Archive for the ‘Myocardial Infarction’ Category
They Are Kidding…Right?
On August 15, 2010 in the American Journal of Cardiology, a group of cardiologists reported on a concept and in doing so, unleashed a firestorm of controversy. At first, lay people and physicians didn’t know if they were kidding and then became angry at the proposal.
What was this heresy? These British cardiologists proposed that next to the ketchup, salt and mayonnaise at the condiment counter there should be a container of ground up statin that people would sprinkle on their burgers, and by doing so would alleviate the damage they were doing by eating the burger.
Where does one start discussing this? First, I would like to note that in Great Britain you can buy a statin, Zocor (simvastatin), over the counter in doses of 10mg. Much like you can buy Zantac here. I applaud them for that. However, most of the science says that you need 20mg to obtain the benefit of simvastatin. Again, I will mention that we believe the benefit is an anti inflammatory effect of the statin on the cholesterol. And that effect lowers the of risk of further cardiac problems.
But where does the inflammatory effect come from? Most people believe it comes from our diet. There are some individuals that feel it comes from infection, but that line of investigation has not led us to any solutions. It seems to be our diet. Interesting sociologic data from many years ago, and you will have to excuse me because I cannot quote it exactly, shows that when you take the native Japanese population and move them closer to New York, the closer you get to New York, the higher incidence of heart disease you have. Indeed, in any population of people who eat like us, the increase in coronary disease is noticeable. The latest example is in China.
Come on people we are all basically the same genetic code. How come we have such a high level of disease in New York but such a low level of disease in Africa? “It’s the diet, stupid”, to paraphrase a recent president who, by the way, lost a great deal of weight for his daughter’s wedding. The genetic component of coronary disease seems to be the turning on and off of genes when they are exposed to a western diet full of all the things we love to eat. This, coupled with cigarette smoking and high blood pressure, seems to be enough.
My 35 year old patient, with multi vessel disease, that I admitted after an anterior myocardial infarction says “hello”. We are seeing this illness at a younger and younger age.
What are we to do…
What To Do When “Annie” Goes Down
This is not the end of the story. We have a way to increase survival in sudden cardiac death. Most people have seen the devices known as AED or automatic external defibrillators in public places. The AED is a device, which when placed on a collapsed person’s chest, will automatically perform and allow the patient to survive 36% of the time. Yes, the survival rate goes from 7% to 36%.
Here is a brief how-to if you are confronted with an individual that has collapsed. First you must call for help and 911. Immediately begin compressing the individual’s chest firmly and yes you might hear ribs or sternum breaking. THIS IS OK and does not lead to problems. Compress the chest firmly about 100 times a minute. Send someone to find an AED and use it even if it means stopping chest compressions for a few moments. Allow the AED to work over and over with intermittent chest compression until EMS arrives. Know that you did the best you could and that the situation is bleak in the best of circumstances. The outcome is not your fault.
A brief note - and maybe in the future I will blog about it further. One of the challenges with the whole process is a patient that arrives at the hospital alive, but who is neurologically impaired by the brain not getting enough oxygen or blood. We now have an evolving technique known as induced hypothermia which cools the brain down. This procedure is allowing improved neurologic survival in some patients.
Don’t give up. CPR is fifty years old this year, and the entire concept and treatment of sudden cardiac death continues to evolve. I don’t know how “Resusci-Annie” got her name, but she has taught an untold number of individuals who have stepped forward to learn CPR. An estimated 295,000 individuals a year experience sudden cardiac death. You can understand the magnitude of the issue. The number of deaths in this manner far surpasses all other diseases. There will continue to be research in this area and we will continue to improve. From 7% to 36% is a good start - but only a start.
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.
Do statins make you immortal?
My blogs over the past week have been concerned about the screening of asymptomatic patients for coronary artery disease and whether we make a difference in their morbidity and mortality if we find it.
That’s really all we are concerned with: Can we, as physicians, change a patient’s outcome by putting in place a medicine or a lifestyle? What good is it to find a problem if you can’t act on it?
To date, what we do when we find a patient who we believe to be at risk is tell them to stop smoking, control their blood pressure and their diabetes. And, we put them on statins. As those that read my blogs know, statins are our first line of defense against progression of coronary artery disease when a patient already has an infarct, angioplasty or coronary artery bypass surgery.
An article was published in Arch Intern Med 2010;170:1024-1031 which addresses this question. It is titled Statins and All-Cause Mortality in High -Risk Primary Prevention: A Meta-Analysis of 11 Randomized Controlled Trials involving 65,229 Participants.
This represents over 244,000 person- years of follow up. The average LDL cholesterol was 138 mg/dl and the results of giving statins yielded an average LDL of 94 mg/dl. An average of 3.7 years of follow up occurred in these studies and there was no evidence of benefit in these findings (7 fewer deaths for every 10,000 person years of treatment).
Although compelling, I believe that this study is flawed by the short follow up. Remember, this is not a randomized clinical trial which is the highest level of significance; it is a Meta-Analysis and only collates the data already collected in like studies.
Statins were approved because they were tested in randomized clinical trials against placebo and there was always a statistically significant reduction in a triple endpoint of unstable angina, myocardial infarction and death. Death however is usually the least affected because we are much better at preventing it if patients who are affected by an acute event present to hospitals. Patients who are found to be “at risk” will continue to be offered statins and the data shows that the lower the LDL is driven, the lower the vent rate. There seems to be no plateau. Every time a study drives the number lower, the event rate follows and some studies have the LDL as low as 50 mg/dl. The study known as TNT, or Treating to new targets,
showed this result in a study with over 10,000 patients.
The real study we want to do can not be done because it is not ethical anymore. Withholding statins from patients would never pass muster. It could be done in patients who refuse statins but the numbers would never be great enough. We will just have to accept the premise for the time being until science moves ahead of need.
