Heartfelt with Dr Melissa Walton-ShirleyView all posts »
Tea leaves or science? Factors that can impact our risk of MINov 4, 2012 18:50 EST
I am a mere junior leaguer among the giants of medical journalism but count myself as privileged to have had the opportunity to rub elbows with many. Despite my enthusiasm for writing, today's AHA press conference was fairly painful. It was steeped in medical economics, a very necessary but "butt–numbing" topic. When combined with the fact that the embargos on the presentations don't lift until about a year from now (okay, I admit to only a slight exaggeration), the immediacy that used to serve as motivation for my writing is now replaced with complacency and a healthy dose of hesitation. I was anxious to write about things like TACT (chelation therapy) and FREEDOM (DES in diabetics) but wanted to get some news out on other topics before the Thanksgiving holiday (sorry—more sarcasm), so for therapy, I wandered aimlessly among the "Environmental and Psychological Risks for CVD" poster display. Without further ado, here are some tidbits from macabre to the reassuring that might guide us in general conversation with our patients behind the exam-room door.
"Doctor, can I go to a sauna?" is not a frequently asked question by my CHF patients, but it's good to know there are a few studies from which to start a conversation. In 2009, a paper in the Journal of Cardiology concluded there was a positive impact of sauna therapy on CHF prognosis. Today's poster detailed a 15-minute 60°C far-infrared dry bath followed by 30 minutes of bed rest in warm blankets performed two to three times per week. In Japan, this common practice, called waon, demonstrated that the average left ventricular systolic ejection fraction in nonischemic cardiomyopathy improved slightly. Endothelial function as measured by flow-mediated brachial artery dilatation and six-minute-walk parameters were also improved. The patients were directed to weigh in before and after and drink enough fluid afterward to only replace their weight. For Americans like me, who have no idea how hot 60°C is, that's 140°F. Writing from a cold, dark, convention-center pressroom, 140° on either scale sounds pretty fantastic right about now.
Grab your meds as you run out the door! Natural disasters are bad for heart patients. Earthquakes and tsunamis are particularly bad for heart-attack risk, but a poster today outlined the multifactorial etiologies of those disasters on later CHF decompensation, ie, psychological stress can impact sympathetic activation, coagulation, plaque rupture, an increase in afterload, and depression. Environmental impact including poor nutrition and lack of access to medication can spell a health disaster. In the continental US, flooding, blizzards, tornadoes, ice storms (and some might say national presidential campaigns) would all be surrogates for the tsunamis and earthquakes the rest of the US and the world are sometimes forced to experience, so instruct your patients to plan accordingly.
Insomnia can kill you. J ust ask Stephen King, who has served as a frequent medical reference during my training. Researchers in Taipei followed insomniacs for four years and demonstrated an even greater increase in stroke than MI among restless keepers of the night. Over 10 000 subjects were examined and compared with equally matched patients without a history of insomnia. The greater question: Will sleep aids improve mortality? Only future study will answer that $63-billion-per-year question. Come Tuesday night, perhaps President Obama or President-elect Romney can add that cost of insomnia information to their armamentarium so they can solve our $16 221 685 381 838.28 dilemma. We know "every little bit counts" when it comes to sleep hours as well as the national debt
Shop for a hospital that bypasses the ER in AMI therapy . Beggars can't be choosers, but if you aren't a beggar, ask in advance which local hospital still makes you stop in the ER during an MI. In this presentation, >80% of patients achieved "device activation" within 90 minutes of hitting the NON-ER door of a hospital, further proof that the ER is the best place to grind down the progress of any active STEMI lab. Time equals muscle. Muscle equals life-years, so CEOs, makes sure your blueprints for the new cath lab place it squarely on the ground floor of your facility with drive-up access. Take a lesson from a cardiologist in Poland who told me his D2B time was an average of 12 minutes. Granted, his patients must have kept their pants on for their procedure, but they were more likely to be able to tell about it 10 years later.
A pack of Marlboro lights and a fish oil, please. Researchers from Edinburgh, Scotland studied young smokers age 26 to 30 years by measuring plasma phospholipids in those supplemented with 2 g of omega-3 daily for six weeks. They found an increase in endothelium-dependent vasodilatation and substance-P, which produced a dose-dependent increase in natural tPA (clot-buster) production. There was no effect on platelet monocyte aggregation, to my surprise. Before the cigarette industry starts selling fish-oil capsules strapped to a smoke with a red rubber band, note there was no mortality data with this combination. Smokers should still run (do not walk) away from the nearest cigarette!
There were a several interesting posters that deserve at least a "one- or two-liner."
- Congestive heart failure patients with C Difficile experience an increased length of stay and an increase in hospital-associated mortality, so act accordingly. It should make us pause before we push those patients out the door to appease third-party payers. As a matter of fact, I vote that all third-party payers should be punished with diarrhea if they push their providers to discharge anyone too soon. Wish I were kidding.
- Sleep-disordered breathing seen in 54% of this study of ACS patients was an independent risk factor for MACE—ie, CV death, stroke, heart failure, and ACS. Controls without sleep apnea demonstrated 89% MACE-free survival vs apneics, of whom 76% were MACE-free at six years.
- RDW (red cell distribution width) increases mortality but not 30-day readmit rates in AMI patients. Uh . . . this is either a surrogate for all-cause mortality or an even worse surrogate of not making it back into the hospital in time to be counted.
- New York women ages 25 to 34 with ischemic heart disease (IHD) are dying due to diabetes as an associated risk factor more than any other. NYU vital statistics found the incidence of diabetes at 16.5% in females compared with 8% in males who died of IHD. HIV was the second most common diagnosis in 3.8% of females, followed by lupus at 2.3%, then chronic kidney disease and cocaine use, both at 0.6%.
- Tinnitus or ear ringing, thought to be impacted by the presence of oxidative stress, was studied in statin users. Thought to be a possible side effect of statins, patients on pravastatin 40 mg and simvastatin 20 mg vs placebo reported a change in fatigue, which mirrored either a decrease or an increase in the symptom. This "bidirectional" effect is confusing but likely provides a hint that we aren't smart enough to figure out in 2012 about the etiology of this most aggravating and common malady.
Think I'll smoke a cigarette, swallow a fish-oil capsule, take a nap and go to the sauna, and if I still have an MI, whatever you do, don't stop rolling my gurney until you are well past the ER.