Archive for the ‘High Blood Pressure’ Category
One More Word About Weight Loss
As I believe we can acknowledge that long term weight loss of large amounts of weight is about as challenging as climbing Mt. Everest — many try and few succeed, but the view is worth it. It is hard enough losing and keeping off ten pounds let alone 75-100 lbs.
There is a way if you are morbidly obese. Remember morbid obesity is a definition in which you have a BMI of 40 or higher. I put the calculator site in a previous blog where you can get your number if you wish. The way for morbid obesity is gastric bypass. An abstract was discussed at the annual meeting of the American Society for Metabolic and Bariatric Surgery this past June which discussed the benefits of gastric bypass on high lipids.
Let’s start with some basic information on Gastric Bypass. We have a certified center at Holy Cross Hospital that we are very proud of. It is run by Dr. Michael Perez and I would direct you to the Holy Cross web site, and for those that are not reading this blog from that site it is www.holy-cross.com.
In 1991, the NIH at a consensus meeting decided that gastric bypass was a consideration as a tool for weight loss. Gastric bypass could be used, in addition to lifestyle changes if you had a BMI of 40 or more, or if you had a BMI equal to or greater than 35, and if you had a co-morbid condition such as diabetes or hypertension.
The operation, which is now often done with a laparoscope, consists of two parts. The first is the creation of a small pouch in the stomach, and I do mean small. It is generally the size of 15-30 ml or the size of a thumb. The stomach is then diverted into the small intestine in several ways. The most common is the Proximal version in which one limb is constructed from the pouch to the proximal portion of the small intestine to preserve the ability to absorb nutrients. The other limb is constructed to the “bypassed” stomach to drain it.
Impressive weight loss can be rapidly achieved along with several added benefits. In general this operation has a 30 day mortality of 0.11% and a 90 day mortality of 0.3% and a complication rate of 7%. Weight loss of 65-80% occurs. Diabetes is eliminated in almost 90% of the patients and it has been proposed that it maybe the treatment of choice for that subset of patients. High blood pressure is relieved in almost 70% of patients and in those that it is not fully treated the numbers of medications needed to treat the hypertension are reduced.
The abstract presented dealt with the effects on hyperlipidemia. The patients had an average drop in total cholesterol of 20% from 220mg/dl to 179 mg/dl. LDL dropped from 135mg/dl to 106 mg/dl. This result was seen as long as six years later so it is long lasting. The average BMI was 50 and the average weight loss was 40% of their BMI. Notice that the levels that we wish to achieve in patients who have documented coronary disease would still require statins.
Obviously, this is not a great way to deal with the effects of overeating. I don’t think that people set out to achieve a BMI of 40. Weight loss consists of the principle of eat less than you need. If we all just cut down on the amount of food we eat, we will all be better for it and much of our health care costs would be controlled.
It has been said, that as a society, we are not good at providing general preventive medical care but we are the best at “rescue” care. This represents “rescue” care for morbid obesity. Let’s all pledge to do better.
Share Our Mission to Heal
Holy Cross Hospital is seeking studio audience members for A Mission to Heal, a new show all about the heart.
Needed: 75 audience members for each show; Mix of demographics. No children under 18; Community groups are encouraged to have representation in the audience, as well as community leaders.
Where
A studio in Davie, FL. Details will be provided to audience members upon selection.
When
September 30, 2010; Refreshments will be served.
The show is not “live” but it is being recorded “live” so it will be edited and shown at a later date. Audience members should dress comfortably for long periods of sitting. No white blouses, shirts, hats or sweaters.
Please email info@holy-cross.com and put A Mission to Heal in the subject field OR call 954-776-3244 if you are interested in being part of the studio audience.
Please provide your full name, phone number, e-mail address, age range (20s, 30s, 40s, 50+) and race/ethnicity. Someone will be in touch to let you know if you have been selected and provide additional information.
