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An Update on New Research – Part 2

IMG_8348rt5x7bwThere is always plenty of research being conducted on heart disease prevention, but this week I decided to go straight to the source. This week I will be blogging directly from the Cardiometabolic Health Congress in Boston – a collection of presentations on recent concepts and new research in the treatment of conditions like high blood pressure, high cholesterol and diabetes. The goal? To prevent heart disease and stroke.

For part 1 of my post, see here.

At this meeting, we have been hearing from experts in the fields of heart prevention, high blood pressure, high cholesterol, diabetes, and obesity. To point out some key findings, here are common questions from patients and the answers from some of the speakers at this meeting:

What type of exercise is best for prevention?  We all understand the importance of staying active, and many of us now count our steps to ensure we meet our activity goals. But one expert pointed out that to have maximal impact on weight loss, we need to go beyond light activity – he termed them “sweat episodes”. We should aim for 3-5 “sweat episodes” weekly – and no specific type of exercise to accomplish this is superior. For much more information on exercise, click here.

What diet is best to prevent heart disease? We are bombarded with diet advice – but very few diets have really been studied to see their effect on disease prevention. Dr. Frank Sachs, a Professor of Nutrition here is Boston, summarized the evidence for many of the commonly recommended diets. His conclusion – a Mediterranean Diet has the best evidence for prevention – not just for heart disease and stroke, but there is also evidence that it can improve mental function! Here are his slides summarizing the diet and its benefits:

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Slides reproduced from Dr. Frank Sacks “The Science Behind Heart Healthy Nutrition”, October 23, 2015

What is the ideal blood pressure target? For years, we have used 140/90 as a “target” blood pressure for patients on therapy for high blood pressure.   However, an important new study which was announced recently suggests that a more aggressive target (below 130) may be better at preventing heart complications. This study generated a lot of media attention – but the experts here warn that the full study has yet to be released and analyzed. However, it is promising evidence that “lower may be better” – stay tuned for further advice.

Why is high blood pressure so difficult to control? It is frustrating to patients with HBP (and their doctors!) when their BP cannot be fully controlled, even with multiple medications. Dr. George Bakris, an expert on hypertension, notes that the most common culprit (other than missing medication!) is excess sodium in the diet. Even patients who think they are “watching their salt” may be eating more than needed, especially from hidden sources. This can cancel out the effect of medication. The optimal diet for patients with HBP is the “DASH” diet – for more information, see here. 

What is the “right dose” of exercise for a long and healthy life?

IMG_8348rt5x7bwFor some guidance, here is a nice summary from the New York Times of some recent research. . . .

Exercise has had a Goldilocks problem, with experts debating just how much exercise is too little, too much or just the right amount to improve health and longevity. Two new, impressively large-scale studies provide some clarity, suggesting that the ideal dose of exercise for a long life is a bit more than many of us currently believe we should get, but less than many of us might expect. The studies also found that prolonged or intense exercise is unlikely to be harmful and could add years to people’s lives. Click here for the full article.

The conclusions?

1. The recommended weekly does of 150 minutes of exercise is a good starting point, but those who are able should strive for more, up to an hour a day of moderate exercise (such as steady walking)

2. Adding more intense exercise for short periods (jogging or brisk walking) is even more beneficial.

3. While more intense training, such as distance running, may not be harmful, the overall benefit on longevity is questionable. This should not stop those who are able from pursuing vigorous exercise,

Atrial fibrillation – A Common Heart Condition

IMG_8348rt5x7bwRecently, Dr. Albers and myself were asked to participate in the “Living with Heart Disease” lecture series sponsored by the American College of Cardiology. I spoke about a very common type of irregular heart rhythm called atrial fibrillation. If you or a family member has suffered from this condition, you may find this presentation helpful, as I discussed the causes, symptoms, and common treatments of this condition. here is a link to a video of my recent presentation.  As always, only a physician who has personally assessed you can give specific advice about your (or your family member’s) condition.

If you want to learn more about atrial fibrillation or many other heart conditions, an excellent resource is the CardioSmart website which we refer to often in our blog.

A great prescription

BW ARA labcoatWe have written and posted about the heart health benefits of exercise at HeartHealthDocs – including programs like Cardiac Rehabilitation (Rehab)

heart to start book. In the book Heart to Start, Dr. James Beckerman, a cardiologist who lives in Portland, Oregon, writes a detailed prescription for anyone to use to start living heart healthy. The gut-check forward “What’s your legacy?” written by David Watkins is followed by patient examples, vignettes, and Beckerman’s own personal reasons for the book. The Warm Up, Work Out, Cool Down sections echo a training session, and take the reader through the paces – the what, why, how, for fitness assessment and growth toward heart & circulation health.

The chapter Cardiac Reboot asks “Got Rehab?” and points out the current reality that if you (the patient) don’t bring up cardiac rehab, “it is possible no one else will.” This relates to the low numbers (20-30%) of eligible patients being referred to cardiac rehab, and of those only 40% actually completing this effective treatment regimen.

