Madely Health Headlines Commentary for August 27, 2010

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Gaining on death, cooling therapy catches on slowly

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What are some of the means at our disposal to assess how well our hearts are functioning? What new technologies are available and what are some of the promising avenues in imagiing research and development. Dr. Robert Beanlands will also be presenting at the World Society of Cardio-Thoracic Surgeons conference and the title of his presentation is What’s New in Imaging For The Cardio-Thoracic Surgery Patient?

• Dr. Robert Beanlands, M.D., F.R.C.P.(C) [UOHI],
  Chief, Cardiac Imaging
  Director, Cardiac PET Centre
  Professor of Medicine (Cardiology)/Radiology (Cross-Appointment)
  Division of Cardiology – University of Ottawa Heart Institute

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Originally published in The Ottawa Citizen December 14, 2004

According to the Heart and Stroke Foundation of Canada, stroke accounted for 20 per cent of the 79,389 deaths from cardiovascular diseases in 1998. The Canadian statistics are indeed disconcerting, reflecting tremendous suffering and financial burdens to families and society.

There are 40,000 to 50,000 strokes a year and 300,000 people are living with the debilitating consequences — loss of independence, paralysis, cognitive impairment, dementia, recurrent pneumonias and skin ulcers, among others.

The outcome of a first stroke is alarming: 15 per cent of stroke victims will die, 10 per cent will completely recover, 25 per cent will recover with a minor impairment or disability, 40 per cent will be left with a moderate to severe impairment, and the remaining 10 per cent will require long-term care.

Twenty per cent of people who survive their first stroke will succumb to another stroke within two years. More women than men die each year from stroke. One can regrettably assume this number will continue to increase in the future.

Strokes cost the Canadian economy about $2.7 billion a year and account for about three million days in hospital each year.

The incidence of stroke can be reduced with a good knowledge of prevention strategies that are proven to be effective. There are certain risk factors that cannot be modified, like older age, male sex, non-white race, a family history of stroke or heart attack, and the presence of pre-existing coronary heart disease or congestive heart failure.

Most risk factors are associated with the buildup of plaques and clots within the arterial network. The areas that are prone to formation of these clots include the carotid arteries in the neck, the coronary arteries, and areas around the heart valves.

What are some of the modifiable factors that you can proactively incorporate into your life?

Lifestyle modifications are assumed to be of benefit. Although there have not been many randomized clinical trials that have studied the effect of obesity, lack of regular exercise, alcohol intake and smoking on stroke risk, there is indeed great observational data that supports the modification of these factors. Indeed, the elevated stroke risk in smokers will disappear within five years of quitting — it is never too late to stop.

The major modifiable risk factors include: high blood pressure (hypertension), diabetes, elevated cholesterol levels (hypercholesterolemia), and a heart beat irregularity called atrial fibrillation.

- A plethora of high-quality randomized placebo-controlled trials indicates that lowering blood pressure in hypertensive patients decreases the relative risk of stroke from bleeding (hemorrhagic stroke) and arterial clots that block oxygen-rich blood to the brain (ischemic stroke) by 35 to 45 per cent within three years of starting therapy. This risk reduction even applies to people older than 80.

Of the group of 4.5 million Canadians with hypertension, only 16 per cent are treated and controlled. Twenty three per cent are treated and uncontrolled. Most worrisome are the 19 per cent that is aware they have hypertension but remain untreated, and that the remaining 42 per cent are unaware that they have hypertension. You cannot feel or sense this disease. It cannot be seen, hence many people suffer a terrible fate that seems to come out of the blue.

There are many effective medications like thiazide diuretics and angiotensin-converting enzyme inhibitors (ACEs) to treat hypertension. New studies continue to show the benefits for heart health and stroke prevention.

High cholesterol levels play a major role in heart disease and, by extension, the development of stroke risk. Although many studies focus on the effect of cholesterol on the heart, the information has been used to determine that cholesterol reduction does reduce stroke risk. Studies are ongoing to help to improve treatment guidelines.

Cholesterol-lowering medications like the statins (Crestor, Lipitor, Zocor, Pravachol and Mevacor) are effective and are offered to patients with multiple risk factors.

Type 2 diabetes often occurs concurrently with hypertension and elevated blood cholesterol. Tight control of sugar levels will reduce the risk of damage to the small arteries or microvasculature.

