Unique Stroke Symptoms in Women

Stroke - NIHIn a previous blog I have discussed the need to recognize stroke symptoms rapidly so that an individual can be transported to an approved stroke center quickly and receive treatment within 60 minutes of arrival and hopefully within 3 hours of the onset of the symptoms. The classical symptoms include:

  • Sudden numbness, weakness or paralysis of your face, arm or leg usually on one side of your body
  • Abrupt onset of difficulty speaking or understanding speech
  • Sudden vision change with blurring, double or decreased vision
  • Sudden dizziness, loss of balance or loss of coordination
  • The onset of a severe sudden headache which may be associated with a stiff neck, facial pain, vomiting or pain between your eyes
  • Sudden change in mental status or level of consciousness
  • Sudden confusion, loss of memory or orientation or perception.

New research shows that women often delay seeking help. It is believed this occurs because women often exhibit different warning signs in addition to the traditional ones. Women having a stroke may exhibit:

  •  Loss or consciousness or fainting
  • Shortness of Breath
  • Falls or Accidents
  • Seizures
  • Sudden pain in the face, chest, arms or legs

Benefits of Smoking Cessation Outweigh Negatives of Weight Gain

A196HJ Woman smoking a cigarette Exhaling tobacco smokeIf you wish to extend your life and stay healthy then giving up smoking tobacco is a major positive step. The benefits include an immediate drop in your cardiovascular disease risk profile, a drop in the possibility of developing numerous types of cancer and a decrease in the likelihood of developing chronic obstructive lung disease.

Smoking is an expensive, dirty habit that not only sickens you but exposes those around you to an increased chance of disease due to others breathing in your second hand smoke. Asthma in children is now believed to be related to the children’s exposure to their parents’ second hand smoke. One of the negatives of stopping smoking is that individuals tend to put on weight. Weight gain and obesity are known risk factors for the development of heart disease and vascular disease.

In the March 13th issue of the Journal of the American Medical Association (JAMA), Carole Clair, MD, of the University of Lausanne in Switzerland examined the question of whether the weight gain was detrimental to your heart health. She accessed data from the famed and long term Framingham Offspring Study looking at the years 1984 through 2011 for 3251 study participants who were free of cardiovascular disease at the start of the analysis. These participants underwent a checkup every four years and were placed into categories such as “recent quitter” (stopped smoking within 4 years),” long term quitter” (nonsmoker for > 4 years) and nonsmoker.

As anticipated, smoking cessation was associated with a weight gain of 5.9 lbs. in the recent quitters and 1.9 lbs. in the long term quitters. Smokers also gained weight during the study period while the country underwent and obesity epidemic. Smokers gained an average of 1.9 lbs. while nonsmokers gained about 3 lbs.

They followed these people for 25 years and defined 631 “cardiovascular events.” In reviewing the data they concluded that former smokers had about one half the risk of developing cardiovascular disease as smokers. When they factored in the weight gain associated with smoking cessation it had no effect on the reduction in cardiovascular disease.

They concluded that the findings support, “a net cardiovascular benefit of smoking cessation, despite subsequent weight gain.” The goal is clear. Stop smoking and then we will work on the weight gain.

ACE Inhibitors Linked to Hallucinations In The Elderly

????????????????John Doane, MD, and Barry Stults, MD, from the University of Utah Health Science Center in Salt Lake City reported in the Journal of Clinical Hypertension on four cases of visual hallucinations in elderly patients taking the drug lisinopril for blood pressure control. ACE inhibitors are a popular and relatively safe drug. They are used for blood pressure control especially in diabetics.

The patients’ adverse effect profile has been limited to a dry allergic cough, elevated potassium, rash, angioedema and renal insufficiency.   They ranged in age from 92-101 and were being treated for hypertension or heart failure. Two had mild cognitive impairment, one had Alzheimer’s disease and one had vascular dementia. The time from beginning the drugs until hallucinations appeared varied from two months to six years. In each case when the drug was stopped the hallucinations resolved. In one case the patient was re-challenged with lisinopril and the hallucinations returned.

The authors conducted a thorough literature search and found several other reports of ACE inhibitor related hallucinations. In each case the hallucinations resolved when the drug was discontinued. It is believed that ACE inhibitors raise the level of opioid peptides causing these hallucinations. While the side effect is rare, it is certainly worth knowing about as the population ages and clinicians are looking for safe drugs to treat high blood pressure and heart failure.

The Benefits of Exercise and Fitness

Woman with DumbbellsThe highly acclaimed Cooper Clinic has been following 20,000 patients’ fitness levels for the last 40 years. They recently published an article in the Annals of Internal Medicine proclaiming that fitness in the middle years of life lowers your risk of developing dementia in your senior years. The Cooper Clinic has been following these patients for evaluation of cardiovascular fitness and development of heart disease but decided to use the same data to review who, if any, developed dementia by their 70th, 75th, 80th and 85th birthdays. All participants initially were screened with exercise treadmill testing. They found that those who were the fittest were 36% less likely to be diagnosed with dementia after age 65 than the least fit.

David Geldmacher, MD, of the University of Alabama at Birmingham, told MedPage Today that the potential benefit of exercise to reduce dementia risk is worth bringing up with patients, even though recommendations for exercise are made routinely for cardiovascular health reasons. Many patients are willing to forego exercise with the belief that sudden death by a heart related illness isn’t such a bad way to expire. On the other hand the thought of living with a chronic debilitating disease like dementia is highly undesirable and exercise might be an acceptable lifestyle change to prevent that process. Knowing that fitness can reduce the Alzheimer risk may give them further motivation to follow through with an exercise and fitness plan.