Gimmee a Pill Part Three
Science progresses by small steps. If a drug like fenfluramine doesn’t work , can we make a drug specific to the receptor and have it provide no side effects? This would be analogous to the class of drugs that are known as the sartans which block the effect of angiotensin in the body and are used to treat hypertension and heart failure. The 5-HT2C receptor is what is being blocked by the compound lorcaserin and guess what? It provides weight loss.
This paper was published in the N Engl J Med 2010; 363: 245-246 and vigorously commented on in the lay press. The study known as BLOOM for Behavioral Modification and Lorcaserin for Overweight and Obesity Management enrolled 3182 obese patients who had body-mass index between 30 and 45 kg/m2 or if you had hypertension, diabetes, cardiovascular disease, impaired glucose tolerance or sleep apnea. (Just about everyone over the age of 40 years old). Just for grins go to the website http://www.nhlbisupport.com/bmi/ and calculate your own. Don’t cry. I need to become taller or lose 15 lbs.
The participants took 10 mg lorcaserin twice a day or placebo and everyone was instructed to exercise 30 minutes daily and to reduce caloric intake by 600 kcal a day. That translates into a diet roughly 1400 cal a day for most patients. Forget the doughnuts at breakfast.
At one year, 74.5% of the treated patients lost 5% or more of their body weight, not their BMI, compared to 20.3% of the placebo treated patients. If I weighed 175 and lost 8.75 lbs. over one year I would be a success. On average, patients lost 5.8 kg or 12.78 lbs. in one year. The placebo group lost 2.2 kg or 4.85 lbs. Here’s the real kicker. After one year, patients in the lorcaserin group were randomized again to continue the medication or take placebo. Those that continued the medication maintained their weight and those that took placebo regained the weight to roughly the placebo group level.
Personally, I’m not at all sure that taking a medication to achieve a 12 lb. weight loss is what we are really looking for. I will go back to my original premise that what is needed is for the American population is to “man up” and stop whining. We need to eat less far less and exercise more far more. Lifestyle modification is what is needed, and though it is hard and not sexy, you are never going to have abs like “the Situation” until you eat and exercise like him. Jack LaLanne told us this in the 1960’s “eat right and you can’t go wrong”. He is now 96 years old and still going strong.
We must remove the mind set from the population that medicine can solve all the effects of bad choices that we make. Do you really want that second helping of food, or are you willing to do the exercise that it takes to work it off.? It’s our choice and as you can see by looking around we are losing the battle.
Can We Do Better?
A considerable number of strategies in American medicine are troubling. One of the most troubling is our insistence on spending large amounts of resources treating illnesses that might be able to be prevented at an earlier stage. Simple examples are providing better treatment of diabetes and hypertension by making the drugs and materials needed more readily available to patients.
As the readers of my blogs know, a large proportion of this country’s resources go to treating coronary artery disease and its consequences. Couldn’t we do better if we prevented this? Roughly 50% of the major cardiovascular events that occur in this country every year, which by the way amounts to over 700,000, occur without warning. At the time of writing in 2006, it was felt that by implementing the SHAPE recommendations 21.5 billion dollars could be saved.
This subject has been discussed before. In 2006 a taskforce was developed to address this problem and provided the SHAPE guidelines. SHAPE stands for Screening for Heart Attack Prevention and Education. It was a committee set up by big Pharma mostly Pfizer and never received much support mostly because it would make heavy use of drugs i.e. Lipitor, made by Pfizer, in its prevention mode.
This past week one of the editorial leaders of the SHAPE study Dr. Prediman Shah was the lead author on an article published in the Journal of the American College of Cardiology titled Screening Asymptomatic Subjects for Subclinical Atherosclerosis . I want to point out that Dr. Shah, who practices at Cedars Sinai in Los Angeles, is a widely published and respected researcher.
Screening for disease, although it sounds like a perfect solution, is sometimes no solution at all. One can point to the use of the PSA test for prostate disease. Screening with it has not led to changes in the diagnosis of advanced prostate disease or lowered the death rate of prostate cancer. Recently, the physician who invented the test wrote that he thought our use of it should be reevaluated.
