Heart Failure

Your Health Portfolio Part One: Learn How to Manage Your Hypertension

bloodpressureIn the age of increasing complexity in medical care, it is in a patient's best interest to take a more active role in health maintenance. It is an irony that many patients have a better handle upon their finances than their own health status. Technological advances allow people to track their financial data, anticipate and make changes by logging onto a computer. Therefore, why shouldn’t a patient be able to track their own health metrics, anticipate, and make changes (with medical supervision) in between office visits? After all, without health and prevention, how can one ensure financial health for self and family?

Hypertension is a medical disease that can be effectively self-managed. Control of blood pressure is one of the most cost-effective ways to assure longevity and quality of life (without disease). Uncontrolled blood pressure is often a silent process. Unfortunately, disastrous consequences (stroke, heart attack, heart failure, kidney disease) can occur due to a lack of blood pressure control. Uncontrolled hypertension can therefore lead to excessive medical costs and financial strain.

An essential point to this blog is that patients know the definition of normal blood pressure. The optimal blood pressure, as defined by the American Heart Association, is a systolic blood pressure of 120 mmHg and a diastolic blood pressure of less than 80 mmHg. Consistent numbers above 120/80 should be a signal to patients that they may have undiagnosed hypertension. It is important that patient undergo annual blood pressure screenings by a physician to evaluate for the presence of hypertension.

Once hypertension has been diagnosed, it is not enough to make decisions based upon blood pressure readings obtained in-between doctor visits.  Hypertension is an active disease, blood pressure fluctuates throughout the day, and I therefore encourage every patient to maintain a blood pressure diary until there is adequate and consistent blood pressure control. Most available home blood pressure cuffs are relatively inexpensive, require little expertise, and provide accurate readings. Many home blood pressure cuffs will, in fact, record blood pressure readings and track averages over time. There are computer-based and web-based applications that also allow patients to input and follow their blood pressure readings, as if they were reviewing a bank account.

I often find that, when a patient monitors his or her blood pressure, the act of data monitoring allows for a far greater understanding of what controls blood pressure and what causes blood pressure to elevate. This personal understanding of one’s self may result in greater changes in lifestyle (reducing salt, reducing stress, increasing exercise) that clearly improve hypertension.

It is my experience that home blood pressure diaries also help the physician make better decisions with respect to therapy. Adjustment of medical therapy may be made without an office visit.  After all, multiple points of data within the span of one month are far more valuable to the physician than two points of data (from one office visit to the next).

It is important that patients become open minded to starting medical therapy.  I will often counsel patients that medicines supplement lifestyle changes such as diet, weight loss, and exercise.  This multifaceted approach most effectively maintains the blood pressure over time.  Most antihypertensive medicines are safe, have been used for a number of years, and have no common side-effects.  Most antihypertensive medicines are also cost-effective.  I often educate patients that the many effective blood pressure medicines can also be found in a generic format.  A patient need not take the “latest and greatest” blood pressure medicine in order to achieve maximal benefit.

I can not express enough the importance of a “lifestyle prescription.”  Regular exercise can be a challenge for the busy person, yet is not impossible. Walking is a safe and effective way to incorporate effective exercise.  Park at the farthest space away from your workplace, use the stairs, take neighborhood walks, and the benefits will follow.  Be conscious of maintaining a healthy weight.  An effective health diary should incorporate daily weights in addition to blood pressure readings.  By tracking your health data, you will see that your lifestyle contribution to your health is actually working!  Use computer based technology and track trends in your numbers over time.  Some health systems may even allow the medical team to review this data before your office visit!

Smoking cessation goes without saying or further discussion.  Alcohol, in excess, will increase blood pressure.  Some over the counter medicines may raise blood pressure with chronic use.  It is important to be keenly aware of things that are put into the body that may increase blood pressure.

I would urge all who have uncontrolled hypertension to take an active role in their hypertension management.  The ultimate goal, like in successful investment strategies, is for long-term gains (life free of disease) by applying a little discipline, setting goals, and knowing your targets.  The savings will be invaluable.

Click here to visit the Jim Moran Heart and Vascular Center Blog and future posts from Dr. Joshua Larned.