Beckerman goes on to provide readers a toolkit for being active, while showing how an active lifestyle can be habit forming – and be maintained for years (ie. how not to get injured). The book will get you to your 5K and its finish & beyond, and will teach how nutrition, training, and balance (ie. strength conditioning in addition to walking/running) work together.

Dr. Beckerman gives powerful examples of what motivates him – for the book, and for his practice which includes the PlaySmart heart screening program. The proceeds from the sale of his book will support free heart screenings for kids.  The book will help anyone learn about and apply practical, inspiring information for exercise and heart health. A great way to multitask.

A Great Patient Story

BW ARA labcoatNice to start 2015 with a patient story to teach the importance of your circulation. Circulation includes structures that direct blood and fluids as they move or circulate through the body. Arteries (tubes that take the blood from the heart to the body), veins (tubes that return blood to the heart from the body), and a third part, named lymphatics, are structures that keep our bodies working.

In 2008 the Surgeon General of the United States published a call to action for Venous Thromboembolism, a problem that affects veins and can affect the heart, and is a leading cause of death. Venous thromboembolism refers to blood clots (also called thrombi (plural of thrombus)) that form in a vein in the setting of slow flow, inflammation, injury, or other factors.

The journal Vascular Medicine publishes patient information about vascular diseases – here is the paper on Venous Thromboembolism and Pulmonary Embolus. 

The patient story starts with me before I became a cardiologist or even a high school graduate. I ran on the track team in high school. My coach taught us not just track, but would also tell us he was teaching us how to stay fit and strong so that we would always know the discipline that training required — how to pace, how to stay active, how to prepare for a goal. At the time I had no idea what a gift his coaching was, but went on to apply it to 10 marathons, triathlon, biathlon, rowing, my practice, and my patients because staying active plays a key role in heart health. 

The patient is that coach. He called me in 2013 when my focus was on training for the Philadelphia marathon. I was ready to talk about the 20 miler, how the taper might go, etc. It took a minute to realize he actually had a symptom. He has remained active and exercises at a high level with swimming, calisthenics, weight lifting, and bicycling in addition to travel abroad for work. The symptom was shortness of breath, happening when exercising or at the end of a set of pushups (yes, a set of pushups as in one of multiple reps in multiple sets). He had been getting back to his home exercise regimen after travel to Europe when the symptom started. We talked about his travel for work, how his knees were faring (he had a career as a paratrooper which had inflicted degenerative change to the knees to say the least). While in Europe he had received an injection to the left knee and was evaluated in Germany when he had subsequent significant swelling. 

It was when he mentioned the last bit – the leg swelling – when it clicked: chance of Pulmonary Embolus (PE). In addition to the oddity of him actually experiencing/complaining of a symptom like shortness of breath, the possibility of PE expedited his evaluation. 

Screen Shot 2015-01-04 at 8.38.49 PMA computed tomography (CT) scan of the chest showed bilateral PE. Followup evaluation for deep venous thrombosis (DVT) was positive for a blood clot in the leg where he had had the swelling.  I have his permission to post the blood clot on the Internet so will show a still frame as well as a movie of the vein with grey DVT in the vein.

The blue arrows in the table (Table 1) point to the key symptoms he experienced, and to the shadowy grey clot as it appears on a lower extremity venous duplex (below) (the Vascular Medicine Journal patient information article by Dr.s Evans and Ratchford also has an example of a vascular ultrasound study in Figure 1, with a cross section view).

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Another blog post can be how to keep active people safe when an issue (like PE) happens.  My partner actually showed my coach the video (below) of the blood clot floating in the vein when he broke the news that the trans-Atlantic trip scheduled for later that week as well as leg squats were on hold until treatment progressed.

Another blog post can celebrate the heart healthy benefit of lifelong exercise; the patient’s echocardiogram showed normal function and heart findings of someone younger than chronological age. The leg ultrasound totally normalized after treatment. He did not develop post thrombotic symptoms or syndrome, which can prove challenging – as well described by Dr.s Evans and Ratchford in this Patient Information Page in Vascular Medicine Journal.

For now, I am thankful for my high school track coach calling with the symptom and agreeing to share a great story & add information about blood clots, DVT, and PE for HeartHealthDocs followers interested in education about Circulation & Heart Health.

HeartHealth Docs Road Show. . .Promoting healthy kids

The HH Docs spent this past weekend in Indianapolis, presenting original research from Riverside Hospital. We performed a study analyzing the accuracy of cardiac ultrasound to detect a certain type of cardiac abnormality that may cause sudden death with exertion. Dr. Kyle Feldman, who collaborated on the study, presented the findings to over 300 attendees.

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For more information and a video on promoting heart health for athletes and active teenagers, see this article.

Low Fat or Low Carb? A new study sheds some light. . . .

IMG_8348rt5x7bwWhat is the optimal diet for weight loss and reducing long-term risk? This question has been debated for some time. A new study funded by the National Institutes of Health (NIH), and described in detail here, sheds some light on the issue (but is probably not the final word). In this study, researchers divided about 150 participants into 2 groups – one consumed a “low carb” diet but could eat unlimited fats (even saturated fats, such as butter), while the second group consumed a low-fat diet, as touted by many health organizations for some time. This group had no limits on carb intake. Here is a summary of the results, from the New York Times:

By the end of the yearlong trial, people in the low-carbohydrate group had lost about eight pounds breadmore on average than those in the low-fat group. They had significantly greater reductions in body fat than the low-fat group, and improvements in lean muscle mass — even though neither group changed their levels of physical activity.