SHAPE recommended that all asymptomatic men 45-75 years old and all women 55-75 years old be screened. There are two main ways this is done. The first is the Framingham Risk Score that I have blogged about in the past. This score which identifies the risk of events in ten and twenty year periods has been found to be useful. It is highly dependent on blood pressure and cholesterol values as those were the only modalities available at the time. If you go to the online calculator fiddle with the numbers so you can see the changes in risk that occur. Guess what? This approach has never been subjected to a randomized clinical trial and at this point never will be because it is not ethical.
Next…what about imaging?
Prevalence of high blood pressure
There has been a great deal of discussion recently about the problems with various drugs for hypertension. None of this discussion puts this disease into context. Perhaps the greatest difficulty with hypertension is helping patients understand the concept of “saving now for retirement later.” What I mean by that is the vast majority of patients have no symptoms from their hypertension yet the medicine can impart some problems. If ignored by patients, hypertension can lead to heart, kidney and brain problems. You don’t know it’s a problem until it’s too late. If you take your medicine and “save now” you can “retire” later because you won’t have had a stroke or be on dialysis or have heart difficulties.
An article published in JAMA titled US trends in prevalence, awareness, treatment and control of hypertension highlights these concerns. This data was derived over the years 2007-2008. It showed that only 50% of those treated had their pressure controlled. This 50% number was significantly better than the 2000 number which was 31%. The prevalence of hypertension in the population remains fairly constant at 29%.
Let’s do the math. It’s estimated that 70 million people in the United States have hypertension; 20% don’t know they have it. Of the remaining 80% or roughly 56 million people only 50% have their pressure adequately controlled. It’s enough to give you hypertension thinking about it. Clearly much more can and needs to be done.
One of the first efforts is to prevent the problem. It is felt that many patients would not be hypertensive if they controlled their weight and salt intake. This salt restriction idea is getting a significant amount of press lately and New York city may make a big effort to ban salt just as they did smoking and the use of trans fats in cooking. Just try getting a decent hot dog soon.
One last note. As I have often mentioned in these blogs, we as a nation are not getting any thinner. Weight gain often brings on hypertension. It is felt that we are using better drugs to offset the gains in weight that patients are presenting with and we as physicians are using more drugs to get patients “to goal.” Help us out. Lose weight, limit you salt intake, get some exercise, and don’t smoke. You have heard it all before.
Is it starting to sink in?
If it bleeds it leads
I don’t know who said it, but supposedly the lead story on news programs is always the bloodiest. On Monday the general public was treated to the media version (should I say circus?) of a barely published article in Lancet that was actually leaked before publication. I say barely published because there is a pretty hard and fast rule about discussing studies in the media before they are published. It is an embargo informally named the “Ingelfinger rule” after the long time editor of the New England Journal of Medicine Dr. Franz Ingelfinger. When this article was leaked Lancet released it on line as well as the corresponding editorial by Dr. Nissen of the Cleveland Clinic. Back in Dr. Ingelfinger’s time, there was no internet to release to.
Well what was this article about? On CNN Monday morning it seemed that if you took an ARB or angiotensin receptor blocker you were destined to get cancer. Sounded suspiciously like my mother telling me when I was a child (or was it yesterday) that if I touched the stick I would put my eye out.
What in the world is an angiotensin receptor blocker? Well let me digress for a moment. The substance that causes many patients to have hypertension is angiotensin which is produced in all individuals but to an abnormal amount in some patients. In the late 1970s, researchers at Bristol Myers Squib—now Bristol Myers—named Charles Smith and John Vane isolated pit viper venom and did animal testing to show that the venom lowered blood pressure in the animals. However, it can only be given by injection so it was decided to produce enough pit viper venom to give to humans by injection to “prove the concept.” This cost roughly one million dollars per kilo to produce.
