SCC

It’s a Draw! Low-Fat or Low-Carb Diets Equally Good, Finds Study

steven kypraios — Mon, 26 Feb 2018 00:57:49 +0000

This is an introduction to the original commentary which can be found here: https://www.medscape.com/viewarticle/892859

By Marlene Busko February 20, 2018

In a large, randomized trial, 1-year weight loss was similar with a healthy low-fat diet or a healthy low-carbohydrate diet.

Moreover, neither genotype patterns nor baseline insulin secretion predicted which type of diet would be better for any one individual.

These findings, from the Diet Intervention Examining the Factors Interacting With Treatment Success (DIETFITS) trial by Christopher D Gardner, PhD, from Stanford University, California, and colleagues, were published in the February 20 issue of JAMA.

“In the context of these two common weight-loss diet approaches, neither of the two hypothesized predisposing factors was helpful in identifying which diet was better for whom,” the researchers report.

A small preliminary trial had suggested that overweight people would have greater weight loss success if they followed a low-carb or low-fat diet, based on a certain genotype pattern, but this was not the case.

The current work also shows that individuals with high insulin secretion did not have greater weight-loss success with a low-carb diet.

However, for both diets participants were instructed to minimize or eliminate refined grains and added sugars, and maximize vegetable intake, the researchers stress.

“We conclude that when equal emphasis is given to high dietary quality for both low-fat and low-carbohydrate eating plans, it is not helpful to preferentially direct an individual with high insulin secretion status who is seeking weight loss to follow a lower-carbohydrate eating plan instead of a lower-fat eating plan,” say Gardner and colleagues.

https://www.medscape.com/viewarticle/892859

Published online February 20, 2018. Abstract

Not All Vegetarian, Plant-Based Diets Equal for CHD Risk

Wed, 19 Jul 2017 04:00:17 +0000

Article by Patrice Wendling, published July 17, 2017 originally at :http://www.medscape.com/viewarticle/883047_print

Follow Patrice Wendling on Twitter: @pwendl.

BOSTON, MA — A new study suggests that to reduce the risk of coronary heart disease it is simply not enough to eat a plant-based diet but that the foods in that diet must be high quality[1].

After two decades of follow-up in more than 200,000 adults, researchers found that adherence to a plant-based diet rich in whole grains, fruits, vegetables, nuts, and legumes was associated with a substantially lower relative risk of coronary heart disease (CHD), whereas following a plant-based diet emphasizing less healthy foods such as refined grains and sugar-sweetened beverages had an adverse effect.

Their findings were published July 17, 2017 in the Journal of the American College of Cardiology.

“I think an important contribution of this paper is about the public health message,” lead author Dr Ambika Satija (Harvard School of Public Health, Boston, MA) told theheart.org | Medscape Cardiology. “Just because you’re vegetarian or eating more plant-based foods doesn’t necessarily mean you have a healthy diet. It’s important to think about the quality of foods you’re consuming; more whole grains rather than refined grains, more whole foods rather than juices—that’s the right direction to take.”

She noted that this approach is already reflected in the latest 2015–2020 Dietary Guidelines for Americans, which recommends focusing on nutrient-dense foods across all food groups.

Dr Alice Lichtenstein (Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA) was vice- chair of the US dietary guidelines committee. “What the guidelines said is that there are a number of different dietary approaches—Mediterranean, DASH [Dietary Approaches to Stop Hypertension], or vegetarian, which will get you to the same end, and that’s not inconsistent with what this is saying,” Dr Lichtenstein said, commenting on the current findings.

“Because it doesn’t matter what basic diet you consume; but if you consume more plant-based foods, you’re going to have a better outcome,” she added. “The new factor here is that not all plant-based diets are created equal and you have to use some judgement in choosing the plant-based foods you’re going to include in that diet, just as you use judgment in the animal foods you include in your diet.”

Previous studies have linked plant-based diets with a lower risk of CHD, but have defined these diets dichotomously as being vegetarian or not, and treated all plant foods equally, the investigators note in the article.

To overcome these limitations and understand how gradual reductions in animal foods affect cardiovascular health, Satija and colleagues examined data from semi-quantitative food-frequency questionnaires including about 133 foods collected every 2 to 4 years from 73,710 women in the Nurses’ Health Study (NHS), 92,329 women in the NHS2, and 43,259 men in the Health Professionals Follow-Up study.

The data were collapsed into 18 food groups within three larger categories (healthy plant foods, less healthy plant foods, and animal foods), and then ranked into quintiles.

Positive scores were assigned for healthy plant foods (whole grains, fruits/vegetables, nuts/legumes, vegetable oils, tea/coffee) and reverse scores assigned for less healthy plant-based foods (fruit juices, refined grains, potatoes, sugar-sweetened beverages, sweets/desserts) and animal foods (animal fat, ice cream, meat, miscellaneous animal-based foods). Group scores were summed to create plant-based diet indices.

The indices ranged from a median of 42–44 in the lowest decile, to a median of 66–68 in the highest decile. Animal food intake ranged from 3–4 servings per day in the lowest decile to 5–6 servings per day in the highest decile.