Atrial fibrillation describes the unco-ordinated contractions of the walls of the left atrium of the heart. It can cause the formation of clots within this chamber. Pieces of these clots or emboli can travel to the brain. The death rate for people with this condition is double that of people without atrial fibrillation. For those with clots near the valves, this risk increases to 17 times normal, controlling for age and sex.

Your doctor can offer you a wealth of information about stroke prevention. You can change your history.

More information is available at the Heart and Stroke Foundation of Canada website ww2.heartandstroke.ca

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Originally published in The Ottawa Citizen March 18, 2003
Original Title: The Truth About Women’s Hearts

Perception is everything. Not only does it apply to the political arena but to the public’s perception of health risks.

A survey by the American Heart Association done in 2000 asked women what disease they thought was the major threat to their lives. Eight per cent said heart disease compared to 50 per cent citing cancer. The reality is altogether different. Cardiovascular disease kills more women than the next 14 causes of death combined.

A woman’s lifetime risk of dying from breast cancer is one in 28 whereas one in two will die of cardiovascular disease.

This perception rings true in the office setting. It is uncommon for women to experience a heart attack at 40 or 50 years of age, but many know of someone suffering with breast cancer at this young age. This close-to-home event scares many women. Understandably, breast cancer prevention becomes a primary concern.

This skewing of risk perception leads to the difficult task of focusing preventive health and education on diseases that occur later in one’s life, such as cardiovascular disease. A woman’s risk of death from a heart attack occurs about 10 years later compared to men. Yet more women than men die from heart attack each year.

Studies done in the early ’90s indicate that women with the appearance of heart disease symptoms are less likely to be referred for evaluation and treatment. Further, sex-specific risk-factor differences exist for women. These include elevated cholesterol, high blood pressure (hypertension), diabetes, smoking and premature menopause.

For example, a low good-cholesterol level (HDL-cholesterol) below 1.05 millimoles per litre is more predictive of fatal heart disease for women over the age of 65 compared to men with the same level. In 1998, the U.S. National Health and Nutrition Examination Survey reported that more women than men had cholesterol levels above the desirable range.

Fifty-two per cent of women over the age of 45 have hypertension increasing the risk of heart disease and stroke.

Compared to a non-diabetic woman, a woman with diabetes has a threefold to sevenfold greater risk of heart disease. Compare this to a twofold to threefold greater risk for diabetic men.

More women than men smoke. Smoking rates among teenage girls exceeds those of boys. Smoking accounts for over 50 per cent of heart attack in middle-aged women and will likely increase given the smoking trends.

What can you do to prevent cardiovascular disease? The Web site familydoctor.org provides helpful information (http://familydoctor.org/handouts/667.html).

Consult your family doctor for a thorough medical examination. This includes a detailed family history (heart disease, diabetes, stroke and hypertension) and a personal medical history that reviews previous illnesses, alcohol and drug use, cigarette smoking, and diet.

Your doctor will order blood tests to check for diabetes and elevated cholesterol levels, among others. If the results are abnormal, he or she may order additional tests and offer treatment options.

Lifestyle modifications are the first treatment choice when cholesterol levels are elevated. Women should stop smoking and alter their diet to limit fat intake. Your doctor’s office should have many handouts of sample diets prepared by the Canadian Diabetes Association or log on to the Heart and Stroke Foundation of Canada Web page at http://ww2.heartandstroke.ca/Page.asp?PageID=1559&SubCategoryID=195&Src=&Type=Article.

Weight loss and exercise (30 minutes of moderate intensity exercise three to four times per week) are crucial to reduce the risk of heart disease. These components will increase the HDL-cholesterol, reduce blood pressure and decrease the risk of type 2 diabetes.

If six to 12 weeks of lifestyle changes do not sufficiently reduce cholesterol levels, medical therapy is the next step. The Heart Protection Study demonstrated a dramatic reduction in fatal heart disease and stroke risk equally in men and women using a cholesterol-lowering statin medication.

These medications (Zocor, Lipitor, Mevacor, Lescol, Pravachol) reduce the risk of coronary artery blockage caused by small clots or plaques that accumulate on the arterial walls.

Estrogen replacement therapy, once considered to reduce the risk of heart disease, is no longer a recommendation. The recent Heart and Estrogen/ progestin Replacement Study (HERS) did not show any reduction of fatal or nonfatal heart attack risk in women who had coronary heart disease.

