CAC Score: 96% Accuracy Not Good Enough For Trial Lawyers

Coronary artery calcium scoring, increasingly popular in emergency departments, could misdiagnose four of every 100 patients with significant blockages in their heart arteries, according to the latest research.

Chest pain is one of the most common reasons for an emergency department visit and hospitalization.  It can be life-threatening.  Or it could be a simple chest wall muscle strain.  Much time and money is spent trying to find the cause before it's too late.  Blocked heart arteries is one of the five or six serious, life-threatening causes of chest pain. 

I've written previously about the various tests for blocked arteries in the heart.  Angiography remains the gold standard even though it's riskier than the other tests since it is invasive: needles, catheters, dye injection, etc.  Expensive, too. 

Everyone would like a safer, cheaper, quicker alternative to coronary angiography for chest pain in the emergency department.  One option is determination of heart artery calcium by CT scanning, otherwise known as the CAC score (coronary artery calcium score).  Over time, most blocked heart arteries develop calcium deposits.  But not all heart arteries with significant blockages have the calcium that can be detected by a CT scanner. 

The Multi-Ethnic Study of Atherosclerosis enrolled 6,814 subjects who were free of heart symptoms at baseline.  Over half of these had no CT-detectable calcium in their heart arteries at baseline - a good thing, and generally considered to indicate low risk for future heart disease.  However, over the next 18 months, 175 of the study participants ended up needing coronary angiography. 

In nearly all cases, the extent of heart artery calcification at baseline was directly related to the degree of artery obstruction found at angiography.  But 4% of angiograms showed significant obstruction despite a zero calcium score. 

A four percent misdiagnosis rate might be acceptable to most patients and many physcians, but it won't satisfy a trial lawyer.  He'll be quite happy to sue the ER doctor who gambled and lost on that misdiagnosis rate.  The lawyer is likely to win the case. 

How about avoiding chest pain, ER physicians, and personal injury lawyers altogether?  NutritionData's Heart Health section has some good ideas for you.

-Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

Reference:  Rosen, B.D., et al.  Relationship between baseline coronary calcium srore and demonstration of coronary artery stenosis during follow-up.  MESA: Multi-Ethnic Study of Atherosclerosis.  Journal of the American College of Cardiology Imaging, 2 (2009): 1,175-1,183.

Heart Failure Patients, Is Your Doctor Overlooking a Simple Life-Saving Treatment?

Only one out of three heart failure patients is sent home from the hospital with instructions to take a specific drug proven to prolong life and reduce hospitalization rates, according to the latest research.

In 2007, the American Heart Association estimated that 5.2 million in the U.S. had heart failure.  For perspective, the U.S. population is about 300 million.  At age 40, your risk of ever developing heart failure is one in five.

Five years after a diagnosis of heart failure, 50% of those so diagnosed have died.  And this is with treatment.  So heart failure is a serious marker of diminished lifespan.

The American College of Cardiology and the American Heart Association have issued evidence-based guidelines for treatment of heart failure that include a class of drugs called aldosterone antagonists.  By far the best-known drug in the class is spironolactone (brand name Aldactone, among others).  It's relatively cheap and well-tolerated.

Researchers with the Cleveland Clinic in Ohio analyzed over 43,000 patients admitted to one of 241 hospitals participating in the "Get With The Guidelines" quality improvement project.  They found that only one of every three candidates for aldosterone antagonists were prescribed the drug by the time of hospital discharge.  Moreover, in a large majority of cases they found no valid reasons for failure to prescribe.

The Take-Home Point

If you are a heart failure patient and not taking an aldosterone antagonist, ask your doctor why not.  She may have a good reason.  But it may be a simple oversight and she'll thank you for bringing it to her attention.  Don't hesitate to mention it: your life could depend on it.   

-Steve Parker, M.D.

Reference:  Albert, N.M., et al.  Use of aldosterone antagonists in heart failure.  Journal of the American Medical Association, 302 (2009): 1,658-1,665.

That's Just Great: ANOTHER Epidemic to Worry About!

Metabolic Syndrome affects nearly four of every 10 adults in the U.S., yet most people aren't familiar with it.  The syndrome itself is without symptoms.  The problem is that Metabolic Syndrome increases your risk of type 2 diabetes by five-fold, and doubles your risk of developing cardiovascular disease - heart attacks, strokes, poor circulation - over the next five to 10 years.

"How would I know if I have Metabolic Syndrome?" 

