Archive for June, 2010
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?
No “right” answers
When it comes to prescribing drugs, doctors must weigh the risk of giving any drug versus the benefits of those drugs. Common drugs that we use today have significant and at times fatal reactions.
Guess the drugs that correspond to the following side effects:
Side effects: Anaphylactic shock and death. Drug: Penicillin.
Side effects: fatal bleeding, anaphylactic shock and asthma with severe respiratory distress. Drug: Aspirin.
Side effect: respiratory depression with cessation of breathing. Drug: morphine.
I could go on and on.
This is the practice of medicine. You have a disease and need a treatment. Doctors try and find a treatment which is not worse than the disease. The drugs reported on in this study were being used in the disease of congestive heart failure. Congestive heart failure, when it is Class 3 or 4, has almost 100% mortality at five years. This class of drugs when used in this disease state significantly increases your chance of living and improving your quality of life. Is it worth it to take the drug?
It is true that the same benefit is received when you take angiotensin converting inhibitors but many patients have side effects from those drugs. The angiotensin converting enzyme blockers are better tolerated. They are also much more expensive and many patients are given angiotensin converting enzyme inhibitors first and then when they are not tolerated switched over.
What this study really does is to provide a starting point for further evaluation. There is a wealth of data that the FDA has and these studies are meant to serve as a means of impelling them to review their data or providing it to people who will.
In the next weeks the public will hear about the diabetic drug Avandia which has been in the news over the past year. It is very possible that this drug which already carries a “black box” warning, which is the highest level of warning the FDA has, maybe removed from the market. We will have to wait and see.
In the meantime, if you are taking these drugs continue them and discuss this with your doctor. If you really don’t want to get lung cancer don’t smoke. In London, the cigarette packages say smoking kills in large print. Better than our warnings.
When is a drug a risk?
In my last blog I discussed the origins of a class of drugs known as angiotensin receptor blockers. I have had an opportunity to work with all of these compounds at one time or another. It started with the very first in class losartan developed by Merck when it was still a “number” and not yet given a chemical name.
One of the most interesting things about these compounds is that they were the first drug with “no side effects.” What I mean by that: when drugs are tested, the side effect profile is the number of side effects in the drug class minus the side effects in the placebo class. These were generally equal. These drugs are very well-tolerated–much more so than their sister compounds, the angiotensin converting enzyme inhibitors.
These drugs were widely tested in many disease states and we participated in many of those trials. That is how this Meta analysis came to be. Remember a Meta analysis is a study that combines many different patients across a wide array of studies but uses the same compound.
As reported in The Lancet Oncology, this report found a 25% increase in lung cancer occurrence with this drug class compared with placebo. There was no increase in prostate or breast cancer. There was no significant increase in cancer deaths in the two groups. The number of patients need to treat to developed one cancer was 105 patients treated for four years.
This observation has been seen before in the CHARM study which used the compound candesartan. We contributed to this study. An excess of cancer deaths was seen but felt to be due to “chance”. This Meta analysis study combined the date for 61,950 patients from five trials. 87.5% received the compound telmisartan and the rest losartan or candesartan.
Here is the “kicker”. The 25% number is the RELATIVE RISK. The actual numbers were 7.2% vs. 6.0%. Only lung cancer was more prevalent 0.9% vs. 0.7%.
What does this all mean? What is the perspective here? Next blog…
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.
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.
One year and continuing
It has been one year and 104 blogs since I started this dialogue with you and I hope you are enjoying it. I have learned a great deal and I look forward to continuing it this year.
I would like to thank the people behind the scenes Christine Moncrieffe and Lidia Amoretti who edit and post them for me and allow the administrative functions of the blog to work.
If there are topics you would like to me to blog on please send them on. I appreciate the support and the growth of our readers.
And now for year Two… Not a good week for cardiology. Congress adjourned without changing the payment cuts, so on June 1st every physician got a 20% pay cut. This is on top of the 41% pay cut that cardiologists received January 1st for ancillary testing i.e. stress tests and echoes.
Further, two studies were published recently stating that overtime work leads to heart attacks. Since I have no overtime I have to work until I finish I guess it doesn’t apply to me. Honestly, it doesn’t apply to me since I have never for one day considered what I do work. Also, this week brought news that cardiology is responsible for much of this health care crisis anyway. Let me explain.
At the recent American Heart Association meeting in Washington, DC that I have blogged about recently a study was presented regarding the “Increasing use of cardiovascular devices and rising health care costs.” This study presented by Dr. Peter Groeneveld of the VA Medical Center Philadelphia found that stents and ICDs, implantable cardioverter defibrillators, represented 29% of the total increase in the cost of taking care of those two patient populations.
The study found that from 2003 to 2006 the cost of caring for coronary artery disease increased from $13,558 to $14,215. For every 1% increase in drug-eluting stents, the cost increase was $394. On the heart failure side, the costs rose from $18,930 to $20,235. For every 1% increase in ICD implants an extra $627 was added to the bill. During the years 2003 and 2006 Medicare spent $4.97 billion on drug eluting stents. This accounted for 89% of the total costs for coronary artery patients. On the heart failure side The ICD cost was $893 million or 29% of the total cost.
That is a considerable amount of money but not a complete analysis in that it is not matched by outcome data. These are the types of discussions that were not heard during the recent health care legislation discussion. We are going to have to make choices as we cannot afford this type of expense indefinitely. I have no answers but I know that the answers can not be imposed from above. We are all going to need to become active in the debate before it is to late.
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.
Already Being Used Devices
Last week I blogged about a unique example of common sense, the re-use of pacemakers and defibrillators that were explanted because of infection. Instead of throwing the devices away, the devices were donated, cleaned and implanted in patients who needed them but could not acquire them. This is a serious problem. There are people who die without a pacemaker or are subjected to a life of sickness.
Now a poster presentation was performed at the American Heart Association meeting called the 10th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke. This poster reviewed the situation from a different perspective. The devices that were obtained came from patients that had died.
Before you go “that’s icky,” let me ask you what is the difference between getting someone’s heart or getting someone’s pacemaker. Seriously you are going to die without either and both donors have unfortunately succumbed. As our population ages and needs these devices, does an 89 year old patient need a pacer with a 10 year battery life? What do you do after they die from other causes after one year? After one month? I have a friend in this industry and patients are actually beginning to ask her “why do I need a device that lasts so long?”
Trust me, this isn’t going to fly in this country. The industry will never go for it, but what about just cleaning them and giving them to countries that can’t afford them. The poster showed that 4 trials with a total of 603 patients proved that compared to new devices, the reused devices were not associated with a significant risk of overall complication, infections or device malfunction. There were no device related deaths.
I believe this maybe an idea whose time has come. It just needs organization and some cooperation. I’m going to work on it.
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