In an unrelated but equally fascinating study, researchers at the Durham Veterans Affairs Medical Center in Durham, North Carolina found that Caucasian men who participated in regular exercise at a moderate level were less likely to have prostate cancer on biopsy of suspicious areas of the prostate. If the biopsy did reveal prostate cancer the grade of the cancer tended to be lower indicating a more favorable prognosis. This study of 164 Caucasian men and 143 black men did not show any fitness protection for black men who exercised regularly. The authors went on to point out the small size of the study and the fact that the level and frequency of exercise was self-reported not measured or monitored by the research team. Other factors such as heredity, diet and lifestyle issues may be factors as well. They recommended further study to determine the exact relationship between exercise and prostate health or disease.

Both these studies strongly support the concept that regular exercise of a moderate level probably has strongly favorable influences in multiple areas of health. I will continue to urge my patients to get some form of regular exercise that they enjoy on a daily basis while the researchers confirm the long term benefit of regular exercise and fitness.

Too Much Calcium May Be Harmful For Women

Front view of woman holding seedlingThe Swedish Mammography Cohort, a population based group that includes 61,433 women born between 1914 and 1948 with a median follow-up of 19 years was used to answer the question of whether calcium intake can be harmful? The research team analyzed food intake by questionnaires and estimated the total calcium intake from food and supplements in the study group. Participants were divided into groups based on total daily calcium intake. One group consumed less than 600 mg of calcium per day. A second group consumed between 6000 and 999 mg a day. Group three consumed 1,000 to 1,399 mg per day. The last group consumed more than 1400 mg a day or the equivalent of drinking five 8 ounce glasses of cow’s milk.

The study was led by Karl Michaelsson, MD, of Uppsala University in Sweden and published in the online edition of the British Medical Journal. They found that the group consuming 1400 mg or more per day of calcium had a higher risk of death from cardiovascular disease, ischemic coronary disease and all causes than expected. The high calcium intake did not however increase the risk for strokes. At the other end of the spectrum were those individuals on an extremely low calcium diet with less than 600 mg per day. They were found to have an increased risk of death as well from all the causes mentioned above plus stroke.

Once again this appears to be a call for moderation in one’s diet. Too much or too little of anything is associated with consequences. At the current time postmenopausal women are advised to consume 1600 mg of calcium a day between diet and supplements. It may be time to look at that number and see how it applies to North American women as opposed to Swedish women who participated in this project.

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

 

Lipid Levels Similar Regardless of Whether Patients Are Fasting Before The Test

Blood SampleAn article in the Archives of Internal Medicine, November 12th, 2012 edition, reviewed the lipid profiles of more than 200,000 patients who had different fasting times recorded before their blood was drawn. Many did not fast at all. The results showed that mean levels of total and HDL cholesterol didn’t differ much at all if the patients fasted or did not fast. Triglyceride levels were the most sensitive to eating or fasting. The data indicated that for the most part, unless your fasting triglyceride levels are 400 or greater there is no need to fast before checking your blood lipid levels.

Diabetics or patients with abnormal blood sugars are required to fast to accurately measure their fasting blood sugar levels. Since science and fact should govern our medical decision making, I changed my office lab testing policy beginning January 1, 2013. We will no longer ask patients to fast before blood drawing unless they are diabetics or have high triglycerides. This will make it far easier for patients who are wondering “what can I eat and drink the morning of my blood drawing for tests?” When we schedule appointments for patients being treated for elevated cholesterol we will no longer ask them to fast or not eat. We will reserve fasting appointments for patients who are suffering from diabetes mellitus or who have a history of elevated triglycerides.

If you are not diabetic and if you do not have extremely elevated triglyceride levels, please take your medications and eat before your scheduled appointment.

I will draw a fasting glucose blood test on all non-diabetic patients annually. Fasting is permitted if your visit is for your annual physical exam.

Flight Physicals- FAA Senior Aviation Medical Examiner

Airplane Cockpit and PilotsAbout 20 years ago I was invited by the Federal Aviation Administration (“FAA”) to travel to Oklahoma City and take the one week course to become a certified Aviation Medical Examiner. During the course I was asked to perform tasks members of a flight crew are routinely asked to perform so that I could understand what they went through. I was placed in a decompression chamber and the pressure was dropped to simulate high altitude loss of pressure conditions. I learned to recognize the first signs of low pressure and reach for the oxygen mask and place it over my face. I sat in a commercial airliner fuselage with 100 other participants and we had to exit the plane rapidly as the plane filled up with smoke from a fire limiting your visibility to less than an inch in front of your face. I experienced the Vertigon machine which simulated a slow death spin dive – the type of accident that claimed the life of the late John F. Kennedy, Jr.

There was considerable class room instruction and then a test of your competency. Since then I have been performing Class I, Class II and Class III aviation medical exams on civilian pilots, commercial pilots and students hoping to become pilots. Every other year I am required to participate in a refresher training exercise and this year I will be traveling to Tampa, Florida in January for a weekend cardiology seminar. As new data and medical safety information becomes available, the FAA incorporates it into their agenda to improve safety and modernize for the future.

Aviation Medical Candidates (pilots) can now enter their health information in advance of a visit over a computerized network that I retrieve and review with the pilot candidates before their exam. The results of the exam are now transmitted electronically by computer to the FAA in Oklahoma City rather than by mail. If there are questions or concerns about a pilot’s health and safety I can confer with the Regional Flight Surgeon in Atlanta or call the experienced staff in Oklahoma City.

The goal of the FAA is to encourage civilian flight and to find a safe and healthy way to keep existing pilots flying. While the FAA rules and regulations are strict and developed for the pilot and public’s safety, they do not regulate the fees that Aviation Medical Examiners are permitted to charge for the exam. Different offices still charge different amounts for the same examination.

If you are interested in a FAA Flight Physical give my practice a call. We love seeing pilots and pilots in training.

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.