International Panel Questions the Wisdom of Strict Sodium Guidelines

A technical paper published in the online version of the European Heart Journal suggested that individuals should strive to keep their sodium intake to less than 5 grams per day. This is in marked contrast to the recommendations of the American Heart Association of 1.5 grams per day and American College of Cardiology recommendations of 2.3 grams per day. The authors of the papers included some of the world’s experts on the topic of hypertension including Giuseppe Mancia, MD, Suzanne Oparil, MD and Paul Whelton, MD.  They agreed that consuming more than five grams per day was associated with an increased cardiovascular risk. They believe there is no firm evidence that lowering the sodium intake to below 2.3 or 1.5 grams per day reduces cardiovascular disease without putting you at risk of developing other health issues from having too little sodium.

The report triggered a firestorm of controversy in the hypertension and cardiovascular field with proponents on each side of the issue. Both sides agreed that we need more meticulous research to determine the best lower end of daily sodium intake because current information makes recommending one level or another a guess at best with little data to back you up. That leaves clinicians and patients scrambling for clarity and the media reporting this paper in a manner threatening to further erode the public’s confidence in the scientific method and physicians in general.

As a practicing physician I will continue to recommend a common sense approach to salt intake. Those patients who have a history of congestive heart failure or hypertension which is volume related will still be encouraged to read the sodium content of the foods they are purchasing and try to avoid cooking with or adding sodium chloride to their food at the table. This will be especially important for patients with cardiomyopathies and kidney disease who are following their daily weights closely. For the rest of my patient population I will ask them to use salt judiciously and in moderation only. I will suggest not adding salt at the table and if they do to please add it in moderation. I will allow more salt intake in those patients who work outside all day and are exposed to our high temperatures and humidity.

Like everyone else, I will wait for the meticulous research studies to be performed over time to determine how low and high our sodium chloride consumption should be without hurting ourselves.

Patient Hand-Offs and Communication

document businesspeople 1I was finishing tying my shoes as I got dressed to take my lovely wife out to dinner for our 41st wedding anniversary. It was 7:30 p.m. after a hectic day at work and we had a wonderful dinner planned at a local restaurant.

The telephone rang with the caller ID identifying a call on my office work line. “Hello this is the Emergency Department, please hold on for Dr S.” Before I could get in a word edgewise I was put on hold. Five minutes later Dr S. got on the line. “Steve this is Pete. “Dr. Rheumatology” saw your mutual patient Mrs. T this afternoon and she was complaining of shortness of breath beginning three weeks ago. She complains of overwhelming fatigue. He sent her here for evaluation. Her exam is negative. At rest she doesn’t look short of breath. Her EKG doesn’t show any acute changes but I do not have an old one to compare it to. Her chest x ray is negative and her oxygen saturation on room air is 97 % (normal is greater than 90%). She has lupus and multiple autoimmune problems and is on many immune modulators. Maybe she has a constrictive cardiomyopathy or restrictive lung disease. I called Dr. Rheumatology and he said this isn’t his department to call the PCP (primary care physician) to admit the patient and you are the PCP. “I told the ER physician I had not seen the patient in over six months or heard from her but I would be right in to see her”.

I explained to my wife that duty calls and there was a sick patient in the ER. She was extremely understanding. On the drive to the ER I called the Rheumatologist to ask him his clinical impression because he had been seeing her every two weeks and had examined her just that afternoon. He returned my call and we discussed the clinical aspects of the situation and his thoughts. Then I told him that I thought he should have called me when he sent the patient to the ER if he expected me to assume care. If he did not call then he most certainly should have called me when the ED doctor called him to report on the findings and he said call the PCP. Hand-offs should be direct especially in an acute situation and especially if you sent the patient to the ER and do not intend to take ownership of the situation you sent the patient to the ER for.

He told me that in 30 years of practice no one had ever criticized him for this and he does it all the time. He told me he had been working long hours and did not have time to call referring physicians. I told him that was no excuse and if he was working that late maybe he needed to restrict his patient volume so he could communicate in a professional manner.

I arrived at the ER 20 minutes later and learned that the patient had been there for three and half hours already. She had been in the ER while I had been at the hospital earlier that afternoon checking on another patient. Had I known she was there I could have easily seen her, cared for her and still made my anniversary dinner.

A review of her old EKG and comparing it to the new one, plus taking a thorough history and exam, revealed the problem. She was having a heart attack. Her bouts of shortness of breath with activity with overwhelming fatigue were her equivalent of crushing chest pain.

Getting called to the hospital during “off” hours is part of a physician’s way of life. Having a colleague take your role and time for granted at the expense of the patient is disturbing and unprofessional.

All too often today physicians, both specialists and primary care, don’t take the time to communicate directly and clearly with their colleagues about patient care.  When this happens, clearly the patient is negatively impacted.

