What NOT to Do for Preventing Heart Disease in Women

The American Heart Association (AHA) recently published guidelines regarding prevention of cardiovascular disease in women.  The full text of the guidelines can be found here. Dr. Randi Protter from Capital Health’s Center for Women’s Health recently wrote about some of their dietary recommendations.

The guidelines also have recommendations regarding physical activity, cigarette smoking, as well as management of blood pressure and cholesterol. In general, most of the recommendations are not different than those for men.

The guidelines specifically recommend AGAINST four interventions that previously were thought to be potentially beneficial:

1 – Daily aspirin in healthy women younger than 65. Aspirin is commonly used to prevent heart attacks or strokes in people who have already had a heart attack or stroke (so-called secondary prevention). In young women who do not have such history or evidence of plaque buildup in their artery and are not otherwise at very high cardiac risk, aspirin is not useful and may in fact lead to stomach upset, ulcers and bleeding and should not be used. This is a recommendation that is specific to women.

2 – Hormone replacement therapy (HRT) should not be used to prevent heart disease.  Obviously this is another recommendation that is specific to women. There may be other legitimate reasons for women to be taking hormone replacement therapy, such as to treat symptoms of menopause. However, HRT should not be used solely to prevent heart disease.

3 – Antioxidant vitamins such as vitamin E, vitamin C and beta carotene should not be used to prevent heart disease.

4 – Folic acid supplements should not be used to prevent heart disease. Folic acid does have a very important role in preventing neural tube defects in unborn children and should be taken in women of childbearing age for this purpose. However, it is useless in prevention of heart disease.

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The Basics of Blood Pressure Control

As cardiologists, we work with you to reduce your risk of heart attack, stroke and heart failure. Controlling your blood pressure is an important factor that we look at to help you reduce your risk. 

According to a national guideline on blood pressure management (JNC 7), a normal blood pressure is less than 120/80. JNC 7 says that you’re at risk for having high blood pressure if your blood pressure is between 120/80 to 139/89. Although JNC 7 was written in 2004, it was based on the best information available at that time and it is still used today by most cardiologists as the primary guideline on how to diagnose and treat high blood pressure. 

A new study published in Circulation (the journal of the American Heart Association) last month reviewed the use of high blood pressure medications and whether patients follow their prescribed medications. In other words, what medications are people more likely to continue taking and which are they more likely to stop taking. It was found that the medications recommended to use first in JNC 7 are the least likely to be taken. 

Recommended diuretics and beta blocker medications have side effects which cause some people to stop taking them. Without the medicine, however, a person’s blood pressure goes untreated and they are still at risk. Two other types of blood pressure medications are known as ACE inhibitors or ARB’s (angiotensin receptor blockers). The study showed patients are twice as likely to continue taking these medications compared to diuretics and beta blockers.

Risk for heart disease can be reduced by controlling blood pressure and patients can improve their risk for heart disease if they are willing to take their prescribed medication.

Be sure to talk with you health care provider about your medications and be honest about your usage. There are many options to medically treat blood pressure and we can find the right one for you.  And remember, diet and exercise is the core to any risk reduction plan.

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Get Active for a Good Cause

We all would like to prevent a potential heart attack, right? Well, the key to prevention is diet and exercise. We all know the American diet is not a heart healthy one. Portions are too large, and they include too much fat and way too much salt. We can all improve our diet.

Exercise is the other essential part of a preventive care plan. Any activity is better than none. Some people find exercise fun. I enjoy running, biking and most other activities outdoors. I enjoy it, which is why I continue. Those who find exercise to be a chore will never stick to it. 

My advice it to find something you enjoy, and do it regularly. Or you can find a cause you would like to support and participate in an active event supporting it. Nearly three years ago, my wife and I had twins born at 33 weeks. They are perfectly healthy now, but required a month long stay in the Neonatal Intensive Care Unit (NICU) at Capital Health – Mercer. We had outstanding care and will never forget those who cared for our babies.

Capital Health – Mercer is moving into a new, beautiful building in Hopewell in November, but the first event at the new hospital will take place on May 21. It is called the Diaper Dash and proceeds will support the Capital Health Regional Perinatal Center, part of which is the NICU. There is a 5K run or 2 mile walk. My wife and I signed up last night so you will see us there for the 5K with our twin girls and our newest addition, our son, in jogging strollers. 

