Fish, Fish Oils and Cardiovascular Disease

Years ago the scientific researcher responsible for the promotion of fish oils as an antioxidant and protector against vascular disease recommended we all eat two fleshy fish meals of cold water fish a week. He continued to endorse this dietary addition and included canned tuna fish and canned salmon in the types of fish that produced this positive effect.

Over the years I heard him lecture at a large annual medical conference held in Broward County and he fretted about the growth of the supplement industry encouraging taking fish oils rather than eating fish. He worried about the warnings against eating all fish to women of child bearing age because of the fear of heavy metal contamination and knew that the fish oils and omega 3 Fatty Acids played a developmental role in a growing fetus and child.

I then attended lectures, in particular one sponsored by the Cleveland Clinic, during which they promoted Krill oil as the chosen form of fish oil supplements because it remained liquid and viscous at body temperature of 98.6 while others solidified. I listened to this debate only to hear the father of the science speak again and this time advocate that one or two fleshy fish meals a month was adequate to obtain the protective effect of Omega 3 Fatty acids. He felt that the supplements did not actually provide a protective effect as eating real fish did. Since I love to eat fresh fish I had no problem with this message but others are not comfortable buying and preparing fish at home or eating it at a restaurant. Supplements to them were the answer.

Steve Kopecky, M.D. examined the question in an article published in JAMA Cardiology this week. He looked at 77,917 high risk individuals already diagnosed with coronary artery disease and vascular disease who were taking supplements to prevent a second event. His study concluded that taking these omega 3 supplements had no effect on the prevention of recurrent cardiovascular events. The study did not discuss primary prevention for those who have not yet had a vascular illness or event.

Once again it seems that eating fish in moderation, like most anything, is the best choice. I will continue to eat my fresh fish meals one or two times per week, not necessarily for the health benefit but because I enjoy eating fresh fish.

I advise those worried about preventing primary or secondary heart and vascular disease to find a form of fish they can enjoy if they want this benefit. If you really wish to reduce your risk of a cardiovascular event; I suggest you stop smoking, control your blood pressure and lipid profile, stay active and eat those fresh fish meals.

Testosterone Therapy in Low T Syndrome in Veteran’s tied To Higher Cardiovascular Risk.

Cardiovascular RiskMedPage Today is reporting a Veteran’s Affair study which indicates that men with and without coronary artery disease who received testosterone supplements had a higher risk of death, heart attack and stroke.  The current study looked at 8709 veterans who underwent coronary angiography between 2005 and 2011 and had a testosterone level less than 300 ng/dL.  These findings surprised researchers who had looked at a previous VA study that suggested that testosterone therapy reduced cardiovascular risk.

Steven Nissen, MD of the Cleveland Clinic, a world respected cardiologist felt the study was a “red flag” that “demands attention from not just physicians but also from regulators.”  He is concerned about the “increasingly commonly prescribed (testosterone replacement therapy) “practice which is largely “fueled by direct to consumer advertising that’s urging men to get tested for low testosterone and then to seek replacement.” Nissen pointed out that in both men and women a drop in hormone levels is a normal part of aging and it is not necessarily a disease. “Making it into a disease may end up causing more harm than good.”

Anne R. Coppola, MD of the University of Pennsylvania in an editorial noted that “what is missing from the literature are data from randomized trials that include a sufficient numbers of men for an adequate amount of time to assess the long term benefits and risks of testosterone therapy.”   She cited a small study called the Testosterone Trial in Older Men which had to be stopped early because of a higher rate of cardiovascular events “in the group taking testosterone.

In our market you cannot turn on a sports talk radio show or ride down an Interstate highway without seeing ads for “Low- T Syndrome.”  It is a highly profitable cash business being fueled by testimonials and word of mouth rather than well planned medical studies. Legitimate research is ongoing at Harvard Medical School but it is difficult for others to obtain funding when the producers of the product can make so much money based on here say and nothing else. The number of prescriptions for testosterone products has increased since 2000 from 5.3 million to 1.6 billion.  The American College of Endocrinology has clear and strict guidelines on when supplementation in young men is appropriate. There is a large anti-aging medical community who feel that even if you are older and have normal levels you will feel better and benefit from supplementation. This research questions that feeling and begs for regulators to step in and stop an unproven possibly dangerous practice until we have more data.