It worked so well that the researchers then undertook the task of creating a drug to “mimic” the effect of the venom. This was done by a process now known as rational drug design. They created the molecule captopril which became Capoten and the rest as they say is history.
This drug revolutionized the way we as cardiologists treated hypertension and congestive heart failure. However, captopril had several pesky side effects the worst being a persistent but nonproductive cough. Capoten blocks the creation of angiotensin by inhibiting the enzyme which cleaves the compound renin. It turns out that angiotensin lands on a “receptor” to accomplish its action and this receptor is what the angiotensin receptor blockers block.
In my next blog: What the fuss is about.
Time to relax
Two studies were recently published concerning the cardiovascular risk of working overtime. The first published in Occupational and Environmental Medicine (there is a journal for everyone) and the second in the European Heart Journal. The first studied nurses and the second London civil servants.
Over a 15-year period, 12,116 nurses were studied. They were originally between the ages of 45 and 64 years old. Over this period of time, there were 580 cases of angina or myocardial infarctions. In addition, there were 73 cases of “other” ischemic events but they were not otherwise characterized. When adjusted, the nurses who felt that work pressure was “much too high” had a 1.4 fold increased risk of developing symptomatic heart disease.
The London-based study began in 1985 and looked at participants who were 39 to 61 years old. The study follow up was completed in 2004. Adjusting for all factors, working three to four hours of overtime per day was associated with a 60% higher rate of fatal and nonfatal myocardial infarction or angina.
Although interesting, the reasons for these findings are pure speculation. One could postulate that it is all “stress” and that this is manifested in unhealthy lifestyle choices and high blood pressure. Is there more stress working at a job or not having one? Is it more stressful losing your insurance or working to keep it? Similar findings have occurred when life events such as death of a spouse or child, or divorce have been studied.
It all relates back to keeping your blood pressure under control and trying to reduce stress in your life in anyway that it applies to you. Everyone is different. Some people exercise, some read, some listen to music. Whatever it is, just do it to relieve stress and possibly stay disease-free.
One Pill Cures All
It has long been a goal of doctors, not drug companies, to make a pill that combines multiple medications that can be taken once a day. When I was in school, we named it “Wonderall.” This concept vastly increases compliance and it is hoped would prevent “events.”
The drugs in these pills are generic drugs that we have been used for years and are proven to do the jobs they are supposed to. The drawback is the doses chosen may not be enough for a particular patient. In medicine, one size generally does not fit all.
It is very easy for a patient to have to take more than 10 different medications several times a day. If you have heart disease, diabetes, lung problems, the list gets long indeed. Besides, the cost is just not practical and leads to many problems.
These pills contain 75 mg of aspirin, 40 mg simvastatin, 50 mg of atenolol and 10 mg of lisinopril. There has been some discussion about removing the aspirin because of the recent difficulties that I have blogged about. If you survived a stroke, you get a pill with 12.5 mg hydrochlorothiazide instead of the atenolol.
The study to take place in Great Britain, Ireland and the Netherlands and is known as UMPIRE or Use of a Multidrug Pill in Reducing Cardiovascular Events and will enroll 2000 subjects. To be enrolled they have had to have sustained a stroke, myocardial infarction or be at high risk. The primary end point is compliance but events will be monitored.
Another study which is starting is known as TIPS 2, which uses a pill containing 25 mg hydrochlorothiazide, 100 mg atenolol, 10mg ramipril, 40mg simvastatin and 200mg aspirin. This study will enroll 500 subjects and will be presented at the American College of Cardiology meeting in 2011.
Sadly none of these studies will take place in the United States. What’s up with that? Are we afraid of making it too easy for our patients? It’s really a disgrace, if you ask me. We should be at the forefront of this work to give possibly better, certainly easier care to our patients. Are we as physicians so enamored with 20 medications on a patient’s list? Do we get a prize for the most medications prescribed? Can we get with the program?
