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.

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.

You See a Man Collapse at the Mall. What Do You Do?

Over a million Americans have take CPR (cardiopulmonary resuscitation) classes.  Most don't remember the proper ratio of chest compressions to breaths.  A recent study found that it's far more important to give chest compressions than mouth-to-mouth breathing.  In fact, doing chest compressions and not giving any breaths at all is helpful.  Do both if you can, but don't be paralyzed with indecision.

CPR provides some oxygen and blood flow to someone who is not breathing or is without a pulse (no blood flow).  Of course, the victim is unresponsive and not moving.  The underlying cause in adults is often a rhythm disturbance in the heart: ventricular fibrillation or ventricular tachycardia.

During adult CPR, the current recommendation is for 30 chest compressions, then two breaths, then 30 compressions, then two breaths, and repeat the cycle until paramedics arrive and take over. 

Many people, even health professionals, are hesitant to administer mouth-to-mouth breathing to cardiopulmonary arrest victims.  You might have to deal with vomit and germs, etc. 

My point today is that you might save a life if you just give chest compressions without mouth-to-mouth.  

Here's what to do when you see that 60-year-old man suddenly collapse while window shopping outside Victoria's Secret.  You don't have to do it all yourself; enlist bystanders:

• Confirm that he's unresponsive and not moving
• Call 911 (or your local emergency medical service)
• Get an AED (automatic external defibrillator) if available
• Check to see if the victim is breathing. If not, give two quick breaths that make his chest rise.
• Check for a pulse if you know how.  The neck is the easiest place. No pulse? Then start chest compressions, hard and fast (100 per minute, depressing the chest 1.5 to 2 inches).  After 30 compressions, give two breaths.  Then resume compressions (30), then two breaths, etc., until paramedics arrive and take over.

If someone found an AED and you're pretty sure the victim is pulseless, go ahead and try to use the defibrillator.  They're automated; a recorded voice and pictures walk you through it.  By this time, at least a couple minutes have passed and you have nothing to lose.

Don't feel bad if you can't remember this sequence and all the steps. If the victim is unresponsive, breathing ineffectively or not at all, and has no pulse, at least start chest compressions.

With luck, others will be there to help. You and the team may save a life. 

For CPR classes in your area (U.S.), call 877-242-4277.

-Steve Parker, M.D.

References: 

2005 Adult Basic Life Support Guidelines from the American Heart Association

Christenson, Jim, et al.  Chest compression fraction determines survival in patients with out-of-hospital ventricular fibrillation.  Circulation, online September 14, 2009.  DOI: 10.1101/CIRCULATIONAHA.109.85222

Left Main Heart Disease: Less Work for Surgeons, More for Cardiologists

More heart disease patients can now avoid the pain and long recovery of heart bypass surgery by substituting heart artery angioplasty, according to several recent studies.  This issue involves the single most important heart artery, called the "left main."

Remember that your heart is a hollow muscle that pumps blood, beating 100,000 times a day. Like every exercising muscle, it needs a good blood supply.  "Hardening of the arteries" gradually clogs those arteries, reducing blood flow, and predisposing to heart attack and death.  Management of these blockages could involve drug therapy, angioplasty, bypass surgery, or a combination. 

Bypass surgery involves putting the patient to sleep with anesthesia, cutting the breastbone wide open, and stopping the heart while the surgeon sews in new vessels to bypass clogged segments of heart arteries.  Recovery takes at least 6-8 weeks. 

Angioplasty is much less invasive, with minimal recovery time.  Read details about angioplasty here.

Traditionally, two types of patients have the best outcomes from bypass surgery compared with drug therapy and angioplasty:

1. Multivessel disease, meaning three or more arteries with major blockages.
2. Left Main disease.  The "left main" heart artery supplies about 2/3 of all blood flow to the heart muscle, so it's obviously important.  Many physicians refer to a blockage in the left main artery as a "widowmaker."

