Ideal Cardiovascular Health

You too can have ideal cardiovascular health. What is that you may ask? The American Heart Association has come out with a new report that defines it.

Ideal cardiovascular health means you do all of the following:

1. You do not smoke
2. You are not overweight (normal body mass index, or BME less than 25)
3. You get regular physical activity, about 5 hours a week
4. You eat a healthy diet low in saturated fats and simple sugars

You also have the following:

1. Your total cholesterol is normal (generally below 200 or a healthy ratio of total cholesterol and HDL (good) cholesterol)
2. Your blood pressure is aroung 120/80
3. Your fasting blood sugar is less than 100 (better yet 90 or less)

All of these are within reach of most everyone, with or without treatment. Ideal health is a choice and requires a commitment to action. Go for it. There are no justifiable excuses.

Reference: Circulation: January 20, 2010

The Four Pillars of a Healthy Lifestyle

I recently moved my work to the Palm Springs area of California. I am the Vice President for Primary Care at Eisenhower Medical Center in Rancho Mirage, California. My duties include starting a new primary care practice where I also work as a family physician. This week I developed a preventive medicine presentation I will be giving to groups of people, mostly seniors, in our area. I would like to share my key messages here.

Balance is the key to health in many ways. Our lifestyle choices play the major role in whether we are healthy or sick, outweighing our genetics and the bad luck of getting a disease for no apparent reason. There are four areas where lifestyle play a major role in our health. Do these four things and you are likely to be healthy:

Eat Right: We are what we eat, so what goes in our body is vital to our health. The mainstay of our nutrition should be vegetables and grains. We should avoid the saturated fats found in many animal meats and dairy, and the trans fats found in many fried foods and pastries. Eat healthy fats like those found in nuts and quality vegetable oils, such as canola and olive oil. We should avoid simple sugars that make us hungry and have protein at every meal (Nuts, low fat dairy, lean meats and fish). We should avoid excess salt. Do not eat many more than your body needs to maintain a healthy weight. See my other blogs since I write here about nutrition every month.

Be Active: Use it or lose it is a good rule for keeping our bodies healthy. Look for opportunities in your daily life to walk more, climb stairs and be active. Then, devote 5 of the of the 168 hours in a week to one or more physical activities of your choice. Being physically active is the best long term predictor of living a long and healthy life.

Sleep Well: We trained our children in how to sleep, but many of us forgot the lessons. Prepare for a good night's sleep by winding down our daily activities, turn down the lights, and leave the problems of our day behind. Imagination is ok for adults to use to enter the world of sleep. As adults, 6 to 8 hours of refreshing sleep is usually enough to replenish our bodies.

Manage Stress: Stress can wear down even the healthiest body. Be aware of our stress levels at home and at work, and seek ways to reduce the stressors. Some of us thrive on a certain amount of stress, that is fine. We know when we are distressed because we are not at ease and not smiling as much. I like these three rules for handling stress: 1. Don't sweat the small stuff, 2. Everything (just about) is small stuff, and 3. If you cannot fight, and you cannot flee, then flow.

Take a moment to reflect on these four "pillars" in your life and see what adjustments you can make to preserve your health.

Recent Heart Attack? Consider Cardiac Rehab!

Cardiac rehabilitation, or guided exercise under direction of a physical therapist, is a valuable yet underutilzed therapy for patients suffering a heart attack. Importantly, in those patients with ongoing risk factors related to obesity and insulin resistance/diabetes, aggressive cardiac rehab was recently shown to be especially effective.

Specifically, two groups of patients were enrolled in high intesity (5-7 days weekly of 45-60 minutes exercise) versus standard (3 days weekly of 25-40 minutes exercise).

High intensity patients lost more than twice as much weight over 5 months as standard patients (18 pounds vs. 8 pounds and had significantly greater reductions in 2 major cardiac risk factors -- waist circumference and insulin resistance. At 1 year, both groups had gained a couple of pounds over 5-month weights, but total body-fat percentages in the aggressive group remained significantly lower than initial readings. Other cardiac risk factors changed too - including decreased insulin resistance, increased HDL (good) cholesterol, and decreased measures of insulin, triglycerides, blood pressure, plasminogen activator inhibitor-1, and the ratio of total to HDL (good) cholesterol.

Overall then, patients who took advantage of their motivation after heart attack to aggressively address exercise goals reduced potential risk factors and set the tone for a healthier life. If you have been a heart attack sufferer, ask your doctor about cardiac rehab. If you are not a heart attack sufferer but have risks, ask your doctor about trying a program like this on your own.