Participants with higher scores on the plant-based diet index (PDI) and healthy PDI (hPDI) were older, more active, leaner, and less likely to smoke than those with lower scores. Concerningly, high consumers of an unhealthy PDI (uPDI) were younger, less active, and more likely to smoke.

Over 4,833,042 person-years of follow-up, 8631 participants developed CHD, defined as nonfatal MI and fatal CHD.

After full adjustment for relevant covariates, adherence to PDI was inversely associated with CHD (hazard ratio [HR] 0.92 comparing extreme declines; 95% CI 0.83–1.01). The association was modest, but Satija said this makes sense because the PDI is an aggregate, and thus participants who have a higher intake of both healthy and unhealthy plant foods may have a higher score on the PDI.

“This is kind of getting at the idea that, okay you’re a vegetarian, but if we don’t know the quality of plant foods you’re consuming, we don’t know what your risk profile for CHD is going to be,” she added.

When the hPDI and uPDI were analyzed separately, however, the inverse association was considerably stronger for hPDI, lowering the relative risk of CHD by 25% (HR 0.75 comparing extreme deciles; 95% CI 0.68–0.83, P<0.001 for trend). At the same time, uPDI was positively associated with a 32% higher relative risk of CHD (HR 1.32 comparing extreme deciles; 95% CI 1.20–1.46, P<0.001 for trend).

The associations of hPDI and uPDI with CHD risk were consistent across age, BMI, family history of CHD, and sex.

Associations of both indices were significantly stronger among more active relative to less active participants (P for interaction=0.002 for both), a finding that should be interpreted with caution, Satija said. “We don’t know exactly what’s going on and it would be good to look in an intervention at what happens if you do both a physical intervention and dietary modifications.”

To quantify the benefit of the hPDI due to lower red meat intake, the final model was individually adjusted for red meat and the results were largely unchanged (HR 0.93 for extreme PDI deciles; 95% CI 0.84–1.03).

“For those people who want to improve their diets, want to have a vegetarian or vegan diet but think that change is too extreme or that they won’t be able to make this big lifestyle change, this is good news,” Satija said. “Because even if they reduce the amount of animal foods by a couple of servings per day, they still benefit in terms of CHD risk.”

In an accompanying editorial[2], Drs Kim Allan Williams and Hena Patel (Rush University Medical Center, Chicago, IL) concur that it’s not an all-or-nothing proposition: “Just as physical exercise is a continuum, perhaps an emphasis on starting with smaller dietary tweaks rather than major changes would be more encouraging and sustainable.”

Although the study can’t address the benefits of a purely vegan diet, they note that it “adds to the evidence of gradations of adherence to an overall PDI with CHD incidence, such that one could propose a risk-based approach to PDI prescription: secondary prevention after cardiovascular events and patients at high risk having a stronger recommendation for a strictly hPDI.”

Finally, while a plant-based diet is more environmentally sustainable, Williams and Patel point to the potential implications of a healthier diet on downstream healthcare costs. “If, for example, widespread adoption of plant- based nutrition reduced the incidence of hypertension to 25% of the current rate, this could result in savings of nearly 30% of the Medicare budget.”

The study was supported by research grants from the National Institutes of Health. Satija reported no financial relationships. Disclosures for the coauthors are listed in the paper. Lichtenstein, Williams, and Patel reported no relevant conflicts of interest.

References

1. Satija A, Bhupathiraju SN, Spiegelman D, et al. Healthful and unhealthful plant-based diets and the risk of coronary artery disease in US adults. J Am Coll Cardiol 2017; 70:411-422. Abstract

2. Williams KA, Patel H. Healthy plant-based diet: What does it really mean? J Am Coll Cardiol 2017; 70:423-425. Editorial

10 Tech Advances That Can Change Medicine

Mon, 03 Jul 2017 00:05:12 +0000

Commentary article by: Eric J. Topol, MD
Published on December 16, 2016 at www.medscape.com

http://www.medscape.com/viewarticle/872934

Last year, I put out my first top 10 tech list, and it seemed to get a lot of interest. So here is this year’s list, not in any rank order. There are many more important advances than I list here, but I have focused on the ones that can make a real difference for patients and patient care. I have no conflict of interest with any of the companies listed here.

Artificial intelligence Comes to Medicine

Artificial intelligence (AI) has hit its stride in many other areas of our daily lives, and it is starting to demonstrate the kind of impact it can have in medicine. The extraordinary ability of AI to accurately interpret pathology slides, x-rays, skin lesions, and retinas has recently been shown.[1] There are over 90 start-up companies working on AI applications in healthcare, no less the engagement of tech titans that include IBM (Watson), Apple, Google, and Microsoft, all of which have made major investments. A recent 60 Minutes segment filmed at the University of North Carolina suggested that AI could find an evidence-based therapy for 30% of patients with cancer that was not identified by their oncologists.

Advanced Wearable Sensors

2016 was characterized by remarkable progress in wearable sensor technology with flexible, stretchable, printable, and even battery-less characteristics and ever more tracking of physiologic metrics, chemistries (including glucose, ethanol, and lactate levels), and the environment (such as ultraviolet light exposure).