Events like the Diaper Dash give us a reason to exercise that is close to our heart.  There are events out there supporting any organization you can imagine. Find one you would like to support and sign up. You can run, walk or provide support like handing out water along the course. The rewards are two-fold: you are supporting a cause and getting exercise while you do it.

Exercise should be fun. So as the weather gets warmer, find something you enjoy and get active. And if running or walking is your exercise of choice, then I hope to see you at the Diaper Dash in May!

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Cardiac Risk Testing for People Without Symptoms, Part II

Last week, I posted an entry about the importance of testing and meeting with a cardiologist regularly when it comes to preventing a heart attack. In the post, I highlighted part of a set of national guidelines compiled by medical experts across the country. These are guidelines for assessing the risk of heart attack in patients who have no symptoms. Here are some more guidelines that came from that same report that I hope you find interesting.

Lipid particle size and density

Cholesterol (also known as lipids) is made up of different particles. When your total cholesterol level is high, you’re at increased risk for heart attack and stroke. Total cholesterol is broken down into good (HDL) and bad (LDL) cholesterol. These three parts provide the most significant information on risk. Each particle of HDL or LDL can also vary in size, but there has been no evidence that testing particle size leads to improved outcomes. Therefore, medical experts (including myself) recommend not performing testing of particle size in adults with no symptoms. Rather, a standard fasting lipid profile is used.

C-Reactive Protein (CRP)

C-Reactive protein (CRP) is a protein found in the blood. When CRP levels rise it means there is inflammation in the body. Certain inflammations can be the start of atherosclerosis (clogging of the arteries), the cause of a heart attack. For instance, high sensitivity C-Reactive Protein (hs-CRP), has been shown to identify risk of heart attack. When elevated, it also shows increased risk for developing diabetes, obesity and high blood pressure.

In men 50 years of age or older or women 60 years of age or older with LDL (bad) cholesterol less than 130, hs-CRP measurement is helpful in determining risk. An LDL of less than 130 is generally considered good, however, a recent study showed that hs-CRP can help find those at higher risk when cholesterol looks “good.” People with “good cholesterol” and minimal other risk factors can still have heart attacks so getting a  measurement of hs-CRP can improve your risk assessment, leading to better preventive treatment.

Ankle-Brachial Index (ABI)

Ankle-Brachial Index (ABI) is a simple test done by measuring blood pressure at the ankle and in the arm while a person is at rest. An ABI of 1 is considered normal range (0.9-1.1). This means that your blood pressure at your ankle is the same as the pressure at your arm, and suggests that you do not have significant narrowing or blockage of blood flow. A low ABI, however, may mean a blockage in the arteries of the legs. A high ABI may suggest calcium-caused hardening of the arteries in the legs.

When combined with the Framingham Risk Score (FRS) (see last week’s blog entry), ABI has been shown to be very useful in improving risk assessment.

Coronary Calcium Scoring (CCS)

Plaque build-up in the arteries is the cause of heart attacks. As arteries harden and plaque builds, calcium is found at the site of the blockage. Coronary calcium scoring uses a special X-ray test called computed tomography (CT) to check for the buildup of calcium in plaque on the walls of the arteries of the heart (coronary arteries). The amount of calcium is then measured. The risk of heart attack increases as the amount of calcium increases. Calcium is rarely seen before age 40 in men or age 50 in women, therefore, CCS is not recommended in younger individuals. An additional benefit of measuring your calcium score is that you’ll pay more attention to diet, exercise and medications.

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Natural Supplements and Coenzyme Q10

One of the most common questions I get asked by patients is: Are there any natural supplements I can take that will help my ______ (fill in the blank with “blood pressure”, “high cholesterol”, “heart disease”, etc)? The answer unfortunately is that with the possible exception of fish oil, no one really knows for sure. 

Supplements have an obvious appeal to people who wish to avoid taking pharmaceutical medications. The problem here is that just because a substance came from a natural source, it does not necessarily mean that it is safe or free from side effects. Some of the most poisonous substances known come from natural sources. In addition, their benefits and their interactions with other medications are also often not well known. On the other hand, before a pharmaceutical is allowed to be marketed, its manufacturers spend years doing research on volunteers to demonstrate that the medication in question is:

1) reasonably safe,
2) reasonably effective in treating the condition it is intended to treat, and
3) at least as good if not better than an alternative that is already on the market. 