Questions and comments welcome as always!

Is it Time to Rethink Aspirin?

Aspirin? - Yes, I should take that to prevent heart attack and stroke, right??
Well......perhaps. A new study (called a meta-analysis), the largest comparative trial of its kind, shows that being overzealous about aspirin use for prevention of initial heart attack and stroke may be unsubstantiated.

Specifically 95,000 subjects were evaluated in this series, producing 1671 strokes and heart attacks in the aspirin group and 1883 in the control group. Aspirin was associated with an absolute reduction of 0.06% heart-related events per year. Correspondingly, aspirin did not significantly reduce ischemic (non-bleeding) stroke risk, but researchers noted a borderline-significant increase in hemorrhagic (bleeding) stroke. Aspirin also increased the incidence of bleeding outside the brain. Overall, aspirin was not associated with a significant reduction in vaascular death.

What does it mean? The advantages of aspirin in low risk patients are scant. As cardiovascular risk factors (like smoking, high cholesterol, high blood pressure, diabetes, family history of early stroke/heart attack) pile up, aspirin gains a bit more support, though there is a modest associated bleeding risk.

We will be following this data and it's analysis further. In the meantime, it may be reasonable to discuss things with your doctor, or perhaps cut aspirin dosing to the appropriate lowest dose (81mg in most patients).

Want the original? See Collins R et al. for the Antithrombotic Trialists’ (ATT) Collaboration. Aspirin in the primary and secondary prevention of vascular disease: Collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009 May 30; 373:1849. We will post the appropriate link after publication to make it easier.

Want To Prevent Stroke? Take 4 Steps

Stroke is a major cause of disability and death in the U.S. and worldwide. Modern medicines like statins (and old ones like aspirin) are helpful in preventing both initial and secondary stroke in patients at risk. But, are there simple things you can do to lower risk?

Yes, you say! Well, indeed, you are correct. Twenty thousand men and women (age range, 40–79) without histories of stroke or heart attack were recently analysed in the U.K. for the effect of 4 simple behaviors: not smoking, regular physical activity, moderate alcohol intake (1–14 drinks weekly), and high fruit and vegetable intake .

Patients engaging in 3 or 4 of the activities were significantly less likely (2 times!) to suffer a stroke over the next decade. Patients who slipped up a bit and only did 1 or 2 of the activities did have significant stroke risk, though not quite as much as those who sat on the sideline and engaged none of the behaviors.

So, grab the baton and step up to prevent stroke. As always, questions and comments are welcome.

Should I Take Zetia or Vytorin?

Effectiveness of the cholesterol medications Zetia (ezetimibe) and Vytorin (simvastatin/ezitimibe) were called into question this week in well-publicized reports from the American College of Cardiology meetings, as published in the New England Journal of Medicine.

Specifically, the ENHANCE trial found that although adding ezetimibe to maximal statin doses over 24 months effectively lowered bad cholesterol (LDL) and inflammatory markers of heart disease risk, it did nothing to decrease the size of cholesterol plaques in the large neck arteries (carotid arteries). Such plaque size is a well-documented marker for heart attack risk.

Importantly, the ENHANCE trial does not raise safety concerns about ezetimibe, but rather questions its effectiveness in achieving one clinical outcome. Additionally, the study was conducted on a select population of patients with familial hypercholesterolemia and a very high mean LDL level of 317. The patients did not achieve the target cholesterol goals known to you loyal Bloggers. These facts make the study outcome difficult to interpret and somewhat controversial.

So, what should you do if you are taking these medicines or if you have non-goal cholesterol levels?
* Achive LDL levels at ATP III-recommended levels.
* Utilize lifestyle changes like diet and exercise in addition to optimal sugar and blood pressure control.
* Realize that statins are the first drugs of choice, and should be titrated to the highest tolerated dose to achieve the target.
* Know that if optimal statin dosing does not achieve the goal, additional therapy is needed. Options include niacin, bile acid resins (like Colestipol), psyllium (like Metamusil), and fibrates (like Tricor), in addition to cholesterol absorption inhibitors like ezitimibe (Zetia). Some authorities believe that the non-ezetimibe options should be tried first given results of prior studies.

Ongoing trials will help clarify these issues further. Stay tuned to the Blog, and, as always, if your levels are not at the goal, ask your doctor "why not?"

