThe American Society of Preventive Cardiology presented an educational seminar recently in Boca Raton, Florida to educate physicians, nurses and health care providers that cardiovascular disease in women can be very different than in men.  Failure to recognize these differences has resulted in women being under diagnosed, under treated and suffering worse outcomes.

The difference is first noticeable in pregnancy when the development of elevated blood pressure, super elevation of lipids and the development of gestational diabetes predispose young mothers to earlier, more serious, cardiovascular risk later in life. The faculty noted that women of child bearing age tend to use their obstetrician as their primary care doctor.  They suggested that women with pregnancy related diabetes, hypertension and lipid abnormalities should be referred to a medical doctor knowledgeable in preventive cardiology, post-delivery, for ongoing care.

For reasons that are unclear, women are less likely to be treated to recommended guidelines for lipids, diabetes and hypertension.  Diabetic women have a far worse prognosis with regard to cardiovascular disease as compared to men. They are less likely to be treated with aspirin, which while not as effective in preventing MI in women, is apparently protective against stroke.

Women about to have a heart attack have different symptoms the weeks, to months, before the event. They are more likely to have sleep disturbances, unexplained fatigue, weakness and shortness of breath than the standard exertional angina seen in men.   When they do have a heart attack they are as likely to have shortness of breath and upper abdominal fullness and heartburn as they are to have chest pain. They are more likely to have neck and back pain with nausea than men are.  

Since women have different symptoms than men they are more likely to be sent home from the emergency room without treatment.  They are less likely to have bypass surgery than men, less likely to be treated with the anticoagulants and antiplatelet medications that men are treated with and, they are less likely to be taken to the catheterization lab for diagnosis and intervention as compared to men.

The faculty was comprised of world-class researchers, clinicians and educators who happened to be outstanding speakers as well, bringing a vital message to our community.  They pointed out the different questions and diagnostic tests we should be considering in evaluating a woman as opposed to a man.

This was my first educational seminar through the American College of Preventive Cardiology and I thank them for the message they delivered to the medical and nursing community at probably one of the finest seminars I have had the privilege to attend.

Today’s Seniors Are Not as Healthy as Their Parents

Baby Boomer Couple, cropped

In the online version of the Journal of the American Medical Association an analysis of data compiled by the National Health and Nutrition Examination Survey ( NHANES) suggested that today’s baby boomers are not as healthy as their parent’s generation. The baby boomers, born between 1946 and 1964, may live longer but they do so with more complaints and more chronic illnesses.  The study compared the two generations at ages 46 and 64 on several health measures using the years 2007- 2010 for the baby boomers and comparing it to data they had from 1988- 1994 for the prior generation.

The demographics in the two groups indicated a larger number of Hispanics and non-Hispanic Blacks in the baby boomer generation than the previous generation.  The data in many cases was self-reported with only half as many baby boomers 13% reporting their health as “excellent” while their parents’ generation had 32% respond excellent to the same question.  The baby boomers reported that more were using walking assisted devices, more were limited in work and more had functional limitations than their parents’ generation. As a group, obesity is more common in the baby boomers (39% vs. 29%), as is high blood pressure, elevated cholesterol and diabetes.

The prior generation got more physical exercise than the baby boomers by a margin of 50% compared to 35% when asked if they were getting exercise at least 12 times per month. Smoking was more common in the prior generation.  The study authors concluded that we need to “expand efforts at prevention and healthy lifestyle promotion in the baby boomer generation.”

It is hard for me as a clinician to gain much insight from this data. Clearly the previous generation lived through a depression and fought two major wars. Their definition of “excellent” may be different than baby boomers whose expectations may be completely different from reality.

An epidemic of obesity has contributed to an increase in its associated diseases including diabetes, high blood pressure and lipid abnormalities. The goal of education and prevention is a wise one and needs to start in the preschools and elementary schools if we wish to be a healthier society

 

Is Aspirin Resistance A True Entity?

Aspirin

Aspirin has been a recognized agent to inhibit platelet function and prevent clotting.  We use it to prevent heart attacks and strokes. It’s used in individuals who have a transient ischemic attack or mini-stroke to prevent a future major stroke. It’s also used as a component of the therapy in patients who have stents put in arteries to relieve arterial blockages.

Despite the use of the aspirin, either alone or in concert with other medications, a certain percentage of patients do have the heart attack or stroke we are hoping to avoid. Scientists have postulated that a number of these patients have a condition called aspirin resistance. They believe aspirin may not work in them due to genetic factors that affect the way aspirin works. The belief is so strong that certain labs now offer genetic assays to assess whether you are a patient with aspirin resistance.