911 411 Pradaxa

A small piece of vital information has turned up.  Although this is supposed to be “widely” reported, I found out by accident, and I wish to share it with my readers. It seems that Pradaxa that is given to a patient as a 30 day supply comes in a bottle, and the pills are only stable for 30 days.  That’s right, if you open the bottle you must dispose of it after thirty days.  In Europe this problem has been solved by the use of blister packs which apparently allow the medication to have a longer shelf life. The use of pills outside of this window may not provide adequate effect, which would limit the effect of the medication in preventing strokes related to atrial fibrillation.  This should be avoided and may represent a planning challenge for some patients. Patients should insist on blister packs if at all possible and make certain that they have adequate supplies of the drug.  This is vitally important because if three doses are missed, no activity is present and the risk of stroke is possible. All medications should be used in the correct manner.  This, however, is more important with Pradaxa than some other medications.  Questions regarding this issue should be addressed with your pharmacist or drug source.  Renewals for this drug from your doctor should not wait until the last minute or 4:59 PM on Friday. Patients are going to have to assume some of this responsibility, as well they should.  We are all in this together.  I will keep you posted on updates regarding this drug as they unfold.

Women Listen Up: Time is Muscle!

womanclockI hope I caught your attention with this title; if I did, good, read on. I want you to take just a minute to think about your friends and family and the people you care for. I bet a lot of them are women, right? I can honestly say that most of us think that the women in our lives are the backbone of our families. Take my wife, for example. She cures all the boo boos, she is the carpool driver, and the baker of our birthday cakes. She is always juggling things around, taking the youngest to his basketball games, taking the middle one to school dances, driving everyone to doctors appointments. You get the idea. Yet, I wonder, is she taking the time to think about herself? About what she needs? About her own health?  Unfortunately, many women do not think about this stuff.

It really doesn’t matter to me if you wear red on every Friday during the month of February. Yes I know, National Wear Red Day is a national observance day that raises awareness of cardiovascular disease (CVD) in women. But what matters is that heart disease is the number one killer of women, and I don’t like that. I care about the women that surround me. I care about my wife, my daughter, my mother, my sisters-in-law, and yes, my mother-in-law whom I love dearly. Yet you hear about the stories that women will tell you and their experiences when they were faced with their heart attacks.

I am not going to bore my readers with numbers or statistics; not today. Just know that cardiovascular disease is largely preventable and we all need to be aware that CVD is an equal opportunity killer BUT, when it strikes a woman, the symptoms may be harder to recognize, and her mortality is almost twice that of a man. Let’s not go into the details today.

Just do yourself a favor, don’t be in the 35 percent of women who chose to ignore symptoms or don't report it to a physician. Get regular preventative screenings, and educate yourself about living a heart healthy lifestyle. Even if mild symptoms of a heart attack occur, you need to seek medical attention immediately.

If a heart attack occurs, the outcome and prognosis will be worse if there is a delay in treatment or intervention. The longer the delay, the more damage there will be: TIME IS MUSCLE…and waiting and seeing can be disastrous.

To read future blog posts by Dr. Vicente Font, visit the Jim Moran Heart & Vascular Center Blog.

PROSPECTing for the answer to what causes myocardial infarctions (Part 2)

This study was performed in a group of patients who presented for cardiac catheterization because of an ischemic syndrome -- either myocardial infarction or unstable angina. They were not randomized but were asked before there procedure whether they would agree to the evaluation of all of their arteries in several different ways. Those that agreed were entered into the study and then followed for 3.4 years. A total of 697 patients agreed. Their median age was 58.1 years, 24% were women and 17.1% had diabetes. After successful angioplasty of the coronary lesions that brought them to cath in first place, all three of their heart arteries’ were imaged by the two technologies that were available at the time. As I have often blogged, medicine is a moving target, and if this study was started today, three imaging techniques would be employed.

The imaging techniques were gray scale ultrasound and radiofrequency ultrasound. These techniques are devices that run on the wires we use to do angioplasty. The gray scale ultrasound gives us an indication of the narrowing of the artery, and radiofrequency ultrasound allows an identification of the composition of the coronary plaque. It can identify whether the top of the plaque is “thin” or “thick” and the composition of the plaque which correlates well to pathologic examination. In other words it is much the same as if we cut the artery out and examined it under a microscope.

