Tuesday, February 26, 2013

Unhealthy America

     A recent report from the National Research Council and the Institute of Medicine made headlines when it pointed out how unhealthy Americans are compared with 16 other wealthy, developed nations: Australia, Canada, and all the nations of Europe. This report is nicely summarized in the Journal of the American Medical Association (JAMA February 27, 2013, vol. 309, pp 771-772) The following is a precis of this report. I might add that no cause was found for our lowest ranking in health and highest ranking in death rates.

     Until age 75, we have the highest death rate, compared with those other countries, but if we reach age 75 then we have a higher life expectancy.

     We have higher rates of disease and injury especially in motor vehicle accidents involving alcohol.

     US infants are least likely to reach their first birthdays, compared to the other 16 countries.

     We have lower birth weights, and mortality rates up to age 5 are also higher.

     US teenagers die at a higher rate from motor vehicle crashes and homicides.

     US teenagers also have the highest pregnancy rate and the highest prevalence of sexually transmitted diseases. They are also the least likely to practice safe sex.

     We have the highest incidence of AIDS.

     We also have the highest obesity rates and the highest rate of adult-onset diabetes, as well as the second highest rate of death from ischemic heart disease.

     US patients are more likely to return to the emergency room and to be readmitted after hospital discharge.

     We are less likely to smoke and drink, but we are more likely to abuse drugs and not fasten seat belts.

     We have the highest child poverty rate.
     Even our wealthiest white citizens have a higher mortality than matched adults in other countries.

And no one reason or cause seems to explain our unhealthiness, especially since we pay more per capita on health care than do any of the other industrialized democracies.



Monday, February 18, 2013


     Statins have been in the news lately, so I thought I might write a few words about them. Statins chemically mimic an enzyme in the liver (HMG-Co-A) that is used in the first step of making cholesterol, and when the liver tries to use the statin, then overall less cholesterol is produced, and your serum levels fall. The body makes most of its cholesterol between midnight and dawn, which is why the earliest statins, which had a short half-life, were prescribed to be taken at bedtime. But the later statins such as Lipitor and Crestor have a much longer half-life, so they  may be taken at any time during the day, and food does not significantly affect their absorption.

     There is absolutely no question, based on numerous clinical studies, that statins definitely provide secondary protection against a heart attack or a  stroke. That is, if you have had a heart attack or a (non-hemorrhagic) stroke, taking a statin will lower your risk of having a second one. Whether or not you should also take aspirin should be decided by you and your doctor, and adding a regime of exercise provides an additional benefit above and beyond the benefit from taking the statin. All statins appear to give equivalent results.

     The question of primary prevention is a little more complicated. There is no satisfactory study showing that a person with no risks for heart disease other than elevated  cholesterol benefits from taking a statin. Many doctors will prescribe a statin for a patient with a risk factor for coronary artery disease or a stroke: smokers, diabetics, patients with ASCVD, and patients with significant narrowing of a carotid artery. There is evidence for decreased mortality when a patient with documented ASCVD takes a statin, even in the absence of a heart attack.

     I have found the most troublesome side-effect to be leg cramps, which are sometimes severe enough to awaken patients at night. Often the leg pains can be helped by reducing the dose of the statin or switching to another brand. The statins can also raise liver enzymes, and some patients report difficulty with mental concentration. There is some weak data that statin use can slightly increase your risk of developing adult-onset diabetes, but it may also reduce your risk of getting cancer (see my earlier blog about this). The muscle cramps and occasional myositis may be related to the fact that all statins lower the level of Coenzyme Q-10.

     Statins are one of the few drugs where the ingestion of grapefruit juice should probably be avoided. A chemical in grapefruit inhibits the P450 enzyme that degrades statins, so the use of grapefruits can raise the level of the statin in your blood and your liver.

     Let me close by summarizing the results of the JUPITER study. This study showed that in patients who had an elevated CRP (a marker of inflammation) who also took a statin had a lower incidence of heart attacks, coronary artery surgery, and strokes. Strangely enough, there was no decrease in the indicence of deaths from coronary artery disease, but there were 20% fewer deaths from all causes, mainly cancer.

     There are many, many clinical trials of statins in various medical conditions being conducted, and you can expect to see future stories about their benefits, side effects, or, occasionally, a null result. There was also a recent retrospective study showing that patients that lowered their LDL cholesterol through diet had an increased rate of cardiac events and deaths, so it may well be that the beneficial effect of statins is due more
to their anti-inflammatory effect than to their lowering cholesterol.


Sunday, February 17, 2013

Stress and the Broken Heart

     Gilbert and Sullivan were correct to have Ko-Ko sing in "The Mikado" that "a little tomtit" died of a broken heart. There is a broken heart syndrome well-known to cardiologists, who also refer to it as stress cardiomyopathy or takotsubo cardiomyopathy. Sudden stress, usually of an emotional nature, can cause sudden cardiac death, angina, and acute congestive heart failure. I will first discuss the effects of acute stress on the heart, and then the far-reaching effects of chronic stress on the heart and the circulatory system.

     The broken-heart syndrome, which usually affects women, is thought to be due to the effects of an acute surge of adrenalin on the heart. Such an acute surge can cause reversible spasm of the coronary arteries, ballooning of the left ventricle, and a stunning of the cardiac muscle syncytium. The precise mechanism is not known, but the effect is real, and has been observed many times. Cardiac enzyme tests for a heart attack are normal, but an echocardiogram will show a ballooning and dysfunction of a portion of the left ventricle, thereby causing acute heart failure. Coronary artery catheterization shows no sign of blockage, and the EKG changes are not those shown by a heart attack. Such an attack which can be manifested by acute chest pain and shortness of breath can look like an anxiety attack, but a cardiac exam will typically show signs of heart failure. In some cases, cardiac arrhythmias can also occur. Recovery with proper treatment tends to be rapid, typically within one week. The interval between the emotional shock (often caused by the death of a spouse) and the cardiac event is variable, and any severe emotional shock can be the trigger. There is even one (apocryphal?) story of a woman having such an attack after winning the lottery.

     Chronic stress caused by  anxiety or depression or problems at home or at work can also cause deleterious chemical changes in the bloodstream, with eventual effects on the circulation of coronary as well as peripheral arteries, and a possible fatiguing of the cardiac muscle. We know that the stress caused by these mental conditions can cause elevated adrenalin  and cortisol levels, as well as an elevated pulse rate and white blood count. This effect also raises blood pressure and makes the blood more liable to clot. There is a concomitant elevation of fatty acids, cholesterol and triglycerides. Whether or not chronic stress can lead to heart disease is not known, but, as indicated, chronic stress elevates all the chemicals in our bloodstream that we would prefer to be lower to protect against cardiac disease.

     Unfortunately, there is as yet little or no clinical data to show that lowering stress decreases the risk of developing a cardiac problem; even the type A hypothesis has not been well proven. And I doubt (but who knows?) that the effect of a daily glass of wine on lowering the risk of a heart attack is due to its relieving of stress. Since marijuana mellows most users, it will be interesting to examine the heart attack rates in Colorado and Washington State in 10 years, to see if there is any effect on the incidence of cardiac events that could be attributed to the chronic smoking of marijuana.