Garret A. FitzGerald, MD, and associates from the University of Pennsylvania published their research in the online section of Circulation: Journal of the American Heart Association which questions the existence of aspirin resistance at all. They recruited 400 healthy non-smoking participants between the ages of 18- 55 to measure the response to the ingestion of a traditional 325 mg regular aspirin or an enteric coated version.  They were able to use several different well accepted measures of aspirins anti-platelet effects to divide the group into aspirin responders and non-responders. They basically found that the non-responders were primarily individuals who received enteric coated aspirin. When you tested their blood in the laboratory with regular non-coated aspirin, or tested them with non-coated aspirin, they suddenly became responders.  FitzGerald and colleagues concluded that “pseudo resistance is caused by delayed and reduced absorption of coated aspirins.”

Doctors and pharmacists have encouraged the use of “coated” aspirin to offset aspirin’s tendency to irritate the lining of the stomach and duodenum and initiate gastrointestinal bleeding. Based on this paper it seems reasonable to suggest to patients that they use regular uncoated aspirin to achieve the desired anti-platelet effect if the patient is not high risk for intestinal bleeding.

 

Inflammation and Vascular Disease

Heart, stethescopeI was privileged to hear Bradley Bale, MD and Amy Doneen, MSN, ARNP talk about the development of coronary artery disease and cerebrovascular disease in patients with low or few cardiac risk factors.  They cited American Heart Association studies looking at groups of men and women between ages 45 and 65 who have their first heart attack or stroke despite being in compliance with suggested lipid and blood pressure guidelines. They pointed out that the first Myocardial Infarct or Stroke occurred in 88% of women who met lipid guidelines and 66 % of men.  These are people who do not smoke, do not have untreated or uncontrolled lipid levels, are not diabetics and who lead an active life style.  They asked “why”?

Dr. Bale and Ms. Doneen work with the well respected cardiovascular Center of Excellence at the Cleveland Clinic program in Ohio, and believe that inflammation is the root of the problem.  They believe that soft plaque composed of lipids and other cells lurks beneath the endothelial cells lining blood vessels. In the presence of inflammatory stimulants, this soft plaque ruptures suddenly through the endothelial level into the blood stream. When it comes in contact with the blood flowing through the vessels the body believes we are bleeding and cut and chemical mediators are released that initiate the formation of a clot. When this clot occurs in a small coronary artery we have a heart attack or myocardial infarction or precipitate a lethal irregular heartbeat. When this clot occurs in the blood vessels of the brain, we have an acute stroke or cerebrovascular accident.

The key to prevention in the so called low risk patient is to detect the inflammation in advance, and treat it. They are firm believers in performing B Mode Duplex ultrasounds of the carotid arteries in the neck to look for the presence of soft plaque beneath the endothelial cell lining. This soft plaque is distinctly different from the safe but calcified plaque we can see on CT scans used for cardiac scoring studies.  They couple this imaging study with a series of complex blood tests which identify inflammation. These include a myeloperoxidase level, the Lp-PLA2 level, the urine microalbumen to creatinine ratio, a F2-IsoPs level and the cardiac specific CRP level.

These tests and studies in combination with a traditional history and exam, sugar and lipid levels and EKG can help us identify those “low risk” patients who actually are high risk for a heart attack or stroke. The cause of the inflammation is often difficult to spot and may be in your mouth with dental or periodontal disease or in your joints with inflammatory arthritis.  Patients with excellent dental hygiene and normal appearing gums may harbor specific inflammatory bacteria that put them at risk. While this seems a bit forward thinking, remember we once questioned the research that showed that bacteria (H Pylori) caused gastric ulcers and intestinal bleeding.

I have begun instituting the inflammatory blood marker panels in my practice. Labs are sent to the Cleveland HeartLab for this purpose. I will be initiating periodic carotid ultrasound studies for the appropriate patients in the coming year.

It is often difficult for clinicians to distinguish snake oil sold for profit from cutting edge science. I have tried to spare my patients from worthless but profit driven products. I am convinced the Cleveland Clinic is just ahead of the rest of us in offering these services and I will make them available to the appropriate patients and will do it in a financially structured manner that does not add out of pocket cost to the patient. It’s not about adding another profitable income stream to the practice. It’s about identifying individuals who shouldn’t have a heart attack or stroke before they do.

American Diabetes Association: Fish Oils Do Not Reduce Cardiovascular Event Risk

The American College of Cardiology now recommends that individuals take “fish oil” supplements in pill form to prevent coronary artery and vascular disease. The scientist who discovered that fish oils may have beneficial effects has publically come out and let it be known that he feels differently on the subject. While he once advocated eating two fleshy cold water fish meals a week to gain some degree of protection, he has most recently reduced that requirement to two meals a month. He has additionally scolded the nutritional supplement community for the promotion of fish oils in pill form when it can be safely and effectively obtained by eating a few cans of tuna fish or salmon per month.