Liquid Biopsy for Cancer

Major validation studies of circulating cell-free, plasma tumor DNA (tDNA) versus solid tissue biopsy were published, and the number of companies pursuing this goal, with targeted sequencing of the tDNA, has now expanded to more than 50. The extent of cancer-related genes sequenced from the blood sample has grown substantially. New entrants into the field this year include Grail and Cirina, both of which are doing studies to detect cancer in large cohorts of healthy people, using either tDNA or tDNA methylation.

It remains to be seen whether a liquid biopsy will provide accurate detection in asymptomatic individuals, but the benefits over solid tissue biopsy for patients with a presumptive diagnosis or undergoing surveillance are especially alluring (less expense, risk, and discomfort, and possibly more representative of the cancer biology process, overriding solid tissue heterogeneity).[2]

Virtual Medical Center for Remote Monitoring (‘Bedless Hospital’) and the Rapid Rise of Telemedicine

In St Louis, Mercy Virtual has 330 healthcare professionals overseeing real-time monitoring of thousands of patients remotely. In parallel, the rise of telemedicine for outpatient visits is growing very rapidly.

First CRISPR Genome Editing and Initiation of Clinical Trials

In China, on October 28, the first patient treatment with CRISPR genome editing for lung cancer was performed by removing immune cells, editing them to engender heightened immune function (disabling PD-1), culturing the cells, and injecting them back into the patient.[3] More trials have been approved to start in the United States for cancer and there has been remarkable progress for a variety of monogenic diseases, such as sickle cell, with clinical trials to start soon ( ).[4]

Smartphone Echocardiography

Last year, I highlighted the Philips Lumify smartphone ultrasound as a top tech advance. In 2016, a dedicated cardiac probe was introduced that generates exquisite images through an Android app (see video). A second entry of smartphone ultrasound—Clarius—is also being introduced, and it has a wireless connection to the smartphone. Recently, I’ve been made aware of a third smartphone ultrasound device developed by Healcerion. 2016 was the 200th anniversary of the stethoscope. I think we have far better technology to offer now that supersedes sounds.

Lab in Your Pocket

The point-of-care ability to rapidly and inexpensively diagnose a significant number of infectious diseases is remarkable. The list now includes HIV, human papillomavirus, influenza, and group A streptococcus, with many more in progress.[5]

The mobile device platform that is increasingly being used makes this highly attractive for remote areas. Recently, Imperial College announced a disposable USB memory stick that can accurately determine HIV viral levels from a drop of blood. And “ubiquitous sequencing”—the ability to sequence a pathogen rapidly from a body fluid specimen —holds the promise of revolutionizing our approach to infectious disease diagnosis in the years ahead.

New Genomics for Cancer Predisposition, Whole-Genome Sequencing

In March 2016, Veritas Genetics announced at our Future of Genomic Medicine conference that they will perform whole-genome sequencing for $999. Although there had been much banter about the $1000 genome for years, this was the first real fulfillment of reaching that threshold, given that the path via Illumina HiSeq X Ten required $10M of machine purchases.

We now know a substantial number of the common variants in genes that predispose one to cancer—both in oncogenes and tumor suppressor genes. For individuals with a family history of cancer, 30 of these genes can now be sequenced by Color Genomics for $249. Several other companies are offering mutation panels or other targeted sequencing to help define increased risk. This could sharpen the use of screening and get us toward the promise of prevention by identifying increased risk long before cancer manifests.

Microfluidic Chips for Labs via a Droplet of Blood

I wrote about the Theranos debacle in the updated paperback edition of The Patient Will See You Now (excerpt here). Theranos had promised low-cost, accurate blood tests from a droplet of blood, and although that clearly did not materialize from Theranos, the technology to do this with microfluidics and colorimetrics is moving forward. As an example, here are the immunoassays I had done by Genalyte with a droplet of blood, run before me in 9 minutes. This would normally require a send-out to specialized labs, take a week or two, and cost over $1000.

Microfluidic technology can make a substantial proportion of assays cheap, fast, and accurate. In contrast to Theranos, this company is fully transparent, and has published a number of peer-reviewed validation papers.

Virtual Reality for Pain, Phobias, and Prevention of Falls

The tech titans have placed big bets on the future of virtual reality (VR), such as Facebook’s acquisition of Oculus Rift. At the time, not many people realized how effective VR could be in medicine. A randomized trial in the Lancet showed how VR can reduce the propensity for falls,[6] which adds to highly promising data published or presented for relief of pain, phobias, and posttraumatic stress disorder. On top of treatment, the use of VR for surgery and simulation for medical education is taking off.

Related to VR is augmented reality, which had some buzz with Google Glass and more recently showed up in the CBS TV series Pure Genius (which I reviewed in an article that will be forthcoming in JAMA).

I’m sure I have left out some advances that you consider worthy or have included ones you may not agree with. But I hope you find this list useful. I try to put out progress on a daily basis via Twitter, so follow me there @erictopol if you want a constant infusion.