More On Calcium Scores
My last blog concerned the use of calcium scores to determine whether a patient did or did not have coronary artery disease. An article has been published that I would like to share with you because it compares the Framingham risk calculator and the use of calcium scoring to determine which is better in defining patient illness.
This article titled “The detection of any coronary calcium outperforms Framingham risk score as a first step in screening for coronary atherosclerosis” was published in the Am J Roentgenol 2010: 194:1235-1243. The study details that 1416 men and 707 women were included. The mean age of the men equaled 51.4 years, and the mean age of the women equaled 56.9 years.
In those patients who had a presence of a segment plague score of 4 or higher, any calcium was 98% sensitive in men and 97% sensitive in women. In the same population if you had a Framingham risk score of 10% or higher, it correlated with the findings only 74% of the time in men and 36% of the time in women.
If your plague segment score was 3 or higher, the presence of calcium was 97% sensitive in men and 92% sensitive in women. In contrast, the Framingham score of 10% or greater was found in 88% of men and 35% in women.
This is not really surprising as I explained before that the presence of any calcium infers that the patient has the illness and needs to be treated. It does not mean that they have symptomatic disease but the data can be used to propel the patient to “make the right decision” and stop smoking, control their blood pressure and take statins. In much the same way the Framingham calculator does that because you input the blood pressure, the smoking status and the LDL level as some of the information to achieve a score. By “manipulating” the data, one can point out that lowering numbers or stopping smoking reduces risk considerably.
Why the disparity in women and men scores is so great, I do not know. It is widely understood that the diagnosis of coronary disease in women lags behind men, although equal numbers of men and women die each year. Perhaps women should have scoring and men the Framingham test and then the numbers would be more reflective of need.
Technology may help us lead the way to better patient care in both men and women.
The Perfect Storm for Health Care
I knew things were bad, but recent data released from the National Health and Nutrition Examination Survey (NHANES) report that what I have been blogging about lately takes the cake (Excuse the pun.) The report is published @ Fryar CD, Hirsch R, et. al. Hypertension, high serum cholesterol, and diabetes: Racial and ethnic prevalence differences in U.S. adults, 1999-2006. Hyattsville, MD: National Center for Health Statistics, 2010.
In brief, the report outlines 45% of individuals who are 20 years or older have hypercholesterolemia, hypertension, or diabetes. 3% had all three, and 13% had two most commonly; hypertension and hypercholesterolemia.
In 15% of all US adults, these conditions are undiagnosed. The levels used in these studies are not as “stringent “as the levels with which we cardiologists work with, which would undoubtedly would lead to an increase in these issues.
This brings up many points. The first one is people are going to have to take more responsibility for their health. Weight loss is the primary goal, as it will lead to a decrease in all three of these events. If you are at your “ideal” weight (and who among us are), then medications are warranted to prevent the long term consequences of these illnesses. As I have blogged about before, these illnesses start early and progress silently over time until the myocardial infarction or stroke occurs. It doesn’t really do much good the hose the burning barn down. It is far better to protect the barn.
Data has shown and I have blogged that as your LDL cholesterol drops the event rate for stroke and myocardial infarction drops. There is no plateau. An LDL of 70 is better than 80 and an LDL of 50 is better than 70. If you are taking cholesterol medication, get the maximum benefit and take the maximum amount. There is no significant increase in side effects and that is well documented. One scary event that is occurring is the constant switching of medications by insurance companies for no other reason than price. The statin drugs are not the same and to reach “goal” the amounts that patients need vary widely. Don’t get lulled into the amount you are taking. If you don’t take the “right” amount, you are risking the side effects without the full benefit.
Hypertension is more controversial. As we have recently seen and I have blogged about the ACCORD trial shows that lower is not necessarily better. You should strive to keep your systolic numbers below 140 and your diastolic numbers below 90.
The biggest benefit comes from exercise, which will help with diabetes, hypertension, and cholesterol. As Nike says Just Do It.
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