The first major finding was that if you had an ischemic event you had a 20.4% chance of another in three years. These events occur in spite of a successful angioplasty and the multiple medical managements we employ today. That fact in and of itself is scary.

149 major adverse cardiac events occurred in 135 patients. The majority were rehospitalization for unstable angina or progressive angina. 31 patients had cardiac death, cardiac arrest or myocardial infarction.

As Billie Mays said, "but wait there’s more." Of the events that occurred, 12.9% were related to the original culprit lesion that underwent angioplasty. 11.6% of the lesions were non culprit lesions and were angiographically mild at baseline. In other words, if you have unstable angina again, it is as likely to be a new blockage as it is the past blockage. This illness can progress in spite of all we do to halt it. The mean blockage doubled from the first event to the second from 30% to 65%. 51% of the non culprit lesions were thin capped fibroatheromas and we presently believe that these are a problem. However, a total of 595 thin capped lesions were found, and only 26 resulted in an event. Further, all 106 non culprit lesions were seen on angiogram, but only 55 were identified on gray scale and 51 on radiofrequency ultrasound.

I know that this is a great deal of information. These investigators found that it is not possible to predict where a cardiac event will occur in the coronary tree by these techniques. We are not able, as yet, to treat these areas so that they will not progress and cause more difficulty with the imaging technology that was used. New technology known as Ocular coherence imaging is the next up to be tried.

This is a worthy goal. We would like to be able to treat patients to prevent future problems. As you see, you are as likely to have a problem in one artery as the next if you have the disease of atherosclerosis. Don’t smoke, get some aerobic exercise, treat your diabetes aggressively, and use large doses of statins and antiplatelet agents. The rest seems to be out of anyone’s control at this time.

We will keep trying.

PROSPECTing for the answer to what causes myocardial infarctions - Part 1

emsThe readers of my blog know that studies come in all forms.  I try to bring some additional information to the readers of this blog that I feel they should know because it affects so many of them or their loved ones.  Studies are often done on compounds or devices for approval.  Some that I have reported on are different treatment strategies to see which treatment path might be more effective.  Some studies are Meta-analysis that adds multiple studies together to define a topic.

Every once in a while a study is published that is purely research.  These studies are hard to do because they require funding, which is difficult to find, and a great deal of institutional and technical support.  Just such a study has been published, and it goes to the heart of much of what we do as cardiologists.

Published in the New England Journal of Medicine on January 20th (N Engl J MED 2011: 364:226-235) and known as PROSPECT (Providing Regional Observations to Study Predictors of Events in the Coronary Tree), this study asks the question, what type of atherosclerotic coronary lesion causes cardiac ischemic events, either a myocardial infarction or unstable angina?  I know that you are asking “how do they not know that?”  The answer is we didn’t, and we still don’t as i will explain.  Until the early 1980’s, as I described in other blogs, we didn’t know what came first the clot or the myocardial infarction.  It took the seminal work of Dr. Wood and his team in Seattle to show that the clot caused the myocardial infarction, not came after the myocardial infarction.

As I have blogged about before, the challenge we as cardiologists face is to determine who is and who is not at risk of a myocardial infarction.  Stress testing, CT angiography, stress echo and all of our non invasive tests only determine who has a severe blockage in their heart arteries’ and not whether that blockage is going to cause a heart attack.  It is the symptoms and severely abnormal stress tests that propel us to do invasive testing.

Since the more recent use of angioplasty to define and treat myocardial infarctions, it has become clear to us that many patients have myocardial infarctions in arteries that are not severely blocked.  These investigators sought to determine the natural history of a patient’s heart artery.  Further, they sought to determine whether we can make therapeutic decisions about what we find at cardiac catheterization which would change to treatment strategies that are now in place.

This is not a small problem.  Close to 1,350,000 Americans each year suffer from an ischemic syndrome.  These investigators have now presented the basic data as to what a group of these patients look like and what happens to them.  As you will see, we owe the investigators a debt of thanks for a study that provides some answers and many more questions.

Next … what they found and how it will affect us all.

