Your doctor is supposed to assess your cardiac risk for you, and coach you on what you should be doing to reduce that risk. But, despite pleas from medical experts and professional societies to do so, many doctors are still bad at performing accurate risk assessments, and are particularly terrible about spending the necessary time to instruct their patients on appropriate steps to reduce that risk.

This, one supposes, is to be expected when efficiency experts (those employed by insurance companies and the government, the parties whose money is at risk whenever patients see doctors)� have determined that 7.5 minutes is the appropriate average time for a "patient encounter." Doctors who do not want to be officially designated "low quality" need to pay attention to these and other expert-generated guidelines.

It is thus fortunate that, to a large extent, cardiac risk assessment is something you can do yourself.� Here's what you need to know about assessing your risk for heart disease.

How To Assess Your Own Cardiac Risk originally appeared on About.com Heart Disease on Thursday, July 29th, 2010 at 09:02:46.

Permalink | Comment | Email this

Studies now show that smoking is the major cause of heart attacks in people under 40 years of age. Read what this means - for younger smokers, and for those not so young - here.

Major cause of heart attack under 40? Smoking originally appeared on About.com Heart Disease on Monday, July 26th, 2010 at 08:38:20.

Permalink | Comment | Email this

More and more people today are being told that they have "diastolic dysfunction" (or diastolic heart failure.) Diastolic dysfunction occurs when the ventricles of the heart become relatively "stiff," and thus it becomes relatively difficult to fill the ventricles with blood in between heart beats. Read what causes diastolic dysfunction, how it is diagnosed, what it means to have it, and how it is treated, here.

Diastolic Dysfunction originally appeared on About.com Heart Disease on Friday, July 23rd, 2010 at 08:52:17.

Permalink | Comment | Email this

Atrial fibrillation is one of the most common cardiac arrhythmias - and unfortunately, it is of the most difficult to treat. Here is a review of atrial fibrillation, its causes and consequences, and the options for therapy.

Atrial Fibrillation - A Review originally appeared on About.com Heart Disease on Monday, July 19th, 2010 at 08:07:14.

Permalink | Comment | Email this

Today it was announced that former Vice President Dick Cheney has received a left ventricular assist device (LVAD). The device apparently is intended to serve as a "bridge to transplant," which means that it is meant to support his heart temporarily while he awaits heart transplantation.

An LVAD is a surgically implanted, battery driven pump, designed to augment the pumping action of a heart that that has become too weak from heart failure to function effectively.

LVADs are serious business. While they are generally quite effective at supporting the heart's pumping function, and usually go a long way toward relieving the symptoms of heart failure, they are associated with some devastating complications - including life-threatening infections, serious bleeding, and stroke.

This means that the use of LVADs is reserved for only a few clinical situations, and fairly dire ones at that. It also means that when they are used, doctors usually try to keep their usage as temporary as possible.

You can read more about LVADs here.

Dick Cheney Gets an LVAD originally appeared on About.com Heart Disease on Thursday, July 15th, 2010 at 15:58:40.

Permalink | Comment | Email this

George Steinbrenner, the 80-year-old owner of the New York Yankees, reportedly died this morning of "a massive heart attack." Details are sparse, but he apparently died in St. Joseph's Hospital in Tampa, Florida, shortly after he arrived there.

Heart attack, or myocardial infarction, is the most severe form of acute coronary syndrome, and is usually caused by the rupture of a plaque within a coronary artery. This rupture causes blood to clot within the artery, which, in turn, produces at least some obstruction of blood flow. If the obstruction is severe enough, the death of heart muscle - a heart attack - ensues.

If the blockage occurs in one of a few critical locations within the coronary arteries, the amount of heart muscle damage can be very large, and the chance of dying greatly increases.

But in the large majority of people who are having a heart attack, getting rapidly to a hospital - where immediate treatment can be administered to re-open the blocked artery - can result in long-term survival with relatively limited permanent cardiac damage.

Read about how to survive a heart attack here.

George Steinbrenner Has Died From A Heart Attack originally appeared on About.com Heart Disease on Tuesday, July 13th, 2010 at 10:25:22.

Permalink | Comment | Email this

Everyone knows that smoking accelerates atherosclerosis, and makes heart attacks more likely over time.

But did you know that the cigarette you smoke today could cause a heart attack TODAY?� Or that if you quit smoking today, your risk of a heart attack is substantially reduced by tomorrow?

That very next stick you light up could do you in.� Read about it here.

Why You Should Quit Smoking TODAY originally appeared on About.com Heart Disease on Monday, July 12th, 2010 at 07:16:34.