If you have not had a recent heart disease risk assessment, book an appointment with your doctor. There is sufficient evidence-based information available to accurately assess your 10-year risk of heart disease. Women, justifiably vigilant about breast cancer, should be more so for heart disease.

Early intervention can save your life.

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Originally published in The Ottawa Citizen April 16, 2002
Original Title: Cholesterol Secrets

Many people are aware of the effects of elevated cholesterol upon their health. Indeed, the rates of heart disease and stroke continue to rise. Concomitant risk factors for heart disease like diabetes, hypertension, obesity, smoking and family history of heart disease and stroke complicate the picture.

Those with some or all these conditions use cholesterol-lowering agents as one means to reduce their risk of heart disease and stroke.

The medical terms reflecting the various cholesterol factors and lab measurements sometimes have a numbing effect as the patient tries to synthesize the results.

A lipid profile, the test used to diagnose hypercholesterolemia or a combination of elevated cholesterol and triglycerides, provides results for several lipid components; total cholesterol (TC), low density lipoprotein (LDL), high density lipoprotein (HDL) and triglycerides.

LDL and HDL are proteins that carry cholesterol to specific destinations. They act as transport trucks. They are respectively known as “bad” and “good” cholesterol.

LDL’s function is to transport the cholesterol produced in the liver and deliver it to the cells in the body. Cholesterol is necessary to maintain the integrity of the cell walls and for the synthesis of certain hormones.

The majority of cholesterol is produced in the liver from a variety of foods laden with saturated fat. It is the reason why healthy diets are low in saturated fat.

Consistent consumption of foods containing saturated fat stimulates the liver to produce more LDL. An elevated LDL means that the liver is producing too much cholesterol.

The LDL is sent out into the body with too much cargo. This results in deposition of the extra cholesterol into the arterial walls causing blockages or plaques; hence LDL is the bad guy.

HDL picks up and transports cholesterol from the cells and bloodstream back to the liver to be destroyed thus its good-guy image.

Triglycerides are molecules that act as a storage reservoir for fatty acids. Fatty acids are used as an energy source for various metabolic processes. Elevated triglycerides contribute to the problems associated with elevated cholesterol levels.

Initial treatment for people who do not have risk factors for heart disease nor have had a heart attack is diet (foods containing polyunsaturated fats do not promote cholesterol synthesis thereby reducing LDL levels), exercise (to increase HDL levels), smoking cessation and lifestyle modification. After three to six months, medical therapy is indicated if the initial treatment is unsuccessful.

The recommendation for people who have a genetic predisposition to high levels of triglycerides is to use medication because lifestyle modifications other than smoking cessation have little effect.

The risk of heart disease is related to the tug of war between LDL and HDL. A measure of the risk of heart disease is calculated from the total cholesterol divided by the HDL (TC/HDL ratio). The lower the ratio, the better.

Ideally the net effect should be efficient removal of extra cholesterol from the bloodstream and the arteries. The goal is to reduce LDL and total cholesterol and increase HDL.

The results of the Heart Protection Study released in November 2001 may possibly change the treatment approach for heart disease and stoke prevention.

This five-year study had 20,000 volunteers between 40 and 80 years of age at high risk of coronary heart disease. The study wanted to know if cholesterol-lowering therapy was of use in specific groups of individuals where there was a lack of evidence of the benefits of drug treatment.

These groups were women, diabetics, people over 70 years of age, those with arterial disease not involving the heart, and those with average or below-average cholesterol levels.

Volunteers used either 40 milligrams of simvastatin per day as cholesterol-lowering therapy, or matching placebos. The study’s major findings include:

A one-third risk-reduction of heart attack and stroke with statin use reducing the need for arterial surgery, angioplasty (dilation of the coronary arteries) and amputations.
High-risk patients with normal cholesterol levels, women and men over 70 benefited from treatment.
About five years of simvastatin treatment typically prevents heart attacks, strokes or other major vascular events in:

• 100 of every 1,000 people who’ve previously had a heart attack
• 80 of every 1,000 people with angina or some other evidence of coronary heart disease
• 70 of every 1000 patients who’ve previously had a stroke
• 70 of every 1000 people with occlusive disease in leg or other arteries
• 70 of every 1000 people with diabetes
• A reduction of hospitalization risk because of worsening angina by about 30 fewer admissions per 1,000 treated for five years.
• Like high blood pressure, it takes time for elevated cholesterol levels to cause harm. Talk to your doctor about whether you need to be tested.