In the end, people in the low-carbohydrate group saw markers of inflammation and triglycerides — a type of fat that circulates in the blood — plunge. Their HDL, the so-called good cholesterol, rose more sharply than it did for people in the low-fat group.  Blood pressure, total cholesterol and LDL, the so-called bad cholesterol, stayed about the same for people in each group.

Nonetheless, those on the low-carbohydrate diet ultimately did so well that they managed to lower their Framingham risk scores, which calculate the likelihood of a heart attack within the next 10 years. The low-fat group on average had no improvement in their scores.

So the low-carb group, despite eating high levels of fat (mostly unsaturated – the good kind), lost more weight and improved the cardiovascular risk profile, in comparison to the low-fat group.

HeartHealth Docs take home message: This study was not large, but well done, and shows that reducing carbohydrate intake may be more important than reducing saturated fat. We advocate this type of diet, but still recommend moderation of saturated fats. So when you raise a toast of red (or white) wine this weekend, enjoy some cheese. . .but skip the crackers!

Here are several more articles on a heart healthy diet, as well as saturated fats, and nutrition counts.

 

Our favorite website to learn about heart disease and prevention

IMG_8348rt5x7bwWhen someone learns that they, or a family member, is afflicted by heart disease, it is natural to seek out additional information. Unfortunately, the internet can be a source of both information and misinformation, and sorting through the web for relevant health information can be a daunting task. For both patients as well as their families, the most useful site we have come across (other than HeartHealth docs!) for education and understanding is  cardiosmart.org. This site was created by the American College of Cardiology

logo-cardiosmart-redblue(ACC)and has a wealth of information on the origins, therapies, and manifestations of various heart disease and disorders. Here are some of the key features that you may find helpful:

1. There are disease specific pages that explain various conditions and therapies, such as this page for heart attack, or this detailed explanation of atrial fibrillation.

2. For those who do not currently have a heart condition, but are curious about the risk for heart disease, there is a simple but accurate risk calculator.

3. For those taking cardiac medications, this section lists each medication, with information on dosing, side effects, etc.

4. Those who register here are able to set specific goals, received tailored advice about research and other treatments, and a specific plan for prevention.

Are you aware of other useful educational sites for Heart Disease? If so, please let us know, and help the spread the message of prevention!

 

New findings about exercise – even 5 minutes can help!

What is the minimum amount of exercise that can be beneficial? this new study from the New York times has an encouraging finding- even 5 minutes of hard exercise such as running can have a long-lasting positive effect on your health.

What is “moderate” exercise?  While most of us know that we should exercise several times per week, this recent article shows that many adults overestimate the intensity of their typical activity, and therefore may not get the maximal benefit. Here is a link to the article.

How do you know when your exercise intensity is adequate? See our recent article about exercise (and also this and this), as well as our recent video  for some tips. . .and remember, keep moving!

Saturated Fat: Old Foe, or New Friend?

IMG_8348rt5x7bwYou may have seen some of the recent media articles that address the debate over saturated fat. This is based on some newly published research that suggests that adults who reduce their intake of saturated fats don’t necessarily reduce the heart risk. Popular media has covered this widely, and even the New York Times declared that “Butter is Back”. So does that mean we now have the green light to load up on red meat, butter, and other sources of saturated fat?

The short answer is – probably not. I recently addressed this topic on the video blogging site Vidoyen.com, which you can view by clicking here. Many nutrition and public health experts, who certainly have more expertise than myself, have also weighed in (one of my favorites, Dr. David Katz, has this video and this excellent article which help rebut the “butter is back” theory). The consensus is that this recent research, which was a pooled analysis of prior research, not new data, has some serious flaws. Here is what the “experts” seem to conclude:

1. Saturated fattty acids (or SFA, such as red meat, cheese, and butter) have long been known to be linked to the development of heart disease.

2. While reducing SFA can reduce heart risk, what is important is how the “bad” fats are replaced – many diets (and people) tend to increase intake of carbohydrates – especially the processed kind, which are probably worse for long term heath. That is why many “low fat” foods really don’t improve your health- they replace the SFA with bad carbs instead.

3. The key seems to be to replace the SFA with “good” fats instead – that is, unsaturated fatty acids such as nuts, olive and other vegetable oils, and fish. When this has been studied, there appears to be a beneficial effect on heart risk and overall health. In fact, this is the exact goal of the Mediterranean Diet, which has been studied extensively and shown to reduce heart risk.

More importantly, think less about the “components” of your diet, and focus more on eating whole foods. For example, butter may actually be better than some of the processed spreads, but not as good as olive or vegetable oil. So the “old foe” is still a “new foe”!

Here are some more links to our articles on diet and nutrition:

Our overall guide to a heart healthy diet

Our top 10 eating tips

Nutrition Counts

The perils of carbohydrates