From Beaumont Physicians and Allied Health Professionals
Summer Issue 2013
Venous thromboembolism: A clot in the vein that can be deadly CLINICAL CARDIOLOGY
Terry Bowers, M.D. Medical Director, Vascular Medicine Beaumont Hospital, Royal Oak
We all know people that seemed to be healthy, developed leg pain or swelling and then died suddenly. The medical terminology for this condition is deep venous thrombosis (DVT), which causes leg swelling and pain due to a clot in the leg vein. If the clot breaks away and travels in the venous system to the lung where it lodges in the pulmonary artery it is called a pulmonary embolism (PE), which is a common, lethal disorder that affects hospitalized and non-hospitalized patients. Venous thromboembolism (DVT and/or PE) results from a combination of hereditary and acquired risk factors. The risk for this disorder is increased in people with cancer, infection, severe acute medical Blood clot (embolism) illness, immobilization, a prior history travels up through vena Heart cava to heart and lungs of venous clotting, smokers, the elderly (over 75 years), and patients after orthopedic and major surgery. Venous thromboembolism is the third most common cardiovascular disorder after heart attack and stroke. It is believed that there are approximately 1 million cases in the U.S. each year, accounting for an estimated 300,000 deaths per year.
PE is also the third most common cause of hospital-related death, yet is the most common preventable cause of hospital-related death. The key to prevention is diligent attention to those patients at risk with anticoagulation therapy and leg compression devices, which can reduce the occurrence of this killer by as much as 70 percent. Although prevention is the best treatment, early detection is essential in patients who develop venous clotting to keep it from migrating to the lung. If suspected, an ultrasound of the leg veins should be Pulmonary done as soon as possible to identify the clot. This embolism blocking is a simple test to perform that does not cause pulmonary any discomfort. Once a clot travels to the lung, arteries patients develop shortness of breath, cough Lung (occasionally with blood), high heart rates and damage experience chest pain that worsens with breathing. Unfortunately, it can also cause sudden collapse and death. If PE is suspected, a computed tomographic scan of the chest is performed to evaluate the lung arteries for a blood clot. Left lung
Blood clot within vein
Treatment is focused on blood thinners (anticoagulants) that keep the clots from progressing and allow the body to dissolve the clot. In extreme cases we can give blood clot dissolving medications called thrombolytics. There is now a new oral form of anticoagulation called Xarelto that has greatly simplified treatment of patients with these disorders. Beaumont is actively involved in research efforts to improve outcomes of patients with venous thromboembolism.
INSIDE THIS ISSUE
Venous thromboembolism: A clot in the vein that can be deadly Prescribed cardiac medications: Patient and physician challenges Triggers of acute cardiac events: Preventive strategies Coronary artery disease: The fork in the road $1M gift from Pam and Bob Rossiter names cardiac cath suite Beaumont’s Cardiovascular Performance Clinic Weight loss surgery reduces subsequent health risks
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Promising new heart attack treatment: “Supersaturated oxygen” Preventing your next heart attack: Know your numbers! Varicose veins: The blue epidemic Disguise your exercise…Work out with your canine companion! Common Q & A Renovascular hypertension: Causes and lifestyle treatment strategies Women Exercising to Live Longer: Beaumont’s WELL Program
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CLINIC AL C ARDIOLOGY
Prescribed cardiac medications: Patient and physician challenges Michael McNamara, M.D. Former Cardiology Fellow Department of Cardiovascular Medicine Beaumont Hospital, Royal Oak
For many patients, their list of medications is long and seemingly continues to grow with subsequent visits to their physician’s office. One of the most common requests in the outpatient clinic is for this list to be shortened. For cardiac patients, one diagnosis may require therapy with several medications. For example, if a patient is admitted to the hospital with a heart attack (especially if they undergo a cardiac catheterization and receive a stent), they may be discharged on a minimum of four or five cardiac medications. This is a big change for someone not previously taking any medications. If their health is complicated by high blood pressure and diabetes, this may easily add another three to five medications to treat these chronic diseases. And that word, chronic, is the main reason many of these drugs become lifelong therapies. Furthermore, when patients are admitted to the hospital, they are often discharged on different doses of previous medications or put on new medications. Reconciling these differences may be difficult for some patients, especially those on a complex regimen. It is important to bring your discharge paperwork (especially if from a hospital other than where your physician has privileges), so your physician can review your discharge medications to determine if any additional changes need to be made.
As cardiologists, our field and clinical guidelines are driven by a wealth of data from research trials. From this research, we’ve found that certain medications for particular diagnoses offer a survival benefit to our patients; meaning, taking this medication will improve your chances of living a longer life. Other medications may provide symptom improvement or relief, but do not decrease mortality. As symptoms wax and wane, it is imperative that we, as physicians, revisit whether those "Drugs don't work in patients who don't take them." – C. Everett Koop, M.D.
medications are still necessary. For example, after a patient receives a stent, their anti-anginal medication may no longer be necessary. It is our responsibility to review, in detail, our patient’s medical regimen each and every time they are in the office. Sometimes a reminder from the patient may be all it takes to ensure their physician reviews their list of prescribed medications. To Dr. Koop's point, researchers have studied medication adherence and its impact on cardiovascular outcomes (Circulation, June 2009). The results
Walnuts may cut risk for diabetes Women who eat two or more servings per week of walnuts are 23 percent less likely to develop type 2 diabetes than women who never/rarely consume walnuts. Possible reason: Walnuts are especially rich in polyunsaturated fats, dietary fiber and antioxidants, which may help prevent diabetes. The researchers suggested the results most likely apply to men, too.