There is now evidence to expand treatment options for people who fall into one of the high-risk groups to prevent much hardship. That is what it is all about.

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Originally published in The Ottawa Citizen April 9, 2002
Original Title: Blowing a Gasket

High blood pressure (Hypertension) is another silent disease with catastrophic results if left untreated. Heart disease is the number one cause of physical and emotional harm (morbidity) and mortality in Canada and the United States. Despite the myriad of information targeted to Canadians, the problem grows worse. Money and human resources are stretched to the limit to combat cardiovascular disorders.

Of Canadians between 18 to 70 years of age 22 percent or 4.5 million people have hypertension. It is a condition that exerts it effect over time. Damage accumulates and organs such as the heart, kidneys and brain eventually fail.

Left untreated, it virtually guarantees an increased risk of stroke (cerebrovascular disease), heart attacks and angina (cardiovascular disease), congestive heart failure, kidney (renal) failure and poor circulation to the feet, lower legs and hands (peripheral vascular disease).

Hypertension is insidious. About 98 percent of all hypertension has no discernable cause and is called Essential Hypertension. There are no symptoms in people with mild to moderate levels of hypertension while headache and vision changes occur with severe levels.

Consider the following challenge. You have five seconds to exhale all the air in your lungs. What effort is required to completely exhale through an empty paper towel roll versus a straw? Obviously, it would require a more forceful effort to get the same volume of air through the straw in five seconds compared to the wide paper towel roll. The straw’s airflow resistance is greater than the roll. The arteries are no different.

When the artery’s resistance increases due to hardening or loss of their ability to stretch in width (elasticity), the heart has to work and pump more forcefully to circulate the same volume of blood throughout the body. Like any muscle that works harder, the heart’s left ventricle increases in size (left ventricular hypertrophy) to compensate for the increased workload. This mechanism works for a while but at a price. There are limits to heart size. Eventually the heart begins to irreversibly fail leading to congestive heart failure (a five-year mortality rate of 50 percent).

Another long-term effect of high blood pressure is damage to the smaller arteries and even smaller arterioles in the kidneys, brain and extremities. The kidney has millions of microscopic filtration systems called glomeruli. These effectively remove toxic waste products of metabolism from the body. The glomeruli are disrupted and destroyed leading to kidney failure. The arteries in the brain (cerebral arteries) can rupture leading to stroke. Less blood circulates to the feet and toes resulting in pain, loss of skin sensation, difficulty walking and in some situations, loss of limb(s).

All these risks and symptoms worsen with diabetes, smoking, high cholesterol, obesity and lack of exercise. Many of hypertension’s effects can be minimized and for some reversed. Normalization of blood pressure before the heart muscle fails can reverse the hypertrophy and prevent heart failure. Treatment in people under 60 years old reduces the risk of stroke by 42 percent and heart attack by 14 percent. People over 60 see a reduction of overall mortality by 20 percent, cardiovascular mortality by 33 percent, stroke incidence by 40% and coronary artery disease by 15 percent. These are amazing rate reductions.

So why do so many people continue to suffer and die from cardiovascular complications? Of the group of 4.5 million Canadians with hypertension only 16 percent are treated and controlled. Twenty three percent are treated and uncontrolled. Most worrisome are the 19 percent of this group that is aware they have hypertension but remain untreated and that the remaining 42 percent are unaware that they have hypertension.

There is no reason for people to suffer so needlessly from this condition. Treatment is effective with most people reporting minimal side effects. There is no end to the refrain that our health care system is under pressure to provide more services for less money. There are fewer health professionals available to provide care for end stage heart and kidney disease.

The cost of treating end-stage heart disease and renal failure is staggering. There are over three million people lined up to become future members of the end-stage club. There are billions of dollars in potential savings per year if all hypertension would be treated. These funds could then be redirected towards other areas of our health care system in desperate need of help.

There are many people who should see their doctor to find out if they suffer from hypertension. If you have not seen you doctor in years, do so. You may be one of those 42 percent. Do not join those 19 percent who know they have hypertension and do nothing about it. Appropriate lifestyle changes and medical therapy will reduce future disability and hardship. And that’s 100 percent for sure.

For more information: The Canadian Hypertension Society www.chs.md.

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