Technical advances in angioplasty over the last 10 years now make angioplasty equivalent to bypass surgery for blockages in the left main artery.  The main advance has been use of stents that prevent an angioplastied artery from closing off in the future.  Better drugs to prevent blood clots also help.

The ultimate decision to approach a left main artery blockage with angioplasty vs bypass vs drug therapy depends on characteristics of the individual patient.  For instance, the exact location and length of the blockage may make angioplasty impossible due to techical limitations beyond the doctor's control. 

For more ideas on avoidance and management of heart artery blockages, visit NutritionData's Heart Health Section.  And pick the right parents. 

-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:  O'Riordan, Michael.  LE MANS registry: Experts call for relaxation of PCI guidelines in left main disease.  HeartWire, August 20, 2009.

"I got a generic instead of the brand-name drug. Is that OK?"

A 2008 review in the Journal of the American Medical Association indicates that most generic drugs for heart disease are just as good as the brand-name drugs.  This is great news for people who think that generics are just designed to save money for health insurers who pay for drugs. 

Researchers with Harvard Medical School reviewed 47 scientific journal articles that tested effectiveness of common cardiovascular drugs, comparing the brand-name drugs with generic counterparts.  They found strong evidence for the equivalency of generics and brand-name drugs in following classes:

• beta-blockers  (examples: Tenormin, Lopressor)
• diuretics  (examples:  Lasix, Hydrodiuril)
• calcium-channel blockers  (examples: Cardizem, Norvasc)
• warfarin  (example: Coumadin)

They found far fewer comparison studies involving antiplatelet agents, ACE inhibitors, and heart rhythm stabilizers, so no firm concusions were possible. 

It takes millions of dollars for a drug company to bring a new drug to the marketplace.  They have to discover or create the drug, test it thoroughly, then market and distribute it.  If the drug is a dud, the investment is a total loss.  Once on the market, adverse effects may show up later, leading to multi-million dollar lawsuits.  Remember the arthritis drug, Vioxx, and suspicions that it caused heart attacks? 

This is why so many new drugs are very expensive.  Patent protection - effectively for seven to 12 years - allows the drug manufacturer the chance to recoup investment dollars and make a profit.  After the patent expires, other manufacturers can make the drug and sell it at a lower cost, saving money for you and your health insurer.  Enjoy your savings.

-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: Kesselheim, A.S., et al.  Clinical equivalence of generic and brand-name drugs used in cardiovascular disease.  A systematic review and meta-analysis.  Journal of the American Medical Association, 300 (2008): 2,514-2,526.

Is Your Cardiologist Too Aggressive?

If your cardiologist recommends a cardiac catheterization to you when you are doing perfectly well, he may be overly aggressive in managing coronary heart disease.  Show him the reference below for his review.  Coronary angiography is, after all, a prelude to angioplasty.  If a blocked artery is found, it is very tempting to try opening it up with a balloon (angioplasty).

The problem is, that probably won't help you one bit. 

Let's say you had a heart attack a year ago.  You feel fine now.  No chest pain, dizziness, fatigue, trouble breathing, or palpitations. 

At you next check-up, your cardiologist recommends a cardiac stress test on a treadmill, "just to see how you're doing."  After that, he recommends coronary angiography - squirting dye into your heart arteries through a tube - to clarify the severity and exact location of suspected blocked arteries.   

An analysis of multiple studies published earlier this year in Lancet compard the management of coronary heart disease with 1) medical therapy (drugs and lifestyle modification), 2) percutaneous transluminal angioplasty, 3) bare-metal stents, and 4) drug-eluting stents.  The latter three are types of PCI: percutaneous coronary intervention.  Researchers studied outcomes of these therapies in terms of prevention of death and heart attacks. 

They found that medical therapy was just as good as angioplasty and stenting in people with stable coronary heart disease.