Your doctor might tell you, or you can determine it yourself if you know some of your lab values and blood pressure.  The syndrome is defined simply by the presence of at least three of the following five criteria:

1. Waist circumference over 102 cm (40 inches) in men, or over 88 cm (35 inches) in women
2. Serum triglycerides over 150 mg/dl (or already on drug therapy for high triglycerides)
3. HDL cholesterol under 40 mg/dl (men) or under 50 mg/dl (women) (or on already on drug therapy for low HDL)
4. Systolic blood pressure over 130 mmHg and/or diastolic over 85 (systolic is the first or top number) (or already on drug therapy for high blood pressure)
5. Fasting blood glucose level over 100 mg/dl (or already on drug therapy for elevated glucose)

Some physicians argue that there's no reason to label someone as "Metabolic Syndrome."  Others feel that the moniker has helpful therapeutic impact.  The can say, "Look, Mr. Johnson, I care about you and your future health.  Since you have Metabolic Syndrome, over the next decade you have a five-fold increased risk of diabetes and double the risk of heart disease.  Let's talk about how we might reduce that risk before it's too late."

"How can I prevent or even treat Metabolic Syndrome?"

Work with your personal physician, of course.  And consider the following information available at NutritionData:

• Lose excess fat weight
• Start exercising regularly
• Low-glycemic-index eating increases HDL cholesterol, lowers triglycerides and blood sugar, and reduces risk of type 2 diabetes
• The DASH diet lowers blood pressure

-Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

Drugs Don't Work If You Don't Take Them? DUH!

High blood pressure patients who don't take their medications are at major risk of medical complications, according to a new report in the journal Circulation. 

Sure, drug therapy can be exensive and have bothersome side effects.  Medical skeptics invoke Big Pharma conspiracy theories to impugn physician motives for prescribing.  But there's little doubt that blood pressure drugs are effective in reducing rates of cardiovascular events such as heart attacks, strokes, and cardiac deaths.

Italian primary care physicians followed almost 19,000 newly diagnosed high blood pressure patients over the course of five years.  Average age was 62 and they were free of heart disease and strokes at baseline.  One or more drugs for daily use were prescribed.  Adherence to the medication regimen was noted as either high (taking the drugs at least eight of every 10 days), intermediate (taking drugs four to eight of every 10 days), or low (taking drugs less than four of every 10 days). 

Guess how many patients were in the low adherence group . . . . . . . . . . half of them!  Compliance may not be much different in the U.S. 

Compared with the low adherence group, the high adherence group had 38% fewer cardiovascular events such as heart attacks, chest pain, strokes, and heart-related deaths. 

The lesson is clear: If you have high blood pressure and want to reduce the associated medical risks, take your drugs. 

-Steve Parker, M.D.

References: 

Mazzaglia, G., et al.  Adherence to antihypertensive medications and cardiovascular morbidity among newly diagnosed hypertensive patients.  Circulation, 120 (2009): 1598-1605.  Published online ahead of print October 5, 2009

Lowry, Fran.  High adherence to antihypertensive therapy lowers cardiovascular risk.  TheHeart.org, October 9, 2009.

Salt Restriction: Good In Theory, But Impossible to Implement?

Reducing salt intake might be a good idea, but it may not matter since our bodies have irresistible physiologic mechanisms to defend a higher level of salt intake, according to a new report in the Clinical Journal of the American Society of Nephrology.

Another push to lower salt (actually, sodium) intake in the American public started a few years ago.  The idea is that sodium restriction will lower blood pressures, leading to fewer heart attacks and strokes.  That proposition itself is debatable.  The medical/nutrition community hotly debated it 20 years ago.  There are reasonable arguments on both sides.

The authors of the study at hand don't address whether sodium restriction would be healthful.  They question whether any measures at the public health level can even work.  Their answer: probably not.

The Institute of Medicine in 2003 recommended 2,300 mg/day as the upper limit of dietary sodium.  The USDA's 2005 Dietary Guidelines recommend 1,500 mg/day for people at risk of hypertension.

The authors conclude that the average person has powerful physiologic mechanisms working to keep sodium intake around 3,000 mg/day, at least. 

They studied the salt consumption of widespread, diverse populations, including those who were carefully instructed and motivated to reduce salt intake.  In this case, it seems you just can't fight Mother Nature.

I think perhaps two of every 10 people may have blood pressures sensitive to salt intake.  Let's try to identify and target them for intervention rather than attempting sweeping societal changes that affect us all.

If I had elevated blood pressures, I'd make an attempt to reduce my sodium intake over a two or three month trial and note the effect.  You can calculate and monitor your sodium intake with NutritionData's "My ND/My Tracking" feature.  I'd also start exercising regularly and lose my excess body fat.

-Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

References:  McCarron, David, et al.  Can dietary sodium intake be modified by public policy?  Clinical Journal of the American Society of Nephrology.  4 (2009): 1,878-1,882.

Heart Disease in Women vs Men: Two Different Diseases

Up to 50% of women with heart disease symptoms do not have the typical blocked heart arteries seen in men.  Instead the problem seems to lie in the small arteries of the heart not even seen on traditional angiograms, according to a state-of-the-art paper in a recent Journal of the American College of Cardiology.

Physicians are having to re-think our whole approach to women with heart disease symptoms but no atherosclerotic obstructions in the major heart arteries.  The "plumbing model" serves men fairly well; women, not so well.  Yearly in the U.S., more women than men die from heart disase: 455,000 versus 410,000. 

Are the higher cardiac deaths in women related to their higher average C-reactive protein levels, a marker of inflammation and predictor of heart disease?  We don't know yet.

The authors of the paper speculate that abnormal reactivity in the small heart arteries leads to poor blood flow (ischemia) to the heart muscle.  They propose the term "Ischemic Heart Disease" be applied to this phenomenon, reserving "Coronary Heart Disease" for obstructions in the large arteries.

Lead author Leslee Shaw, Ph.D., discussed the journal article in an interview. 

We have drug therapies that reduce chest pain and improve quality of life associated with small artery ischemia.  We need much more research, especially with regards to prevention of heart failure and death in women.  Recognition of the fact that heart disease in women is not the same as in men should lead to better quality research. 

But you don't have to wait years for research results.  You can start today to reduce your heart disease risk: visit NutritionData's Heart Health section. 

-Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

References: 

Shaw, Leslee, et al.  Women and ischemic heart disease.  Journal of the American Journal of Cardiology.  54 (2009): 1,561-1,575.

Interview with the article's lead author

This Drug Interaction Could Ruin Your Hot Date

Men with heart disease who combine their nitrate drug therapy with Viagra are in for a dangerous surprise: fainting and severe low blood pressure. 

I saw the Viagra ad on TV again last night: "Be sure to ask your doctor if your heart is healthy enough for sexual activity."

Men start having heart attacks at an age when many also start using Viagra, Cialis, and Levitra for erectile dysfunction (ED).  Men and women who have had heart attacks are often prescribed nitrate drugs to be used either continuously or intermittently to suppress chest pains.  Combining any of the ED drugs with nitrates is likely to land a man in the ED - Emergency Department, that is - because the resulting low blood pressure causes loss of consciousness. 

Nitrate drugs have lots of different names.  If you're a man in this category and unsure if you're on a nitrate, check with your doctor or pharmacist.  Common nitrates include nitrogycerin (NitroQuick, Nitro-Dur, Transderm-Nitro, Nitro-Bid), isosorbide mononitrate (Imdur, Ismo), isosorbide dinitrate (Isordil, Sorbitrate, Iso-Bid).

This drug interaction is one reason why it's not a good idea to share your drugs with other people.  You may want to help a buddy out by giving him one of your Viagras, but he may not volunteer that he's taking a nitrate for heart disease.  After he combines the two, you may lose a friend.

If you've take one of these ED drugs, your body will eventually clear it out of your system.  Clearance takes 24 hours for Viagra and Levitra, 48 hours for Cialis.  After that, it's generally safe to take a nitrate for your heart. 

-Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any medication, dietary, or exercise changes.

A Heart Attack Isn't a Death Sentence for Your Sex Life

A heart attack will definitely put a damper on your sex life, but it's only temporary.  Nearly all heart attack patients can return to satisfying sexual activity, with a few precautions.

I recently wrote about the odds of a sex-induced heart attack among the general poplulation.  The risk is higher in those who have already had a heart attack or heart pain called angina.

Problems with sexual functioning after a heart attack occur in at least half of patients.  They worry about triggering another heart attack or even sudden death.  They may be depressed or anxious about the new diagnosis.  Heart drugs may interfere with sexual function.  None of these issues are aphrodesiacs.

Safe resumption of sexual activity after a heart attack depends on medical factors specific to an individual.  Is there ongoing chest pain (angina)?  Is blood pressure controlled?  How out-of-shape is the person?  Are there serious heart rhythm disturbances? 

After a heart attack, reducing the risk of a future sex-induced heart attack boils down to:

• managing or resolving chest pain, high blood pressure, rhythm disturbances, and breathing trouble
• passing an exercise stress test
• drug therapy usually including a beta blocker and aspirin

You'll have to work with your personal physician on these.