ACO’s and the Patient Centered Medical Home will not cure this. Only courtesy, respect and putting the patient first will change things.

Chianti Study Refutes Wines Heart Healthy Label

ChiantiResveratrol, the antioxidant found in red wine, grapes, and dark chocolate did not increase longevity or lower the risk of cancer or heart disease in a study conducted in the Italian wine country. The study, led by Richard D. Semba, MD, MPH of the Johns Hopkins University looked at older adults in the Chianti wine making region of Italy with the top dietary intake of resveratrol as indicated by its urinary metabolites. Large consumers were no more or less likely to die over the 9 year study period as small consumers or those who abstained. The actual data showed that those in the lowest consumption range did better than others as reported in the online edition of the Journal of the American Medical Association.

“Inflammatory markers, cardiovascular disease, and cancer all showed the same lack of a significant relationship with resveratrol levels. “The results were different than all of our theories” and hopes. Resveratrol had been hailed as a major component of red wine and dark chocolate and is supposed to be heart healthy. This has led to the growth of sales for it as a supplement. Sales in the USA exceed $30 million dollars per year despite no clinical evidence of its benefits. It is still promoted heavily by noted cardiologist and health televangelist Dr Oz. Derek Lowe, PhD, a drug researcher, doesn’t understand the popularity of the substance. “Personally, I do not see why anyone would take resveratrol supplements.” If it does have an effect it’s sure not a very robust or reproducible one.” The Aging in Chianti Study involved 783 men and women followed from 1998 until 2009. There was no significant difference in cardiovascular disease rates among those with the lowest levels of the drugs metabolite and those with the highest. There were no differences in the incidence of cancer between high consumers of red wine and modest to low consumers either.

While the study clearly did not show any benefit during the study period, critics of the study and its conclusion felt that maybe the benefits were more long term and required a higher dose of resveratrol over a longer period to see any real benefits. Once again I believe consuming dark chocolate and red wine in moderation is probably your best course. It is clear that a larger study with different concentrations of resveratrol over a longer period of time will be needed to reach a definitive conclusion. The study did not show that resveratrol was bad for you either. That being the case, individuals should enjoy their dark chocolate and red wine in moderate measured amounts because they enjoy dark chocolate and red wine.

New Knees and Hips Cut Heart Risk

Heart DiseaseAt the annual meeting of the American Academy of Orthopedics in New Orleans, Bheeshma Ravi, M.D., an orthopedics resident at the University of Toronto, reported that patients who underwent knee and hip replacements were able to dramatically reduce their risk of a heart attack or stroke over a seven year period. He followed 153 patients who were high risk for cardiovascular disease and noted the major risk reduction.

Some of the improvement in risks were assumed to be due to the increased mobility and increased activity the recipients were able to enjoy. The increased physical activity improves cardiac health. While physical activity is one explanation, the reduction in pain, stress, use of painkillers and inflammation is another set of potential reasons. With pain comes use of more nonsteroidal anti-inflammatory medications which have been implicated in the development of acute heart attacks.

In our medical practice we often see senior citizens who are healthy enough to undergo a joint replacement but are too fearful to proceed with the surgery. This particular study provides additional evidence that replacing the inflamed joint and resuming activity is the correct choice to make.

Omega 3 Fatty Acid Levels and the Risk of Prostate Cancer

A recent well publicized research study known as “The SELECT Trail” showed that Vitamin E supplementation increased the risk of Prostate Cancer compared with placebo (NEJM JW Gen Med Oct 25 2011)  Researchers have now used data from that study analyzed separately now claims that individuals with a higher level of omega 3 fatty acids are at a higher risk of developing high grade prostate cancer. The results were published in the Am J Epidemiol 2011; 173:1429.

This was a case – control study in which researchers looked at the plasma omega 3 fatty acid levels in stored blood collected at the beginning of the SELECT trial. They compared the levels in 834 men with prostate cancer and 1393 controls without the disease.  The design of the study does not allow one to conclude that if you ingest omega 3 fatty acid supplements you will develop prostate cancer. The study just noted that individuals with prostate cancer as compared to men without had higher plasma levels of omega 3 fatty acids in their blood.

This particular study raised a great deal of media attention and concern especially with the American College of Cardiology advocating supplementation with fish oils for cardiac protection in recent years. This recommendation came despite two recent studies that indicated just the opposite ( NEJM JW Gen Med May 8 2013, and JAMA 2012; 308: 1024).   It is clear from this controversy that the exact role of omega 3 fatty acids, fish oils, omega 6 fatty acids and vegetable oils is still up for debate. I will advise my patients to eat fish in moderation consuming 1-2 fish meals per week if they enjoy fish.  Eating in moderation and allowing our bodies to use the nutrients they need seems to be the wisest course until more is known.

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.