Does Medicine Really Work?
It is all well and good to tell patients to take a handful of pills every morning and to insist that they spend a considerable amount of money on them…but do they really work? At the present time, five classes of drugs have been found to improve the prognosis of patients sustaining a myocardial infarction. These include aspirin, beta blockers such as Lopressor, renin angiotensin converting inhibitors such as Lisinopril, statins such as Lipitor and thienopyridines such as Plavix. What happens when you take all five of the classes?
This study was recently reported and published in Heart 2010. The study encompassed two groups and a total of 5,353 patients with acute myocardial infarctions over the years 2003-2004. The primary outcome was mortality adjusted for patient risk at baseline.
In the “optimal” group referred to as OMT, the mean age was 66.3 years and in the “suboptimal” group, the mean age was 70.5 years. Roughly 63% had angioplasty in each group and 5% had bypass surgery. At discharge, 89% received aspirin, 90% beta blockers, 84% statins, 81% renin blockers, 70% Plavix.; 6.2% received all five classes of OMT. These patients were younger, had more risk factors and were more likely male.
There was an astounding 74% reduction in mortality in the group that had OMT. Diabetics were the only subgroup showing no benefit. Most importantly, the withdrawal of beta blockers or withdrawing aspirin/Plavix from the OMT group abolished the benefit. Like I always say, don’t stop your Plavix!
This study is groundbreaking and shows how mortality benefit could possibly be improved. Only 50% of the patients received OMT so there seems to be a substantial room for improvement. Some of these drugs are what is known as Quality Indicators and are reported to Medicare and there is a grading system in place. Obviously the cost may be worth the benefit and most of these drugs are generic so the costs can be minimized. Plavix will go generic in 2011.
So when your doctor hands you 5 prescriptions just take them. It may save your life.
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.
Everything You Wanted to Know About Sex But Were Afraid to Ask
My apologies to Dr. David Reuben, who wrote the book by this title in 1971, for stealing his title. Yes it seems a long time ago that people thought this was so controversial. I guess that’s what the Internet has done. People are definitely more informed. Or are they?
It turns out that we cardiologists are not doing a very good job giving advice on resuming sexual activity after sustaining a myocardial infarction, and it seems we must do better. I must plead guilty as charged. I spend considerable time telling people to take Plavix and aspirin, and to increase their statin dose, but honestly, it never really occurred to me to tell people about sex.
A study known as TRIUMPH or Translational Research Investigating Underlying Disparities in Recovery from Acute Myocardial Infarction: Patients’ Health Status was presented at the recent American Heart Association meeting in Washington D.C. It is quite an eye opener. Only 46% of the men and 34% of the women received post discharge instruction when to resume sexual activity. Less than 40% of men and less than 20% of women had any discussion at all about sex with any of their physicians in the year after a heart attack.
The study found that 67% of men resumed sexual activity, but only 40% of women in that year. These data were controlled for variables such as age and partner status, so the reasons for the disparity is not that women were single or uninvolved more than men. It seems that there is significant room for improvement.
This lack of information clearly needs to be improved, and to become a greater focus of our discussion with patients. It may help to start a program with a trained health care professional who would take the lead in providing information and guidance with a doctor’s order. This is similar to other outreach programs that have been successful. Cardiac rehab may also serve as a place to provide this kind of information. Offices visits post hospitalization also seem like a place to start the conversation, as these areas are generally more private than a patient room or other hospital settings.
It’s time to help “Stella get her groove back.” It’s just one more example that we must care for the whole patient not just the lipid levels. Thanks to these researcher’s for pointing out an area of much needed improvement.
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?
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.
Correcting Urban Legends in Medicine
Urban legends are situations or things that are thought to exist but don’t. Their power is such that they can lead to excessive attempts to change behavior that didn’t need to be done in the first place.
Urban legends in medicine lead to an overuse of resources and an enormous increase in the overall cost of medical care in spite of contrary evidence. I don’t claim to know how to stamp it out. Education is one way, but people and physicians are incredibly resistant to it.
One such “Urban Medical Legend” is preoperative cardiac risk evaluation. The legend holds that it is possible to identify and then rectify the condition of patients who are at risk for cardiovascular incident and death before they have an operation. This is the so called cardiac clearance for surgery. It comes in two flavors the “emergency clearance” and the classical “elective clearance.”
Although there are Guidelines published by The American College of Cardiology in conjunction with The American Heart Association, neither are closely followed by most practitioners. The guidelines suggest that patients who have no evidence of angina or congestive heart failure are at no adverse risk for any surgery. In the process of screening for “problems” patients are generally subjected to nuclear stress tests and these tests identify those lesions that are “significant.” However, significant lesions cause angina and not myocardial infarctions and many myocardial infarctions are from lesions that are not considered significant.
The most important study done on this was a study that identified these patients and then randomized them to medical therapy and “corrective” therapy, either angioplasty or coronary artery bypass surgery. This study revealed that the “corrected group” had a statistically significant worse outcome than the medically treated group because of the incidents that occurred during the correction. This included the data for the surgery that they then went for after they were cleared.
The medical therapy most often applied is the use of preoperative beta blockers. These are drugs like Toprol and atenolol which control heart rate and blood pressure. This too has been called into question in that the routine use of these drugs can have important consequences for patients.
There is no perfect answer but what we presently do is unjustified by the data. The use of selective functional testing and the selective correction and treatment is evidence based but not necessarily the current standard of practice. This arises from legal concerns, compensation from testing and procedures and possibly from surgeons.
We as physicians need to do better. This is one area that we can make a difference in the quality and cost of health care. Beware of clearance that requires testing that you would not have gotten without the pending surgery.
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