Note also that regular exercise also leads to "safer sex."  Your doctor can refer you to a cardiac rehabilitation program or you can get started with Four Weeks to a Fitter You if your doctor approves.

-Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

Does Sex Cause Heart Attacks?

I have good news and bad news.  Which do you want first?  OK.  Yes, sexual activity does cause heart attacks, but not many.  And you can take steps to reduce sex-induced heart attacks.

If you watch TV, you can't miss all those adds for Viagra, Cialis, and Levitra.  One of them cautions, "Be sure to check with your doctor to see if you're healthy enough for sexual activity."  In over two decades of medical practice, I've had only two people ask me; they had previous heart attacks.

I'll assume you have a good idea what I mean by sexual activity.  Two consenting adults, more than just a peck on the cheek . . . Intercourse, in other words.

Early studies of volunteers in labs showed dramatic changes in vital signs during sexual activity: heart rates up to 140-180 beats per minute, blood pressures increased by 80 points, respiratory rates comparable to moderately severe physical exertion.  That could put a major strain on the heart and cause a heart attack in someone with risk factors.

Later studies of married couples in real-life settings found heart rates averaged 117 (lower than rates during normal daily activities), and blood pressures around 160/90 mmHg.  The work load of average sexual acitivity is equivalent to walking at 2-4 miles per hour on a level surface.  Your mileage may vary.

Surveys of heart attack patients reveal that the relative risk of a heart attack within two hours after sex is 2.5.  Huh?  If your risk of a heart attack at a given time is 1 in 5000, your risk of a heart attack within two hours of sex is 2.5 in 5000.  [I pulled 1 in 5000 out of thin air for illustrative purposes.]  Risk is less in people who exercise regularly. 

Put in other terms, sexual activity contributes to onset of heart attack in only 1% of patients.

Several conditions increase the risk for a sex-induced heart attack: prior heart attack, other known heart diseases (e.g., angina, heart failure, heart valve problems, rhythm disturbances), previous heart bypass or angioplasty,  and uncontrolled high blood pressure.  Work with your doctor to manage these.  A treadmill stress test can be very reassuring.

Also, increase your fitness level through regular exercise.  NutritionData's Four Weeks to a Fitter You will help you get started.

-Steve Parker, M.D. 

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

Will Mercury in Fish Make You "Mad as a Hatter"?

A new study published in Hypertension suggests that mercury in consumed fish may raise blood pressure, a risk factor for heart disease.  Readers of this blog may recall that I advocate fish consumption for its heart-healthy benefits. 

The news was covered by HealthDay (MedlinePlus), who quotes the lead investigator, Dr. Eric DeWailly, saying, " For every 10 percent increase in blood mercury level, there is a 0.2 millimeter increase in blood pressure.  Even if you apply that to an entire population, that is a small effect."

I agree!  I wouldn't worry about it.

But the report reminded me of the fear of mercury poisoning that inhibits fish consumption by a number of people.  Mercury toxicity is potentially much more dangerous than these tiny blood pressure elevations among Inuit with very high fish consumption.

What does mercury poisoning - methylmercury, actually - from fish look like in an adult? It mainly affects the nervous system and kidneys. 

The central nervous system would be affected first: numbness or tingling around the mouth, malaise, loss of peripheral vision, hearing loss, unsteady gait. You could see one of these, or all.   Later, the kidneys start losing protein into the urine, leading to nephrotic syndrome: swollen legs, fluid retention, and low blood albumin level. 

Remember The Mad Hatter in Alice in Wonderland?  Felt hat makers formerly used mercury in the manufacturing process.  Severe poisoning with mercury, usually by inhalation, can cause psychiatric changes including insanity or "madness."  Mercury poisoning from fish won't make you go crazy.

How common is fish-related mercury poisoning in the U.S.?  In over 20 years of practice, I've never seen a case of it.  Nor have the physicians in my circle of colleagues.  And I worked on the Gulf Coast for twelve years.  If you think you may have mercury poisoning, have your doctor check a blood or urine level. 

For more information on mercury, visit MedlinePlus.

Also search Monica Reinagel's Nutrition Data Blog.  She's written extensively about fish, including Fishing for Answers.

-Steve Parker, M.D.

Reference: DeWailly, Eric, et al.  Environmental mercury exposure and blood pressure among Nunavik Inuit adults.  Hypertension online October 5, 2009.  doi: 10.1161/HYPERTENSIONAHA.109.135046