Permalink | Comment | Email this

A prolonged heat wave can be tough on anyone, but if you have heart disease you need to be especially careful when it's hot. This is because the high environmental temperatures can put excess stress on your heart, and also because it is often easier for people with heart disease to develop potentially dangerous heat illness.

In a hot environment, the body attempts to dissipate excess heat (mainly by sweating, and by radiating heat from the skin) to maintain a reasonably normal body temperature. The need to dissipate heat places added stress on your cardiovascular system, and this stress may cause the symptoms of your underlying heart disease to worsen. For instance, a person with coronary artery disease may develop angina; or a person with heart failure may have more shortness of breath.

In extreme heat, the body's attempts to dissipate heat can become overwhelmed, and if this happens the body's temperature begins to rise. The increase in body temperature, along with the dehydration and electrolyte imbalances that most often accompany it, produces heat illness.

Heat illness is a continuum of disorders ranging from heat rash, to heat cramps (muscle cramps), to heat exhaustion (cramps, weakness, dizziness, nausea and vomiting, headache), to heat stroke (body temperature of 106 degrees F. or higher, plus neurological symptoms such as seizures, disorientation, or coma). Heat stroke can be fatal.

Unfortunately, the drugs that are often used in treating heart disease can make it more difficult for your body to dissipate excess heat when temperatures are very high, and thus, may make heat illness more likely. Almost any cardiovascular medication can make you more prone to heat illness, but this is especially true with beta blockers, calcium channel blockers, and diuretics.

So, while everyone should take precautions during a heat wave, it is especially important to do so if you have heart disease. The most important thing to do is to stay in a cool environment during the heat of the day. If you don't have air conditioning, consider going to the mall, to a church, or to a neighbor's. Avoid exertion, since the calories you burn during exercise will just produce that much more heat that your body will need to dissipate. And stay very well hydrated on hot days, preferably by drinking water (and avoiding caffeine, which is a diuretic).

If you should develop signs of heat illness, such as muscle cramps or nausea, call your doctor immediately.

And DO NOT stop any of your cardiac medications on your own, without checking with your doctor first.

Heat Waves and Heart Disease originally appeared on About.com Heart Disease on Thursday, July 8th, 2010 at 12:48:49.

Permalink | Comment | Email this

"Resistant hypertension" is the name doctors give to high blood pressure that turns out to be very difficult to treat effectively. Specifically, resistant hypertension is said to be present if your blood pressure is still not adequately controlled despite taking at least three medications for hypertension. Resistant hypertension affects more than 20% of all patients with high blood pressure.

A recent (but small) study suggests that in people with resistant hypertension, significant restriction of dietary salt can result in rather large improvements in blood pressure control - generally, the improvement was greater than would normally be expected by adding an additional medication.

In this study, 12 patients with resistant hypertension at the University of Alabama were randomized to one of two diets - a 5700 mg per day sodium diet or a 1150 mg per day sodium diet. All patients were treated, in a randomized cross-over pattern, with each of these diets for a period of time. Investigators found that when the patients were on the lower sodium diet, their blood pressures were signficantly improved, by more than 22 mm Hg for systolic, and more than 9 mm Hg for diastolic pressures.

Somewhat surprisingly (since salt restriction has long been a staple of blood pressure control) this small trial was the first time sodium restriction was specifically evaluated in patients with resistant hypertension.

Because the trial was so small, and the duration of the trial was limited to about two weeks, the trial cannot be considered definitive. Undoubtedly, larger, longer-lasting trials will now be designed to test the sodium-restriction hypothesis in patients with resistant hypertension.

But if you are one of the 20+% of patients with high blood pressure who is taking at least three medications with poor blood pressure control, you might want to talk to your doctor about trying a strict limited-salt diet before adding yet another drug.

_Sources

_{Pimenta E, Gaddam KK, Oparil S, et al. Effects of dietary sodium reduction on blood pressure in subjects with resistant hypertension. Results from a randomized trial. Hypertension 2009; DOI: 10.1161/HYPERTENSIONAHA.109.131235.}

Salt Restriction For Resistant Hypertension originally appeared on About.com Heart Disease on Monday, July 5th, 2010 at 07:47:21.

Permalink | Comment | Email this

This week, the Archives of Internal Medicine published four articles criticizing the JUPITER trial, the landmark study published in 2008 showing that some patients with normal cholesterol levels had markedly improved cardiovascular outcomes when taking the statin drug, Crestor. These critical articles have received a fair amount of play in the general media.

JUPITER was a clinical trial that randomized over 18,000 men and women, who had normal cholesterol levels but elevated CRP levels (and, to be sure, often had other risk factors), to receive either 20 mg/day of Crestor, or placebo. The study was stopped after a little less than two years, when the study's independent Data Safety Monitoring Board (DSMB) determined that it would be unethical to continue the study. For, at that point, individuals taking the statin had a 20% reduction in overall mortality, a dramatic reduction in heart attacks, a 50% reduction in stroke, and a 40% reduction in venous thrombosis and pulmonary embolism. All these findings were highly statistically significant.