Sleep Apnea, the Phantom Cause of Heart Disease and Accidents

sleepSleep apnea syndrome is a major threat to health; 10% of men and 5% of women are estimated to have sleep apnea. Many deaths among people in their 40s and older, which are attributed to heart disease and transportation accidents, may actually be related to an unseen epidemic of snoring and sleep apnea. Apnea is indeed a potentially deadly phantom; it is the frequent stoppage of breathing caused by relaxed tissues in the throat during sleep. Snoring is caused by vibrations of the relaxed throat tissues and is often the precursor or companion of sleep apnea. Although effective medical treatment for sleep apnea exists, this information has not entered routine medical practice, nor does the public recognize the dangers. Unfortunately, even when apnea is suspected, it may be difficult to obtain qualified care. As a result, 95% of the millions of people who suffer from sleep apnea have not and may never be diagnosed, let alone treated. Nevertheless, the informed person with sleep apnea can take the initiative to get appropriate diagnosis and treatment and take the steps necessary to assure recovery.

Some cardiac problems associated with sleep apnea are known, and their risk may be diminished by treatment of the sleep apnea:

  • Sleep apnea increases your risk of high blood pressure, heart attack, stroke, obesity, and diabetes.
  • People with coronary artery disease whose blood oxygen is lowered by sleep disordered breathing may be at risk of ventricular arrhythmias and nocturnal sudden death. CPAP treatment may reduce this risk.
  • In obstructive sleep apnea, often marked by snoring, the right side of the heart may suffer damage because it has to pump harder to support the extra effort of the lungs trying to overcome the obstruction of the airway. This condition may lead to heart failure.
  • Central apnea may cause high blood pressure, surges of adrenaline, and irregular heart rhythm. (Central apnea occurs without snoring and is not caused by obstruction, rather it is caused by the failure of the brain to signal for a breath)

Obstructive sleep apnea is overdue for public attention; it is the second leading cause of daytime fatigue, after insomnia. The worst, one-third of people with untreated sleep apnea has an increased auto crash rate and consequent fatalities. As you can see, poor sleep caused by sleep apnea is a major public health problem.

People with sleep apnea syndrome have a higher risk of death than the normal population. You may ask, if this is true, why is sleep apnea syndrome ignored? Well, you see, the most obvious symptom of sleep apnea syndrome, snoring, is seen by most people, even doctors, as an annoyance or joke, or even as a sign of good sleep. In fact, snoring and gasping may be the body's cry for help. People with sleep apnea suffer from repeated obstructions of the throat during sleep. They literally can't breathe while sleeping. They must wake up in order to breathe (but they don't usually recall these awakenings). This repeated fragmentation of sleep patterns keeps them from having normal, restorative sleep.

Even though effective medical treatment to overcome this epidemic is available, people who suffer from this problem usually don't realize it (after all, they are asleep while the damage is being done). Further, most patients usually don't remember their nightly struggles to breathe.

Treatment is not easy. Since the patient must use a treatment device every night in order to control this chronic condition, treatment may be incomplete or fail unless there is careful follow-up and very good communication between doctor and patient.

Unfortunately, sleep apnea cases are expected to increase due to the current epidemics of obesity, high blood pressure, atrial fibrillation and heart failure in the United States. Many more questions remain about sleep and sleep disorders, but if you think you have sleep apnea, visit your doctor to get evaluated.

To read future blog posts by Dr. Vicente Font, visit the Jim Moran Heart & Vascular Center Blog.

Dr. Evil finally gets his number

moneytree1Not so long ago, when movies were funny, Dr. Evil used to hold the world hostage.  In the first movie, he wanted one million dollars not to blow the world up.  By the second movie, he wanted 100 billion dollars not to use his laser to destroy Washington, D.C.  In the third movie, the amount of money he wanted was “1 billion, gagillion, fafillion, shabolubalu million illion yillion…yen."  This seems to be the exact number of yen we will need to pay for cardiovascular disease in 2030.

Published online in Circulation on January 24, 2011, the article is an attempt to forecast the future of cardiovascular disease in the United States.  It reminds me a little of a former weather forecaster Dr Frank Field who used to do the weather for WNBC in New York City.  He was an optometrist by training, and it was before there were all these fancy degrees in meteorology.  Someone asked him how he forecasted the weather, and he told them that he had a “weather rock” hanging outside his window.  If the rock was wet, it was raining. If it was swinging, it was windy.