Recent Heart Attack? - Take Your Clopidogrel!

Current guidelines recommend taking Plavix (clopidogrel) for 1 year following a heart attack. But what happens at the end of that period? A recent VA study suggests that there is a sort of "rebound period" at the end of clopidogrel therapy that might increase risk.

Specifically, among 3000 patients split between medical therapy and stenting, analysis showed a nearly twofold increase in risk for adverse events during the first 90 days after clopidogrel cessation. The theory is that platelets may become temporarily re-activated, leading to recurrent risk of thrombosis within the artery. The study has some limitations in that it involved a retrospective review of charts, but it does prompt certain steps to be taken by patient and physician:

First, be sure to complete your Plavix therapy for the full duration and then move seamlessly into aspirin therapy as directed. Second, if you have risks for recurrent arterial clogging, like multiple past stents, diabetes, or other uncontrolled risk factors, ask your doctor if extending Plavix therapy is reasonable. Better yet, control those risk factors as we discuss on the Blog!

Management of Chronic Angina

For those of you who've been diagnosed with so-called "chronic angina" or stable chest pain that it attributed to mild to moderate heart disease, medical management has become a preferred strategy. Accordingly, be sure that your treatments are optimal. The following points are taken from recently updated guidelines, include both medications and lifestyle techniques, and are to be used long term.

1. Know Your Blood Pressure:
Blood pressure control should target levels at least below <140/90 (<130/80 for patients with diabetes or chronic kidney disease) and preferentially less than 120/80 for all patients. Patients should be treated with the following blood pressure medications whenever possible: beta-blockers and ACE inhibitors, with the addition of other drugs like diuretics (such as HCTZ or chlorthalidone), if possible, and calcium blockers, if needed.

2. Take aspirin:
Aspirin should be taken daily at 81 mg (or 162 mg post CABG), preferably uncoated, unless there is a contraindication.

3. Exercise:
Daily physical activity is recommended for all patients. It should consist of 30 to 60 minutes of moderate-intensity aerobic activity like walking or swimming; additional resistance training 2 days per week is reasonable.

4.Know your Cholesterol Panel:
For LDL-cholesterol reduction, it is reasonable to aim for levels of <70 mg/dL and to use high-dose statin therapy, as we've discussed here on the Blog previously. Metamusil (pysllium) and plant sterol supplements are also helpful. For non-HDL (the total minus the good kind) and HDL (the good kind) optimization, niacin and fibrates (like Tricor) can be useful medication additions along with exercise, monosaturated oils (like olive oil), fish and fish oils, and nuts from trees (the edible kind - not the human kind).

5. Know your Ejection Fraction (EF):
This is tested via echocardiogram. In the absence of significant kidney dysfunction or high potassium, post-heart attack patients with an ejection fraction <40% and either diabetes or heart failure should receive an aldosterone inhibitor (like Aldactone) in addition to therapeutic doses of an ACE inhibitor and a beta-blocker.

6. Know your BMI:
It should be between 18.5 and 24.9 kg/m2

7. Know your Waist Size:
It should be less than 35 (women) or less than 40 (men).

8. Don't smoke. Period.

9. All patients with heart disease should receive an annual influenza vaccination.

10. Chelation therapy may cause low calcium levels and is not recommended for patients with heart disease.

Review these recommendations against your current medication list and lifestyle plan. If you're not taking these medications or achieving these lifestyle goals, ask your doctor why not.

Youngsters Under 60: Save Yourselves!

Most Americans know that we have made much progress in decreasing rates of heart attack in recent decades. Indeed, modern insights and medicines have produced an overall 50% decrease in heart attack deaths since 1980. Are we, however, maintaining that decrease appropriately in more recent years. Recent data say "NO."

Specifically, among men between 35-54, the annual decrease in heart attack deaths has slowed from 6.2% (1980 to 1989) to 2.3% (1989 to 2000) to 0.5% (2000 to 2002). Among women age 35-54, the decline was 5.4% from 1980 to 1989 and 1.2% from 1989 to 2000. From 2000 to 2002, however, the estimated death rate increased to 1.5% annually. By contrast, for men and women 55 and older, the rate of decrease accelerated comfortably with time.

Overall then, modern preventative cardiology is working for older patients; for the young, however, especially young women, we need to pay more attention. Loyal Bloggers know what preventative steps to take from our prior posts - so spread the word so that the young can stay "young at heart."