 

Gum Health Associated With Carotids

GumsOver the years I have attended lectures led by Bradley Bale, MD and Amy Doneen, RN who promote the theory that inflammation is one of the major causes of acute heart attack and stroke.  They measure inflammation in men and women with normal lipid levels, normal blood pressure who are non-smokers and exercise but still have cardiovascular events such as heart attacks and strokes.  They talk about the formation of soft lipid plaque or foam cells forming in the walls of the blood vessels and then erupting into the lumen of the blood vessel under the influence of inflammation setting off a clotting cascade that leads to heart attacks and strokes acutely. They measure the degree of inflammation using a series of blood tests patented by the Cleveland Clinic and look for atherosclerosis by doing carotid ultrasounds in a special way to measure carotid artery intimae thickness which they believe correlates with the presence of atherosclerosis, soft plaque and the risk of an acute event.  When all traditional major  risk factors such as smoking, blood pressure, blood glucose level, high blood pressure , activity level and family history have been taken into account and treated there are individuals who still have inflammation and acute events.  They believe oral periodontal disease is the culprit and suggest treating it.

They receive confirmation of their theory in an online article in the Journal of the American Heart Association written by Moise Desvarieux, MD, PhD of Columbia University’s Mailman School of Public Health in NYC with his colleagues.  They demonstrated that by reducing periodontal disease over a three year period there was less progression of carotid artery intima media thickening.  As the gums improved and the oral microbes that are associated with periodontal disease decreased the progression of intimal thickness slowed.

It is clear that more research is needed but while it is ongoing simply seeing your dentist regularly and caring for your teeth and gums can go a long way to reducing your risk of a heart attack or stroke. The long hypothesized relationship between mouth disease and vascular disease has much stronger evidence after this study and it makes it necessary for those of us discussing prevention and risk factor reduction to ask you at your visits “are you up to date on your dental visits and dental hygiene?” It additionally adds clout to the argument that health insurance includes dental coverage as well!

Pradaxa: More Concerns. More Myocardial Infarctions?

Pradaxa is part of a new group of anticoagulants (thrombin X inhibitors) that eventually will allow anticoagulation by the pill route without requiring patients to alter their food and medication intake and avoid foods and medications that interfere with the anticoagulant as patients must do with Warfarin. Pradaxa additionally eliminates the need to take blood tests (INR/ PT) to monitor the dosage as one has to do with Warfarin (Coumadin).

There is a large commercial advertising campaign underway on TV and print media to encourage patients with atrial fibrillation to ask their doctors to switch them from Coumadin to Pradaxa (Dabigatrin).  The campaign bases its claims on the RE-LY trial of 18,000 patients at 80 medical centers throughout the world who took the 150 mg dosage and had significantly fewer strokes than patients taking Warfarin.  The original study was criticized because many of the patients in the Warfarin (Coumadin) group were not on enough Warfarin or at a therapeutic PT/INR to prevent embolic strokes so the comparison with Pradaxa may not be valid. Another criticism involved the fact that Pradaxa can cause major bleeding and there is no antidote to stop the bleeding. Patients on Pradaxa who are bleeding are advised to undergo hemodialysis to remove the drug from their system because there are no medications or treatments available to stop Pradaxa related bleeding.

One wonders how the Food and Drug Administration approved this product for general use under these circumstances without conducting further testing?  The issue becomes even more confusing with the addition of data presented by Ken Uchino, MD, and Adrian Hernandez MD, PhD of the Cleveland Clinic in the online version of the Archives of Internal Medicine. They claim that by reviewing the RE-LY data there is a 38% relative increase in the risk of a myocardial infarction (MI) or heart attack in the Pradaxa group. In an accompanying editorial in the same journal, clinicians at the Hadassah- Hebrew University Medical Center in Jerusalem wrote, “The robust finding that Dabigatran is associated with increased rates of MI (heart attack) is alarming and emphasizes the need for continued critical appraisal of new drugs after phase III trials.”

In my practice I generally will not switch to a new or controversial medication until it has been on the US market for at least one year. I make exceptions for orphan drugs, products to treat incurable diseases with no other choices available. The 12 months gives the medical and scientific community a chance to see how the medication performs and what unexpected adverse effects may be associated with it.

Thrombin X inhibitors are the wave of the future. With no way to stop the bleeding, and data on their safety and efficacy still accumulating, they are just not ready for prime time yet.