Percutaneous coronary interventions should be reserved for unstable coronary disease, including heart attacks and selected patients with unstable angina.  It also helps relieve angina and other coronary heart disease symptoms in patients not adequately controlled by medical therapy, but does not prevent heart attacks or premature deaths in them. 

MedlinePlus on March 12, 2009, quoted Dr. David Moliterno, chief of cardiovascluar medicine at the University of Kentucky's Gill Heart Institute, with regards to this study: "To improve life span takes more than a few minutes in the catherterization laboratory.  Rather, a lifetime of change is usually needed."

Visit NutritionData's Heart Health section for information on lifestyle modifications that can prevent and alleviate coronary heart disease.  And, of course, work with your personal physician if you already have heart disease.

-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:  Trikalinos, Thomas, et al.  Percutaneous coronary interventions for non-acute coronary artery disease: a quantitive 20-year synopsis and a network meta-analysis.  Lancet, 373 (2009): 911-918.

Don't Measure Blood Pressure; Just Treat Everybody?

A study published last week in the British Medical Journal advocates giving everyone over a certain age (55? 60?) a pill to lower blood pressure, regardless of whether they have high blood pressure or not.

The two London-based researchers who performed the meta-analysis - Malcolm Law and Nicholas Wald - believe that blood pressure lowering pills prevent heart attacks and strokes regardless of baseline blood pressure.  Traditionally, physicians measure blood pressures several times, then treat only people who are over 140/90.

A meta-analysis, by the way, combines multiple studies done at different times and circumstances, aiming for greater statistical power.

Law and Wald say that all all five majore classes of the main blood pressure pills lower risk of heart disease and stroke.  In the abstract of the study at hand, Law and Wald write that combining three drugs at low dosages reduces risk of heart disease and stroke by about 50%.  Using single drugs, the risk reduction is only about 20-25%. 

Law and Wald six years ago advocated the "polypill" for prevention of heart attacks and strokes in everyone 55 years and older.  The polypill would contain a statin (cholestrol-lowering agent), three blood pressure pills at low dose, folic acid, and aspirin.  They hold a patent on at least one polypill formulation.

The science behind this meta-analysis has been questioned.  See TheHeart.org article below for details.

Would you take a blood pressure lowering pill even if your blood pressure were normal, just because you turned 55?  I'd want to see more data first. 

Regardless, check your blood pressure periodically - once a year minimum - to see if it's over 140/90.  If so, consult your personal physician.  The usual goal for people with diabetes is 130/80 or less.  You can check your blood pressure in private on free machines at many supermarkets and pharmacies.  

-Steve Parker, M.D.

References:

Law, M.R.,  and Wald, N.J.  Use of blood pressure lowering drugs in the prevention of cardiovascular disease:  meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies.  British Medical Journal, 338 (2009): b1665.

Lowry, Fran.  Give blood pressure drugs to all.  TheHeart.org article, May 22, 2009.

Cardiologists Underutilize TLC: Therapeutic Lifestyle Change

If you have coronary heart disease, you can augment the effects of heart pills and procedures with therapeutic lifestyle changes, such as:

• Eat cold-water fatty fish twice weekly.  These include salmon, trout, tuna (white/albacore), sardines, herring, swordfish, halibut, mackerel, and sea bass.
• Eat nuts: three to five 1-ounce servings a week.
• Exercise regularly. 
• Eat legumes twice a week.
• Consider low-glycemic index eating. 

Some of these measures are as potent as drug therapy.

If you or someone you love has coronary heart disease, you need to know that there's more to successful treatment than drug therapy, angioplasty, and open heart surgery. 

It's just a fact that many cardiologists - certainly not all - focus on invasive intervention and drug therapy.  Invasive intervention typically involves threading a small tube into the heart via the groin artery, opening up a blocked artery with a balloon (angioplasty), and leaving a metal frame behind to keep the artery open. 