Wishing you a happy holiday season and all the best for 2017, Eric J. Topol, MD
@EricTopol
Editor-in-Chief, Medscape

Editors’ Recommendations

Topol on Physician and Patient Attitudes Toward New Technology

Three Grand Books: Genetics, Life and Death, and Humankind

References

1. Jha S, Topol EJ. Adapting to artificial intelligence radiologists and pathologists as information specialists. JAMA. 2016 Nov 29. [Epub ahead of print]

10 of 11 7/3/17, 9:56 AM

http://www.medscape.com/viewarticle/872934_print

Lanman RB, Mortimer SA, Zill OA, et al. Analytical and clinical validation of a digital sequencing panel for quantitative, highly accurate evaluation of cell-free circulating tumor DNA. PLoS One. 2015;10:e0140712.
Cyranoski D. CRISPR gene-editing tested in a person for the first time. Nature. 2016;539:479.
DeWitt MA, Magis W, Bray NL, et al. Selection-free genome editing of the sickle mutation in human adult hematopoietic stem/progenitor cells. Sci Transl Med. 2016;8:360ra134.
Radin JM, Topol EJ, Andersen KG, Steinhubl SR. A laboratory in your pocket. Lancet. 2016;388:1875.
Mirelman A, Rochester L, Maidan I, et al. Addition of a non-immersive virtual reality component to treadmill training to reduce fall risk in older adults (V-TIME): a randomised controlled trial. Lancet. 2016;388:1170-1182.

Medscape © 2016 WebMD, LLC
Any views expressed above are the author’s own and do not necessarily reflect the views of WebMD or Medscape or Sunshine Coast Cardiology.

For John Mellencamp and Other Smokers

Sun, 02 Jul 2017 23:46:47 +0000

Commentary article by Melissa Walton-Shirley, MD published June 30, 2017

at www. medscape.com,

http://www.medscape.com/viewarticle/882313_print

It was the summer of ’82 when I fell in love with the music of John Cougar Mellencamp. My acceptance to med school prompted a brisk drive on I-65 south with the windows down and the radio blaring. The now legendary riff of the hit “Jack & Diane” with an intermittent clap of the hands leapt from the console of “the big banana,” my 1972 LaSabre Buick. Its wailing speakers could transport me from anxious medical student to the status of imaginary rock star with a turn of a knob. That day, it did its magic again.

“A little ditty ’bout Jack and Diane. Two American kids growin’ up in the heartland . . . ”

“Oh my gosh, who is this?” I later asked my fiance? (now husband) Tony Shirley, who has always been a wealth of music trivia. “John Cougar Mellencamp and he’s from Seymour, Indiana,” he replied. The state of Indiana was just across the river from our home in Louisville, KY; we felt a connection to the singer.

Med school at the University of Louisville kept me so busy that for a time, I didn’t even know what John Cougar Mellencamp looked like. I didn’t know that he considered himself a painter first and a combination musician/singer /songwriter second. I didn’t know then that in the 1990s Tony and I would have the privilege of seeing him perform as John Mellencamp (no Cougar) at the Nashville Starwood Amphitheater or that I would glance stage right and my heart would sink when I saw the fire-red glow from a burning cigarette slowly elevate to his lips deliberately and methodically between sets.

He had already developed coronary artery disease and suffered a heart attack, while continuing to struggle with nicotine addiction. I would never understand his choices or why the personal business of a human being I would never meet could generate such concern. For some odd reason it still does.

The Mature Rock Star

The years have passed. Tony and I took a road trip this month. To pass the time, I grabbed scores of reading material from pharmacy magazine racks and vulnerable coffee tables of family members—anything with an interesting cover. In one of those publications[1] I spotted a great photo of this maturing superstar, his head cocked slightly to his left, eyes downcast and steel gray hair haphazardly reaching for some unknown skyward destination. He exuded cool. And dangling from his mouth was the demon cigarette once again, an imminent threat to his longevity held tightly.

That cigarette might as well have been a dagger. I read with hurried enthusiasm that Mellencamp was born with spina bifida, was raised by his grandmother, continues to paint, and then the paragraph that is the mantra of so many smokers that really broke my heart.

“I lift weights and I run, but my exercise is not about vanity. I work out because I smoke. If I’m going to afford myself the luxury of smoking, I’d better do something to offset it,” he said.

Does he really think he can offset his risk of death from heart attack, cancer, COPD, and stroke by exercising? Does he know that smoking just one to 10 cigarettes per day increases his mortality by as much as 85%?[2] Does he not understand that at this very moment his intracoronary clot-buster levels are probably those of a 90-year-old man? How will he play a guitar or paint with one arm if he has a stroke? How will he sing with no vocal chords if he develops cancer? How will his family deal with his preventable sudden death if he develops a critical blockage? How on earth does he justify taking the chance of leaving this world and silencing his enormous talent over the love of a burning weed?

I wondered if he has seen his cardiologist since the Bio-RESORT trial publication.[3] That Dutch study showed that silent diabetes affects whether your stent stays open or not. Has he had a 2-hour GTT? I vented to my nonmedical spouse, as I twisted the entire point of this joyous article into an impending death announcement.