Unfortunately, natural supplements lack this thorough level of research. 

One of the more common supplements patients report taking is coenzyme Q10. Coenzyme Q10 is a substance that is naturally found in most cells of the body and is involved in generating energy. Coenzyme Q10 is used for overall heart health and to treat a variety of conditions, including muscle aches caused by statin (cholesterol-lowering) medications.

A recently published study looked at blood levels of coenzyme Q10 in patients with heart failure and the effect of treatment with Crestor (rosuvastatin), a statin medication. Researchers found that patients with low coenzyme Q10 levels were indeed sicker, but when other risk factors were considered, there was no relationship between coenzyme Q10 levels and outcomes. Crestor did lower conezyme Q10 levels, but the patients who were taking Crestor or had lower coenzyme Q10 levels did not seem to have more muscle aches.

This study suggests that low coenzyme Q10 levels are a marker of more advanced heart disease but not the cause. It suggests that using coenzyme Q10 may not be helpful for treatment of heart failure. It also casts doubt on the claimed relationship between low coenzyme Q10 levels and muscle aches thought to be caused by statin medications.

More studies such as this are needed before we can give more definitive answers to our patients regarding benefits of natural supplements. 

Note: In addition to our regular blog entries, please also check out the blog of Dr. Randi Protter, director of the Capital Health Center for Women’s Health, for some very useful information regarding women’s health. 

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Cardiac Risk Testing for People Without Symptoms

Many of us are willing to do everything we can to prevent a heart attack. Symptoms, including chest pain, are a late, major indicator for a heart attack, however, some people are at very high risk for a heart attack and have no symptoms to let them know. Treatment for obesity, high cholesterol and blood pressure are essential, but those who do not have any of these obvious risks should be evaluated more closely so that we (your cardiologists) can provide more effective treatment recommendations. Last December, a set of guidelines was compiled by medical experts across the country to discuss the assessment of risk in patients who have no symptoms (also known as asymptomatic patients). Many tests were discussed, and I will highlight a few of these in this and other upcoming entries. 

Framingham Risk Score

Dr. Parang discussed the Framingham Risk Score in a previous blog. If you missed it, the Framingham Risk Score was composed after years of following a population of 30-60 year old men and women living in Framingham, Massachusetts. From this study, a risk calculator was created to provide people with a 10-year risk assessment for heart attack.

Major risk factors were not included, such as weight, presence of diabetes or prediabetes, and family history, so needless to say, the Framingham Risk Score has some major shortcomings. For example, many people, especially women, have their risk underestimated by the Framingham Risk Score. A vast majority of women less than 75 years old are classified by Framingham Risk Score to be at low risk for heart attack. However, according to most cardiologists and the American Heart Association, a woman’s risk of heart disease and stroke begins to rise and keeps rising with older age.

Adding together all levels of risk improves our overall assessment of risk. It also helps us doctors know who needs the most aggressive treatment to reduce risk. Despite its limitations, the Framingham Risk Score is one of the most widely recommended guidelines used to assess risk of heart attack. However, additional testing beyond the Framingham Risk Score has been shown to better assess risk. And don’t forget, the earlier you get tested, the earlier we can start to take preventive measures against advanced heart disease.

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Top Five Heart Healthy

How can you eat better and live longer? The American Heart Association recommends a dietary emphasis on fruits, vegetables, nuts and lean meat including fish. Keep your ticker in good shape by substituting in these healthy foods to your daily routine:

1.  Oatmeal. It’s got tons of soluble fiber that can help lower cholesterol. Add in fruit for taste and make it even healthier. Just remember to avoid instant oatmeal since the real stuff has more fiber.
2.  Salmon. It has omega-3 fatty acids and antioxidants and its low in saturated fat. Look for wild-caught rather than the farmed variety and avoid frying in oil. Pair with fresh vegetables for a heart-healthy dinner.
3.  Avocado. Packed with “good fat”, eating avocado rather than less healthy fat sources still tastes good and helps lower cholesterol.
4.  Nuts. Especially walnuts have high levels of fiber and contain good fat. These can make a great snack on their own or add flavor and texture to a salad.
5.  Olive oil. Substituting butter for extra-virgin olive oil in your cooking is an easy way to make everything you eat healthier.
Remember to burn as many calories per day as you take in if you’re looking to maintain your weight as is. If you’d like to talk more about how diet and lifestyle choices can impact your heart health, call 609-393-1524 to schedule an appointment.
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Learn CPR. You May Save a Life.