Maybe this group should get a weather rock.  As has been reported in the news, the cost of treating cardiovascular disease is predicted to be $818 billion in 2030.  Indirect costs are estimated to be $276 billion.  That is over one trillion dollars.  Today, cardiovascular disease is responsible for 17% of the health care dollar, and that amounts to $278 billion dollars. They are estimating that by 2030, over 40% of the population will have some form of cardiovascular disease. What are we to do?

But wait, it gets worse.  If some risk factors continue to increase, such as diabetes and obesity, the numbers will be correspondingly higher.  If we can begin to get underneath the illness with improved life style changes of weight loss and management, cessation of smoking and improved fitness level, we can make a significant impact.

The report also presents other sobering data.  By 2025, it is estimated that we will be short 260,000 nurses.  It is estimated that we now have a shortage of cardiologists (not in Broward County) of 1,600 general and 2,000 interventional cardiologists.  In 2050, the expected shortage will be 16,000 cardiologists.  It is estimated that CV surgeons will number only 3,000 in 2030.  The training spots for them now go unfilled.

How can we overcome this?  Better early treatments of cholesterol, halting smoking, controlling weight, better fitness are some suggestions.  Ooops, I forgot world peace and an end to hunger while we are at it.  This is not going to be easy.  We have to get started and we have to develop programs that are effective.  These programs need to reach all populations and all economic levels.  If we don’t rise to the challenge, this will sink us.

We are all being held hostage, and no amount of money is going to free us.

Defining Ideal Cardiovascular Health

heartscopeThe concept of cardiovascular health reframes important questions regarding how best to approach cardiovascular disease (CVD), which have long been the focus of numerous professional organizations including the American Heart Association (AHA). The AHA Impact Goal for 2010 focused primarily on reducing coronary heart disease (CHD), stroke death rates and the prevalence of risk factors. The unspoken assumption was that this would improve health. However, it is increasingly evident that health is a broader, more positive construct than just the absence of clinically evident disease. Although there appears to be substantial overlap between the components of cardiovascular health and general health, the AHA acknowledges that there are other components to general health related to physical, mental, and social functioning -- among other things -- that have not been addressed well in the past. Future efforts should include consideration of these important aspects of health and their impact on cardiovascular health and disease as the science evolves.

Earlier this year the American Heart Association published their position statement on the definition of national goals for cardiovascular health promotion and disease reduction. To summarize this article that appeared on Circulation in January 2010, the following table was provided:

fontchart1

For the next decade, the AHA has committed itself to achieving the following Impact Goal: “By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%.” There is a lot of work ahead of us…

To read future blog posts by Dr. Vicente Font, visit the Jim Moran Heart & Vascular Center Blog.

Stay in school…and live longer

booksappleThe concept of “data mining” lives on.  What is data mining?  It is the use of large data bases to identify items of interest using data collected for a study to prove a different hypothesis.  In the past it has provided some interesting concepts, but in general, the medical public follows the findings with a wink and a shrug.  Sometimes the issues are studied in their own right to prove the hypothesis in a second study devoted to the new issue.  It is important to understand that a study can only prove or disprove what it set out to do.  Other identified effects or findings are not proved by what is known as Ad Hoc analysis.

Just such a finding was published this week in the Journal of the American College of Cardiology.  (J Am Coll Cardiol 2011; 57:138-46)  The article is titled Association of mortality with years of education in patients with ST-segment elevation myocardial infacrtion treated with fibrinolysis.  It includes a detailed data review that occurred using the GUSTO III data.

Let me back up a moment and review some ancient history.   In the mid 1990’s, the preferred method of handling a myocardial infarction was not angioplasty like it is today.  We used to infuse a drug known as a fibrinolytic to “dissolve” the clot and re-open the artery.  These studies had thousands of patients, and an enormous amount of ink went into the heralding of one drug over another.  They were world wide trials and eventually led to PCI vs. Fibrinolysis, and fibrinolysis lost, ergo, the current dictum of 90 minute door to balloon time.  In other words, if you come to a hospital, the expectation is that we will have opened your heart artery by 90 minutes.  This is so powerful an assumption that even transportation to another hospital for angioplasty is favored over fibrinolysis.

The data for this study was collected from October 13, 1995 to January 13, 1997 and included 15,059 patients. Patients were then excluded if the country provided <500 patients and if no level of education was identified.  This left a total of 11,326 subjects.