The Path to Quitting: Plead and Educate

My husband knows that my obsession with helping smokers quit isn’t limited to celebrities. Any and every smoker is fair game. Tony was a victim of my successful attempts as well as many family members, friends, neighbors, and the occasional stranger (not withstanding every single patient who walks through my door).

I simultaneously plead and educate because it works. I don’t just “tell patients to quit.” I explain the pathophysiology, paint a Technicolor picture of their family’s lives without them, and give them the tools to quit. I’m not nai?ve. I watched the David Letterman interview from April 2015 where Mellencamp said,

“I’m gonna keep smoking and I’m good at it. I’ve written a couple of good songs. I’m kind of good on stage and I have a good first kiss. Other than that, I’m not worth a s—t. I’m useless.”[4]

Well, Mr Mellencamp, you aren’t useless, but the low self-esteem you harbor is where your addiction flourishes. I’ve seen that attitude in Kentucky men who ask to be buried clutching a pack of Marlboro Lights in their caskets. It’s a macabre last request they think is cute when on this side of the dirt but it’s not so cute for family members sitting on the front row at their eulogy where the me, me, me and the I, I, I of addiction speaks the loudest.

And that’s the point. Any patient with bad habits surely has more to say, more to do, and more to give. Case in point, Mr Mellencamp at age 65 just released an album to critical acclaim in April of this year. It is precisely why I educate with the Mediterranean diet, preach the gospel of a healthy BMI, rail against sedentary lifestyle, and emphasize compliance until my vocal chords are sore every workday, explaining, explaining.

I will keep doing it because the frustration of a 1000 failures is negated by a single success. I also persist because I know Mellencamp and others like him don’t really want to die early. Most just need a combination of nicotine patches and lozenges or varenicline (Chantix) therapy. In my experience, these treatments trump all others for smoking cessation and if given a chance, one of the two systems will work for most. I just know something could work for him.

Then, I continued reading.

“I intend to make my ending good,” Mellencamp said. “I’m hoping it’s one of those long, lingering deathbed conversations. A lot of people go, ‘Oh, I hope I just die quick.’ Not me. I need time to put things right,” he concluded in the last paragraph of the article.

This is for Mr Mellencamp and all smokers: Quitting smoking is the very best bet to have more “time to put things right.” Please don’t let your time run out too soon and leave us wanting more.

And please, don’t ever let it be said that those of us who care stopped trying.

Editor’s note: An earlier version of this post stated that Mellencamp underwent a bypass surgery and received a stent, which could not be verified. Medscape regrets the error.

References

Gunderson E. John Mellencamp: What I know now. AARP Magazine, June-July 2017:11. Available here.
Inoue-Choi M, Liao LM, Reyes-Guzman C, et al. Association of long-term, low-intensity smoking with all- cause and cause-specific mortality in the National Institutes of Health–AARP Diet and Health study. JAMA Intern Med 2017;177:87-95. Article
Van Birgelen C. BIO_RESORT: Silent diabetes substudy. EUROPCR 2017; May 16-19, 2017; Paris, France. Presenter interview

4. The Late Show With David Letterman, April 27, 2015.

Any views expressed above are the author’s own and do not necessarily reflect the views of WebMD or Medscape, or Sunshine Coast Cardiology.

Sunshine Coast’s first Private Emergency Department announced

Tue, 13 Jun 2017 08:15:43 +0000

The Sunshine Coast Private Hospital at Buderim has announced the approval of a new 4 million dollar private Emergency Department on its campus, this first private Emergency Department on the Sunshine Coast. This is good news for patients wishing to directly access private hospital care on the Coast, greatly enhancing the level of service offered at SCPH, and will releive some of the pressure on public hospital EDs, as well as the Queensland Ambulance Service. The department will be open in the first quarter of 2018.

Heart disease is one of the leading killers in the UK.

steven kypraios — Mon, 06 Mar 2017 03:24:18 +0000

Heart disease is one of the leading killers in the UK. According to the British Heart Foundation, heart attacks lead to one hospital visit every three minutes.

They are caused by a decrease in blood flow to the heart, usually as a result of coronary heart disease. Symptoms may include sudden chest pain or a ‘crushing’ sensation that might spread down either arm. Patients might also experience nausea or shortness of breath. However, some heart attacks have more subtle symptoms and may therefore be missed or overlooked.

In this study, the researchers examined records of all 446,744 NHS hospital stays in England between 2006 and 2010 that recorded heart attacks, as well as the hospitalisation history of all 135,950 heart attack deaths.

The records included whether or not patients who died of a heart attack had been admitted to hospital in the past four weeks and if so, whether signs of heart attack were recorded as the main cause of admission (primary diagnosis), additional to the main reason (secondary diagnosis), or not recorded at all.

Of the 135,950 patients who died from heart attack, around half died without a hospital admission in the prior four weeks, and around half died within four weeks of having been in hospital.

21,677 (16 per cent, or one in six) of the patients who died from heart attack had been hospitalised during the four weeks prior, but heart attack symptoms were not mentioned on their hospital records (see figure 2 of paper.)