That's what they are trained to do.  It's easier to prescribe pills and do procedures rather than spend time educating a patient on healthy diet, exercise, weight loss, and mental health.  The educational effort too often seems to fall on deaf ears.     

Let's face it: many heart patients also would rather pop a pill or have a procedure and be done with it.  Or at least think they're done with it.

No doubt about it, pills and invasive procedures save many lives every day.  Therapeutic lifestyle changes also have a role.

-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. 

 

Unusual Diet Modifications to Reduce High Blood Pressure

In addition to salt restriction, you can make other diet modifications to lower your blood pressure.  Why would you want to do that?  High blood pressure causes one in six cases of preventable death. 

The following foods were tested mostly in people already diagnosed with elevated blood pressure.

• Vegetarian diet:  Lowers systolic pressure 5 points (mmHg).
• Fiber supplementation:  Increasing daily intake of fiber by 10-12 grams drops pressure only one point usually, although more in people over 40 or with hypertension.
• Increased calcium intake:  insignificant one point drop.
• Increased fish intake:  Daily fish plus loss of excess weight dropped pressures from an average of 133/77 to 119/68 in a 16-week study.  Daily fish??!!
• Fish oil:  3-4 grams a day drops blood pressure two to six points, usually closer to two.
• Potassium supplementation:  40-80 mEq per day seems to lower blood pressure somewhat, but the effect is mostly lost in someone on a reduced-salt diet.
• Cocoa:  Adding cocoa products lowers systolic pressure by 5 points and diastolic by 3, at least in short-term studies.  Chocolate, anyone?   

The numbers above are averages; your mileage may vary.

The combination of regular exercise, loss of excess weight, and salt restriction is a potent approach to lowering your elevated blood pressure or avoiding hypertension "naturally."  Consider some of these other diet modifications, too.

NDs Nutrient Search Tool will help you find foods rich in potassium and fiber.  Search Monica Reinagel's Nutrition Data Blog for information on vegetarianism.

-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.

Additional Resource:  UpToDate Patient Information: High blood pressure, diet, and weight

Prevent or Control High Blood Pressure by Lowering Salt Intake

Nearly one in three adults in the U.S. has high blood pressure.  Avoid joining that club by reducing your salt intake. 

Salt restriction has long been recognized as a legitimate way to prevent and control high blood pressure.  It doesn't work in everybody, but many will be able to avoid drug therapy or reduce medication use by limiting salt intake.  In case your forgot your high school chemistry, remember that salt is sodium plus chloride.

Sodium restriction lowers blood pressure in the range of 5-10 mmgHg on average in people with high blood pressure.  It lowers pressure in others as well, but to a lesser degree. 

Expert medical panels recommend reduction of sodium intake to 2.3 grams a day.  That's about the amount in one teaspoon of salt.  It ain't much! 

"OK, so how do I cut the salt?" 

The easiest way is to eat more fresh food and less packaged and processed food, and less food from restaurants.

Salty processed foods include lunch meats, snack foods, canned food, prepared frozen meals, sauces, condiments, dressings, and pickled foods.

Don't use the salt shaker.

A 15.5 ounce can of green beans in my house had 1.4 grams of sodium.  A man-sized frozen Salisbury steak meal had 1.5 grams.  That's 2.9 grams of sodium already, in just one meal.  You're shooting for 2.3 grams a day, or less.   

For an idea how much sodium is in your current diet, use NutritionData's "My Tracking" page.  Analyze a couple days of typical intake.  Or use the food search box at the top of every ND web page to find the sodium content of most any single food.

For additional blood pressure reduction through diet modification, see my post on the DASH Diet.

-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.

Additional Resource:  UpToDate.com's Patient Education on Low Sodium Diet.

Update May 15, 2009:

For contrarian viewpoints, see . . .

http://www.cochrane.org/reviews/en/ab004022.html

http://tierneylab.blogs.nytimes.com/2009/04/06/hold-the-salt/?emc=eta1