The JUPITER trial was by no means perfect. It did not tell us whether the beneficial outcome is specific to Crestor, or is a class effect of all statins (which seems very likely). This trial did not tell us whether reducing CRP levels is beneficial - it only tells us that giving Crestor to people with high CRP levels is beneficial. It did not even tell us whether using CRP as a screening tool is actually helpful, since only patients whose CRP was elevated were enrolled in this study. Similar patients - that is, patients who tend to be overweight and have a fairly high incidence of metabolic syndrome and a relatively high incidence of smoking - but with normal CRP levels, might have had the same outcome. And this trial did not tell us the risks of lifelong, or even very long-term, Crestor therapy.

But what it did tell us, with a very high degree of statistical surety, was this: Giving Crestor to patients similar to the ones enrolled in this study can be expected to result in significantly and substantially improved cardiovascular outcomes, and in a relatively short period of time.

There are a lot of reasons that a lot of people are unhappy about these results. Chief among these are that Crestor is very expensive, and if the results of this study were taken to its logical extreme, we would be spending billions of dollars each year on Crestor.

The articles appearing this week in the Archives vary in quality from quite reasonable criticisms to absurdly polemical.

The main article largely consisted of a string of ad hominem attacks aimed at the presumed biases of the sponsor, the clinical investigators, and even the chair of the DSMB (a highly respected individual known for his rigid objectivity). While it may be legitimate to criticise the bias built-in to the study design (for instance, only the sponsor's statin was used in this trial), it remains true that, given that the JUPITER design is what it is, the resultant data - which can only be considered striking - must be evaluated on its own merits. Ironically, the chief author of this critical paper is himself a member of a fringe medical group known as The International Network of Cholesterol Skeptics (THINCS), whose stated mission is to "oppose" the notion that high cholesterol and animal fat play a role in cardiovascular disease. Members of THINCS also take an extraordinarily strong position opposing statins for any clincal use whatsoever. The irony, of course, is that this striking bias was not disclosed in an article whose main thrust was to criticise the disclosed biases of the JUPITER investigators.

The other three articles in the Archives were less problematic, but in real terms do not diminish the overall significance of JUPITER. One pointed out that JUPITER did not tease out the real importance of CRP levels, or whether lowering those levels is useful. Another was a meta-analysis looking at other primary prevention trials using statins, showing what was already known - that JUPITER is the first primary prevention trial with statins to show a marked benefit. And the third criticized the JUPITER DSMB for stopping the trial earlier than originally planned. The DSMB, however, had no real choice in the matter - ethically or legally - given the striking statistical significance of the benefit seen with CRESTOR. (When a patient signs an informed consent agreement to participate in a clinical trial, part of that "contract," a part required by law, is the statement to the effect that if information comes to light during the course of the study that might impact a patient's willingness to continue participating, that information must be made available. The fact that the Crestor branch of the study was found to have markedly better survival, fewer strokes and heart attacks, etc., than the placebo branch, clearly constitutes such information.)

I, too, wish that JUPITER had been designed differently - with less bias, if you will - so that the remaining big questions (questions that were entirely predictable from the outset), had been addressed. If so, we might know today with more surety whether ANY statin would be as useful in such patients (instead of just the most expensive one), and whether measuring and/or reducing CRP levels is actually useful.

But the fact remains, despite the recent attacks emanating from the Archives of Internal Medicine, that JUPITER is an important, landmark clinical trial, whose results, as much as some may wish otherwise, cannot be legitimately ignored.

_Sources:

_{de Lorgeril M, Salen P, Abramson J, et al. Cholesterol lowering, cardiovascular diseases, and the rosuvastatin-JUPITER controversy. A critical reappraisal. Arch Intern Med. 2010; 170:1032-1036.}

_{Kaul S, Morrissey RP, Diamond GA. By Jove! What is a clinician to make of JUPITER? Arch Intern Med. 2010; 170:1073-1077.}

_{Ray KK, Seshasai SRK, Erqou S, et al. Statins and all-cause mortality in high-risk primary prevention. A meta-analysis of 11 randomized controlled trials involving 65 229 participants. Arch Intern Med. 2010; 170:1024-1031.}

_{Green L A. Cholesterol-lowering therapy for primary prevention. Still much we don't know. Arch Intern Med. 2010; 170:1007-1008.}

Attacking JUPITER - Statins For Primary Prevention Assailed originally appeared on About.com Heart Disease on Thursday, July 1st, 2010 at 10:50:15.

Permalink | Comment | Email this