The authors say there are certain symptoms, such as fainting, shortness of breath and chest pain, that were apparent up to a month before death in some of these patients, but doctors may not have been alert to the possibility that these signalled an upcoming fatal heart attack, possibly because there was no obvious damage to the heart at the time.

These results suggest that possible signs of upcoming fatal heart attack may have been missed. The authors’ next step is to look into why this pattern emerged, and to try to prevent more heart attack deaths.

The researchers also found that of all patients admitted with a heart attack, those whose heart attack was recorded as secondary to the main condition were two to three times more likely to die than patients whose records stated heart attack as the main condition.

Lead author Dr Perviz Asaria, from the School of Public Health at Imperial, said: “Doctors are very good at treating heart attacks when they are the main cause of admission, but we don’t do very well treating secondary heart attacks or at picking up subtle signs which might point to a heart attack death in the near future.”

“Unfortunately in the four weeks following a hospital stay, nearly as many heart attack deaths occur in people for whom heart attack is not recorded as a primary cause, as occur after an admission for heart attack.”

The authors say that more detailed investigation must be done to identify reasons for these results so that more deaths from heart attack can be prevented.

Co-author Professor Majid Ezzati, from the School of Public Health at Imperial, said: “We cannot yet say why these signs are being missed, which is why more detailed research must be conducted to make recommendations for change. This might include updated guidance for healthcare professionals, changes in clinical culture, or allowing doctors more time to examine patients and look at their previous records.”

“What we are now asking is, if symptoms are being missed where they could have been discovered using the available information, how should care now be organised and what changes need to be made to prevent unnecessary deaths.”

This article appeared on the Science Daily website at https://www.sciencedaily.com/releases/2017/02/170228222826.htm

Story Source:

Materials provided by Imperial College London. Original written by Caroline Brogan. Note: Content may be edited for style and length.

Journal Reference:

Perviz Asaria, Paul Elliott, Margaret Douglass, Ziad Obermeyer, Michael Soljak, Azeem Majeed, Majid Ezzati. Acute myocardial infarction hospital admissions and deaths in England: a national follow-back and follow-forward record-linkage study. The Lancet Public Health, 2017; DOI: 10.1016/S2468-2667(17)30032-4

Studies Suggest Cardiovascular Sweet Spot at Two Drinks per Day

steven kypraios — Mon, 06 Mar 2017 02:05:12 +0000

This article was by By Patrice Wendling February 28, 2017

TORONTO, ON and LONDON, UK — Two new studies provide reassuring evidence that drinking two alcoholic beverages per day is not harmful to cardiovascular health.

The first study[1], a meta-analysis of 36 trials, found that reducing alcohol intake lowered blood pressure in a dose-dependent fashion.

Lowering alcohol consumption had no significant effect on blood pressure for people drinking two alcoholic beverages per day, but was associated with higher subsequent BP reduction for those drinking beyond this level.

People who threw back six or more drinks per day at baseline and cut their intake roughly in half had the strongest reduction in systolic BP (mean difference -5.50 mm Hg; 95% CI -6.70 to -4.30) and diastolic BP (mean difference -3.97 mm Hg; 95% CI -4.70 to -3.25).

“For heavy drinkers, a reduction in alcohol consumption to two or fewer drinks per day could be the first choice in treatment of hypertension,” lead author Dr Michael Roerecke (Centre for Addiction and Mental Health, Toronto, ON) and colleagues write in the study, published online in Lancet Public Health.

The second study[2] took a rare long view of alcohol consumption over a 25-year time span and its association with changes in arterial stiffness as measured by carotid-femoral pulse-wave velocity (PWV).

PWV has been shown to be a reliable prognostic marker for cardiovascular morbidity and mortality, with higher PWV values signaling greater arterial stiffness.

After analyzing data for 3869 mostly male (73%) civil servants in the Whitehall II cohort study, British investigators found that men who regularly drank heavy amounts of alcohol (>3.9 ounces ethanol/wk or about >14 servings/wk) had higher baseline PWV values than stable moderate (<3.9 ounces ethanol/wk) drinkers (b=0.26 m/s; P=0.045).

A similar effect was seen among women who were regular heavy drinkers in models adjusted for demographic and lifestyle factors (b=0.73 m/s; P=0.029) but the association was no longer significant after full adjustment including clinical covariates (b=0.42 m/s; P=0.169)

“Compared with heavier volumes, moderate intake is known to be associated with higher high-density lipoprotein cholesterol, a protective factor against arterial stiffening,” lead author Dr Darragh O’Neill (University College London, UK) and colleagues write in the study, published February 20, 2017 in the Journal of the American Heart Association.

Commenting to heartwire from Medscape, American Society of Hypertension president Dr John Bisognano (University of Rochester Medical Center, NY) said, “It was known from the cholesterol data in the past that it always looked like two drinks a day was the optimal number if your goal was to improve HDL cholesterol, but what this is telling us now is that there’s a threshold that if you go above two drinks a day you start to move things in the wrong direction.”