You are at home with a family member who suddenly falls to the floor. She is completely unresponsive. She just had cardiac arrest. You immediately call 9-1-1. An ambulance is on its way. Now what do you do?

It’s a scary fact, but more than 300,000 Americans die each year as a result of cardiac arrest. Only 8% of people who have cardiac arrest outside of a hospital survive to be discharged from the hospital.  

A very important step in maximizing the survival odds of a victim is early cardiopulmonary resuscitation (CPR) by bystanders.  

The modern CPR was first described about 50 years ago. The American Heart Association (AHA) developed its first set of guidelines for CPR in 1966. These have periodically been updated with the last set of guidelines being published last fall. 

Knowing CPR may one day save the life of one of your loved ones. The Emergency Medical Services Department at Capital Health offers CPR classes for the public. You can get more information about the schedule of classes or sign up by calling 609-815-7291.

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Finding Out Your Risk for a Heart Attack

As we got through the holiday season and made our New Year’s resolutions, more than a few of us were probably thinking about our health in the upcoming year.

Have you ever wondered what your risk of a heart attack is? It’s perfectly reasonable to be concerned about your heart, since after all, heart disease is still the number one cause of death in our country.

The good news is that over the past fifty years, we have made tremendous progress in preventing heart attacks. This is partly because we are much better at preventing heart disease in the first place. A very important part of prevention is to assess each person’s risk profile and to individualize our prevention plan so that we can focus our most intense treatments for people who are the highest risk.

To assess an individual’s risk, we start by reviewing their risk factors. Have they ever suffered a heart attack or a stroke? Or do they have diabetes or poor circulation in their legs? If any of these are present, that person is automatically considered to be at high risk. 

For folks who have none of these conditions, a useful tool is the Framingham Risk Score. This is an online calculator that gives your risk of a heart attack over the next 10 years. A score of more than 20 percent is considered high risk. If you know your blood pressure and cholesterol, you can calculate your risk yourself.

However, this tool does have some limitations. Since it estimates risk for the next 10 years, young people almost always get a low score, even though their lifetime risk may be quite high. Also, since the data was collected from volunteers from Framingham, Massachusetts, the results may not be equally valid across all ethnic groups. And since it is an average derived from thousands of individuals, it should be considered only an estimate and a good starting point and not a substitute for a physician’s individualized assessment. 

In our practice, my partners and I have a special interest in preventive cardiology. We would much rather prevent the first heart attack, because we may never get the chance to prevent the second one. We would be happy to meet with you for a personalized risk assessment and an individualized plan to minimize that risk. Call us at 609-393-1524 for an appointment.

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Source Of Dietary Protein And Heart Disease

Much has been written about the proportion of dietary fats versus carbohydrates versus proteins and their effect on risk of heart disease. Initially, doctors were recommending a low fat diet to prevent heart attacks. More recently, we have learned that not all fats are bad and that some types of fats such as trans-fats and saturated fats are dangerous and that fats from seafood such as omega-3 fats can actually be good for the heart. So if you substitute oily fish (such as salmon) for a greasy hamburger, it would be much more heart-healthy, even though both meals may contain the same amount of fat.

Could it also be that some proteins are better than other proteins? A recent paper looked at this question. Researchers looked at data from the Nurses’ Health Study. Beginning in 1976, more than 121,000 nurses started filling out questionnaires about their diet and were followed by researchers who looked for any development of heart disease. They found a significant difference in the heart-healthiness of different types of protein. They found that nurses who consume a lot of red meat tend to have more heart disease, whereas nurses who consume more fish, nuts, or beans tend to have less heart disease. 

Is it possible that the nurses who ate more fish were healthier to begin with? In other words, could it be that they had fewer heart attacks not because they ate more fish but because they were more health conscious? The researchers used statistical analysis to adjust their results for other risk factors and they still came up with the same conclusion:  ounce for ounce, it is much more heart healthy to get your protein from fish, beans or nuts than from red meat.

This paper also contained some exciting news for the egg lovers among us:  It found no relationship between eating eggs and heart disease.

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