Inflammation and Increased Risk of Cardiovascular Disease

For years, experts have noted that up to 50% of men who have a heart attack do not have diabetes, high blood pressure, high cholesterol, do not smoke and are active. This has led to an exploration of other causes and risk factors of cardiac and cerebrovascular disease.

In recent years, studies have shown an increased risk of cardiovascular disease in patients with rheumatoid arthritis, in untreated psoriatic arthritis and in severe psoriasis. We can also add atopic eczema to the list of cardiovascular risk factors.

In a publication in the British Medical Journal, investigators noted that patients with severe atopic eczema had a 20% increase risk in stroke, 40 – 50% increase risk of a heart attack, unstable angina, atrial fibrillation and cardiovascular death. There was a 70% increased risk of heart failure. The longer the skin condition remained active the higher their risks.

The study looked at almost 380,000 patients over at least a 5 year period and their outcomes were compared to almost 1.5 million controls without the skin conditions. Data came from a review of medical records and insurance information in the United Kingdom.

It’s clear that severe inflammatory conditions including skin conditions put patients at increased risk. It remains to be seen whether aggressive treatment of the skin conditions with immune modulators and medications to reduce inflammation will reduce the risks?

It will be additionally interesting to see what modalities cardiologists on each side of the Atlantic suggest we should employ for detection and with what frequency? Will it be exercise stress testing or checking coronary artery calcification or even CT coronary artery angiograms? Statins have been used to reduce inflammation by some cardiologists even in patients with reasonable lipid levels? Should we be prescribing statins in men and women with these inflammatory skin and joint conditions but normal lipid patterns?

The correlation of inflammatory situations with increased risk of vascular disease currently raises more questions with few answers at the present time.

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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.

Statins May Reduce Your Energy Level

Beatrice A. Golomb, MD, PhD. of the University of California San Diego and colleagues discussed the results of their ongoing studies in the Archives of Internal Medicine online edition regarding cholesterol lowering drugs Simvastatin and Pravastatin and recipients’ perception of their energy level. Their research suggested that Simvastatin might leave its users, especially women, feeling tired and drained after exertion.  The scores hinted that almost 40% of women felt more tired and fatigued during physical activity on Simvastatin than without the lipid-lowering drug.

The trial included 1,016 men and women with low-density lipoprotein (LDL) cholesterol screened at 115- 19- mg/dL who were randomized to receive 20 mg Simvastatin, 40 mg Pravastatin, or placebo each day for 6 months. These patients did not have documented heart disease, cardiovascular disease or diabetes.

There was a worsening of perceived energy level and exertion related fatigue in 4 of 10 women on Simvastatin. The effect was much less, and not significant, with Pravastatin or placebo.   In a recent review of statins and adverse effects in the Cleveland Clinic Journal of Medicine, the authors pointed out that muscles performing work required  fats and lipids as a source of fuel and energy to work successfully. They hypothesized the possibility that the goals of cardiology to reduce lipid levels to prevent cardiovascular disease to extremely low levels may create an environment in working muscles where the lipid levels are too low to generate the fuel or energy needed to perform the exercise and work needed to be done.

Clearly, further research needs to be done.  We must remember all these participants DID NOT have vascular disease and this is a primary prevention study to prevent them from developing cardiovascular disease.  Might there be other methods to achieve this?  Is Simvastatin the only statin to cause this type of problem or will the other statins do the same?  Is this a problem of the particular generic brand of Simvastatin used or is it an across the board effect of Simvastatin?  All these questions require additional research to obtain the answers that we need.

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.