Bisognano said patients regularly ask whether they should start drinking in order to improve their cholesterol, and while he wouldn’t necessarily recommend someone start just for that reason, alcohol is something that spans almost all cultures and countries.

“What I’m looking at is people who just truly enjoy two glasses of wine or two beers or two mixed drinks a day, and I have reasonable evidence now that they are not doing themselves any harm.”

Asked why the effect of alcohol on arterial stiffness was more pronounced in males than females, Bisognano said it may be due to the small number of female participants, but “it may also be that there’s other cardiovascular risk factors such as hypertension, hyperlipidemia that affect males earlier than females. So it may just be that you are seeing an effect of age.”

Participants in the Whitehall II cohort were originally recruited between 1985 and 1988 (age range 34 to 56 years) and self-reported alcohol consumption through 2009. PWV was measured at baseline and then during follow-up in 2012 and 2013.

Men were more likely to be heavy drinkers (stable 17.l7%, unstable 27.9%) than females, who were more than twice as likely to be stable nondrinkers (8.2%) and former drinkers (18.7%). While few among either sex were current smokers, 68% of males and 74.1% of women failed to meet World Health Organization–recommended weekly exercise levels.

Mean PWV values increased significantly among males from 8.5 m/s at baseline to 9.1 m/s by follow-up and from 8.2 m/s to 8.7 m/s among females (P<0.001 for both).

While all drinker types, regardless of sex, had increases in their PWV from baseline across follow-up, only male former drinkers had significant accelerated progression of arterial stiffness (b=0.11 m/s; P=0.009).

Bisognano said the message for physicians going forward is to ask their patients not whether they consume alcohol, but how much.

“If you have someone who is drinking heavily, they have another issue that has to be addressed in a more formal alcohol-reduction program,” he said.

Roerecke and his meta-analysis colleagues write that “a reduction of both alcohol consumption and blood pressure has the potential for substantial synergistic health gains in terms of morbidity, mortality, and healthcare costs; yet only about half of hypertension guidelines worldwide recommend reduction in alcohol consumption to reduce raised blood pressure.”

By their calculations, if half of UK residents drinking more than two drinks a day reduced their alcohol intake, the proportion of people with systolic blood pressure >140 mm Hg would fall by 4.4% for men and 1.2% for women, with most of the effect emerging in mid-adulthood. This reduction in BP would translate into 7272 inpatient hospitalizations and 678 cardiovascular deaths prevented every year.

The meta-analysis was funded by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health (NIH). Roerecke reports grants from these institutes during the study and grants and personal fees from Lundbeck outside the conduct of the study. Disclosures for the coauthors are listed in the paper. The Whitehall II study was supported by funds from the UK Medical Research Council, British Heart Foundation, and the NIH. The authors as well as Bisognano report no relevant financial relationships.

Follow Patrice Wendling on Twitter: @pwendl.

This article appeared in from theheart.org, – follow on Twitter and Facebook.

References

Roerecke M, Kaczorowski J, Tobe SW, et al. The effect of a reduction in alcohol consumption on blood pressure: a systematic review and meta-analysis. Lancet Public Health 2017; DOI:10.1016/S2468-2667(17)30003-8. Article
O’Neill D, Britton A, Brunner EJ, et al. Twenty-five-year alcohol consumption trajectories and their association with arterial aging: a prospective cohort study. J Am Heart Assoc 2017; DOI:10.1161/JAHA.116.005288. Article

original article appears on: http://www.medscape.com/viewarticle/876422

Mediterranean Diet With Olive Oil Boosted HDL Function: PREDIMED

steven kypraios — Mon, 20 Feb 2017 04:13:48 +0000

In an article by by Patrice Wendling February 13, 2017 appearing at

http://www.medscape.com/viewarticle/875713,

more evidence was presented for the beneficial effects of a mediterranian style diet:

BARCELONA, SPAIN — More research suggests that a Mediterranean-style diet supplemented with either virgin olive oil or mixed nuts enhances the function of HDL cholesterol[1].
In a subset of 296 patients at high risk of heart disease in the PREDIMED study, cholesterol efflux capacity (CEC), the first step in reverse cholesterol transport, was significantly increased at 1 year compared with baseline in those advised to eat a Mediterranean diet rich in virgin olive oil (VOO) (P=0.018) or mixed nuts (P=0.013) rather than a reduced-fat diet.
In addition, both Mediterranean-diet groups had a trend toward improved antioxidant and endothelial functions of HDL, although the changes were statistically significant only in the Mediterranean diet–VOO group.
References
1. Herna?ez A, Castan?er O, Elosua R, et al. Mediterranean diet improves high-density lipoprotein function in high-cardiovascular-risk individuals: A randomized controlled trial. Circulation 2017; 135:633-643.
2 of 3 20/02/2017, 2:08 PM

http://www.medscape.com/viewarticle/875713_print

Abstract
2. Rader DJ. Mediterranean approach to improving high-density lipoprotein function. Circulation 2017; 135:644-647. Editorial

The Amount of Exercise Needed to Reduce All-Cause Mortality

steven kypraios — Mon, 20 Feb 2017 03:56:38 +0000

This article originally appeared in http://www.medscape.com/viewarticle/875779

According to Dr. JoAnn Manson, professor of medicine at Harvard Medical School, Brigham and Women’s Hospital, two recent reports from the UK (England and Scotland) shed light on several key questions about physical activity and health, including how much, how often, and what type is best.