Recently, at the annual meeting of the American Diabetes Association, Jackie Bosch, MSc, from McMaster University and Hamilton Health Sciences in Hamilton, Ontario presented data that suggested that fish oils did not reduce cardiovascular deaths or events.  The data was abstracted from the ongoing ORIGIN (Outcome Reduction with Initial Glargine Intervention) study of 12,536 patients with type 2 diabetes, impaired fasting glucose levels or impaired glucose tolerance. These study participants were composed of 65% men with a mean study age of 64 years who were followed for over six years. The study group received one gram daily of n-3-fatty acids.

The data showed that fish oils did not make a difference in the number of fatal or non-fatal heart attacks, fatal and non-fatal strokes, hospitalizations for heart failure, revascularization procedure numbers, and loss of a limb or digit due to poor circulation for any cardiovascular cause. The study additionally showed that the use of a long-acting insulin Glargine had no detrimental or beneficial effects on cardiovascular disease.  The story was covered and summarized in the online periodical of the University of Pennsylvania Medical School, MedPage.  Interestingly, the placebo group received one gram per day of olive oil.

Clearly this is another indictment against taking pills instead of acquiring nutrients in a well prepared balanced diet that includes cold water fleshy fish weekly.  Upon reading the study, I wondered if the use of olive oil by the placebo group was cardio-protective and fish oils were just no more cardio-protective than olive oil?  Once again, further research is needed. While the research is ongoing, eating cold water fleshy fish once a week as part of a nutritionally sound, well prepared diet rather than taking fish oil pills seems to make sense.

Fish Oils Fail To Stave Off Mental Decline

Dietary supplementation with Omega-3 fatty acids did not prevent cognitive decline in older individuals according to a study which reviewed the subject in the online magazine MedPage, a publication of the University of Pennsylvania School of Medicine.  By the year 2040, more than 80 million people will be affected with dementia. There has been increasing interest in identifying dietary factors that could help diminish these numbers.

The study was performed by Emma Sydenham, MSc of the London School of Hygiene and Tropical Medicine in response to some previous observational studies that suggested that consuming high levels of polyunsaturated fatty acids may reduce the likelihood of cognitive decline with aging. Some evidence does exist that fatty acids play an important role in brain health through the maintenance of neuronal functioning while acting as mediators of inflammation and oxidative stress.

Sydenham and associates looked back at three major studies designed primarily to assess the efficacy of Omega-3 fatty acids in preventing cardiovascular disease.  Cognitive function was assessed by various methods in all three well-designed studies.  All three studies indicated that Omega-3 fatty acids played no role in preventing cognitive decline.

Sydenham’s team suggested that more research is needed in this area. I believe this study emphasizes the wisdom of eating a balanced diet prepared in a way to retain the nutrients – inclusive of several portions of cold water fleshy fish per week.

In general, if you provide your body with the nutrients it needs by consuming appropriately prepared healthy portions, your body will extract what it needs.

Dark Chocolate: Cardiovascular Prevention

A study from Australia predicts that if 10,000 men with big bellies and the “metabolic syndrome” (abdominal obesity, diabetes, hyperlipidemia , hypertension)  ate 100 grams of  dark chocolate daily, it would prevent 70 non-fatal and 15 fatal heart attacks per year.  The total yearly cost of the chocolate is less than $50 per patient.   Recent studies have shown that dark chocolate can reduce high blood pressure and lower lipids.  This study was based on a model that predicted the effects of dark chocolate lasting for 10 years when, in fact, true research studies have not lasted that long.

This is a promising avenue of research involving a food substance that most of us enjoy.  For my patients, almost any food in moderation produces success.

Heart Attack Risk Assessment – Everyone Needs One

MedPage, an online medical news service is reporting that the European Association for Cardiovascular Prevention and Rehabilitation (EuroPrevent), currently meeting in Dublin, Ireland, has called for a once in a lifetime cardiac assessment for all men over age 40 and all women over age 50.

Ian Graham, MD, professor of cardiovascular medicine at Trinity College suggests that we use “age risk terminology,” as it is far easier to understand.  For example, it has been concluded that most 30 year olds are low risk, by virtue of their age, for the presence of cardiovascular disease. “If that 35 year old is a smoker, you can tell him that his risk of having a heart attack is the same as a 65 year old man. That is meaningful.”

The recommendations have been synthesized into a short 63 page document which establishes whether the evidence for each suggestion is strong, moderate or weak.  While many of the guidelines have remained the same, the new documents make it easier for health professionals to access and use the guidelines.  Your primary care physician can easily perform the cardiac assessment.