The levels of education broke down as follows:  19.8% had 7 years of school, 61.6% had completed high school, 14.4% had 12 to 16 years of education and 4.4% had greater than 16 years.  Most doctors have 20 years: 12 in school, 4 in college and 4 in medical school.  This does not include post graduate training.  (I have 7 years.)

The worst marker for mortality after an ST elevation myocardial infarction is age.  After matching up all of the other variables, the second worst marker is years of education.  If you have less education, you are more likely to die.  Overall, one year mortality with <8 years of education was 17.5%; with >12-16 years, mortality was 4.9%; and with >16 years, mortality was 3.5% across the nations studied.  If you stay in school forever, you might not die, at least from a myocardial infarction.

Now, it is not the level of education which provides the benefit, but it seems to be a surrogate marker of other variables -- for instance, more treatment of other predisposing conditions such as hypertension and hyperlipidemia. Perhaps, better life style, less smoking, or better eating habits.  No one really knows because the data was not obtained at study entry.  Moreover, it was best illustrated in the countries of United Kingdom, Germany and Sweden who had a very significant pValue of<0.0001.  We, in the United States, had a pValue of 0.0233, which is not significant.  Our mortality with >16 years of education was 4.2%.

Interesting, but it may not apply anymore. We no longer use fibrinolysis in this manner.  I am sure that out there in wonk land someone is doing the analysis, as you read this, as to what angioplasty in today’s medical care does to mortality.

My only advice is to stay in school.

A New Order For CPR, Spelled C-A-B - American Heart Association

This is an interesting twist for us healthcare providers. The American Heart Association is re-arranging the ABCs of cardiopulmonary resuscitation (CPR) in its 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, published in Circulation: Journal of the American Heart Association. Recommending that chest compressions be the first step for lay and professional rescuers to revive victims of cardiac arrest, the Association said the A-B-Cs (Airway-Breathing-Compressions) of CPR should now be changed to C-A-B (Compressions-Airway-Breathing). For more than 40 years, CPR training has emphasized the ABCs of CPR, which instructed people to open a victim's airway by tilting their head back, pinching the nose and breathing into the victim's mouth, and only then giving chest compressions. This approach was found to cause pretty significant delays in starting chest compressions, which are essential for keeping oxygen-rich blood circulating through the body. Basically, changing the sequence from A-B-C to C-A-B for adults and children allows all rescuers to begin chest compressions right away. In previous guidelines, the association recommended looking, listening and feeling for normal breathing before starting CPR. Now, compressions should be started immediately on anyone who is unresponsive and not breathing normally.

All victims in cardiac arrest need chest compressions. In the first few minutes of a cardiac arrest, victims will have oxygen remaining in their lungs and bloodstream, so starting CPR with chest compressions can pump that blood to the victim's brain and heart sooner. Research shows that rescuers who started CPR with opening the airway took 30 critical seconds longer to begin chest compressions than rescuers who began CPR with chest compressions. The change in the CPR sequence applies to adults, children and infants, but excludes newborns. Other recommendations, based mainly on research published since the last AHA resuscitation guidelines in 2005: - During CPR, rescuers should give chest compressions a little faster, at a rate of at least 100 times a minute. - Rescuers should push deeper on the chest, compressing at least two inches in adults and children and 1.5 inches in         infants. - Between each compression, rescuers should avoid leaning on the chest to allow it to return to its starting position. - Rescuers should avoid stopping chest compressions and avoid excessive ventilation. - All 9-1-1 centers should assertively provide instructions over the telephone to get chest compressions started when    cardiac arrest is suspected. "Sudden cardiac arrest claims hundreds of thousands of lives every year in the United States, and the American Heart Association's guidelines have been used to train millions of people in lifesaving techniques," said Ralph Sacco, M.D., president of the American Heart Association. "Despite our success, the research behind the guidelines are telling us that more people need to do CPR to treat victims of sudden cardiac arrest, and that the quality of CPR matters, whether it's given by a professional or non-professional rescuer." Learning CPR is learning a set of skills that when done correctly can help save lives. I encourage each one of you to enroll in an AHA sanctioned class, and, if you have teenage kids at home, enroll them as well. To read future blog posts by Dr. Vicente Font, visit the Jim Moran Heart & Vascular Center Blog.