Current physical activity guidelines, recommend moderate-intensity exercise for about 30 minutes most days of the week (a total of 150 minutes/week) or vigorous exercise for half that amount of time (75 minutes), spread out over three or more sessions per week. In a report published in JAMA Internal Medicine,^[1] researchers asked a large cohort of more than 63,000 men and women over age 40 about their moderate to vigorous physical activity. Participants were classified into one of four groups: those who did no moderate or vigorous physical activity, those who met the guidelines (150 or 75 minutes/week) and exercised at least three times per week, those who met the guidelines but compressed the activity into one to two sessions per week (commonly referred to as “weekend warriors”), and those who reported some moderate to vigorous physical activity but less than the guidelines.

The results were surprising. All of the active groups, compared with the group not having any moderate to vigorous activity, had substantial reductions in cardiovascular and all-cause mortality. Weekend warriors and those getting less than the recommended amount, compared with those getting no moderate to vigorous exercise, had close to a 30% reduction in all-cause mortality. Those meeting the guidelines and having at least three sessions per week had a 35% reduction in all-cause mortality. So there was not too much difference. All three active groups had about a 40% reduction in cardiovascular mortality compared with those who did not report any moderate to vigorous activity.

In a second report from the UK cohort, published in the British Journal of Sports Medicine,^[2] researchers asked participants about specific types of sports and moderate to vigorous activities that they engaged in. What they found was very interesting. A really wide range of sports and leisure-time activities were associated with substantial reductions in all-cause and cardiovascular mortality, including swimming, racket sports, and aerobics. Similar reductions in cardiovascular mortality were found with these types of activities.

She concludes: “It is a very good clinical public health message that some moderate to vigorous physical activity is substantially better than none, and that more is at least slightly better than some. We should encourage patients who are unable to meet the target, or who have to compress activity into one or two sessions per week or the weekend, to stick with it and be as active as they are able. We can expect that any activity will be better than none.”

“We need more research on physical activity and health, including randomized clinical trials of different types of activity, to further refine the activity guidelines. ”

References

O’Donovan G, Lee IM, Hamer M, Stamatakis E. Association of “weekend warrior” and other leisure time physical activity patterns with risks for all-cause, cardiovascular disease, and cancer mortality. JAMA Intern Med. 2017 Jan 9. [Epub ahead of print]
Oja P, Kelly P, Pedisic Z, et al. Associations of specific types of sports and exercise with all-cause and cardiovascular-disease mortality: a cohort study of 80,306 British adults. Br J Sports Med. 2016 Nov 28. [Epub ahead of print]

Coronary Artery Calcification Predicts All-Cause Mortality

steven kypraios — Mon, 20 Feb 2017 03:48:15 +0000

by Lara C. Pullen, PhD July 06, 2015 original source: http://www.medscape.com/viewarticle/847546
The extent of coronary artery calcification (CAC) is an accurate predictor of 15-year mortality in asymptomatic individuals, according to a new study published online July 6 in the Annals of Internal Medicine.
Leslee J. Shaw, PhD, from Emory University School of Medicine in Atlanta, Georgia, and colleagues found that individuals without CAC had 15-year all-cause mortality rate of 3%. In contrast, overall mortality increased to 28% for individuals with CAC scores of 1000 or higher (P < .001).
The research builds on previous reports on the prognostic value of CAC scores. Many studies have identified an excess hazard for worsening clinical outcomes in individuals with high scores. Most of the studies, however, have been relatively short term.
The current study, with a cohort of 9715 adults, is noteworthy because it is based on a 15-year follow-up. In addition, the use of all-cause mortality as an endpoint expands the study beyond traditional cardiovascular disease outcomes and adds another component to a potential calculation of risk.
“The Framingham risk score is a well-established method for estimating 10-year CHD risk, whereas we applied CAC scoring to estimate 15-year all-cause mortality. A reasonable question is whether overlap exists between these scores. Age is strongly related to CAC, with incidence increasing in older patients; however, our data note substantive risk reclassification (that is, [net reclassification improvement] > 0.20) in patients with CAC and risk factors beyond age and other cardiac risk factors,” the authors write.
The researchers explain, however, that their data do not point toward targeted treatment of patients with high CAC scores. “Our study had a long duration of follow-up with clinical outcome data available only on all-cause mortality. Because we are presenting observational data, causality with regard to influencing outcome cannot be inferred.”
The study can be used, however, to further the discussion as to whether or not routine CAC scanning provides any benefit to society.
One coauthor reports that she has stock holdings/options in Eli Lilly and Pfizer. Another coauthor reports that she has stock holdings in Pfizer. The other authors have disclosed no relevant financial relationships.
Ann Intern Med. Published online July 6, 2015.