(Source: Journal of Nutrition, Feb. 2013)
were sobering. After admissions for acute heart attacks, 24 percent of patients did not even fill their cardiac medications by day seven of hospital discharge. Among patients discharged with prescriptions for aspirin, statins, and beta blockers, 34 percent of patients had stopped at least one of these medications and 12 percent had stopped all three within one month of discharge. In another study, only 21 percent of patients were taking all three of these medications six to 12 months after diagnosis of coronary artery disease by cardiac catheterization. These medications are critical to the long term treatment of heart disease. Why is the compliance to taking prescribed medications so low? There are many reasons, including cost, adverse side effects, poly-pharmacy (too many pills) and poor patient education. Addressing these issues begins with open and honest dialogue between the patient and physician. Cardiologists prescribe medications that offer a survival benefit and/or treat symptoms. These medications can improve outcomes, but only if the patient takes them. Adding lifestyle modification (e.g., healthier dietary choices, regular physical activity, cessation of cigarette smoking) to the medication regimen will provide additional cardioprotective benefits. Streamlining a patient’s medical regimen and explaining why these medications are important will improve patient compliance and clinical outcomes, while minimizing cost, errors from poly-pharmacy and patient inconvenience.
FROM THE EDITOR
Barry A. Franklin, Ph.D. Director, Preventive Cardiology and Rehabilitation, Beaumont Hospital, Royal Oak
Triggers of acute cardiac events: Preventive strategies An increasing body of scientific evidence shows that some emotional and physical ‘stressors’ can transiently increase the risk for a heart attack, stroke or sudden cardiac death (Physician and Sportsmedicine, Nov. 2011). These dangers are highest in people with known heart disease, as well as those with elevated cholesterol, high blood pressure or other cardiovascular risk factors, such as smoking, obesity and/or a sedentary lifestyle. Triggers you should know about include: Trigger #1: Getting angry. When you get really angry, your risk for a heart attack in the next two hours is two to nine times higher than it was before (Circulation, Oct. 1995; Psychosomatic Medicine, Nov.-Dec. 1999). Extreme anger can trigger threatening heartbeat irregularities, transient constriction of the coronary arteries and/or an increase in blood clots. Preventive strategy: Consider counseling or behavioral therapy if you’re prone to extreme anger – for example, during arguments or when someone cuts you off in traffic. In doing so, you’ll learn to respond appropriately to stressful situations and not to overreact. Ask your doctor if he/she recommends taking a daily aspirin to help prevent blood clots and/or a beta-blocker to reduce heart rate and blood pressure. The risk for an emotionally triggered heart attack may be lower in patients who take these medications. Trigger #2: Receiving very bad news. Suppose you’ve just learned that a loved one has died or that you have cancer. Recent studies suggest that the risk of having a heart attack is highest on the day that you receive bad news, but the risk remains higher than normal for at least the next four weeks (Circulation, Jan. 2012; New England Journal of Medicine, April 2012). Preventive strategy: Physical conditioning and some medications (such as a beta-blocker or aspirin) may reduce this cardiovascular risk. It’s believed that regular moderateto-vigorous exercise increases the body’s ability to adapt or safely respond to periodic bursts of sympathetic stimulation (the body’s reaction to stress, such as a faster heartbeat or a spike in blood pressure), which can trigger cardiac events. Patients who have experienced emotional trauma should surround themselves with family and friends. Staying socially active and maintaining close emotional ties have been shown to lower cardiovascular risks.
Trigger #3: Having sex. According to one widely cited report, about 80 percent of heart attack deaths during or after sex take place in hotel rooms when people are not with their spouses (Japanese Journal Legal Medicine, Sept. 1963). Extramarital sex can cause higher-than-normal levels of arousal, which can elicit marked and sustained increases in heart rate and blood pressure. Preventive strategy: Sex is safer if you exercise regularly. Regular brisk walking appears to prevent the triggering of a heart attack during or immediately after sex. Sex with a regular partner or spouse isn’t risky for people who are physically active. Trigger #4: Watching sporting events. During the World Cup soccer matches in Germany in 2006, there were 2.7 times more cardiac emergencies on the days when the German team played (New England Journal of Medicine, Jan. 2008). When sports fans get excited, their resting heart rate may increase from about 70 beats a minute to 170 beats or more in some passionate individuals. In persons with existing heart disease, this can trigger life-threatening blood clots or potentially lethal heart rhythm irregularities. Preventive strategy: Don’t let the excitement of big games lead you into unhealthy practices – for example, forgetting to take your heart medications…drinking excessively…and/or smoking. Trigger #5: Shoveling snow. When habitually sedentary people engage in unaccustomed, vigorous physical activity, they may be 50 to 100 times more likely to have a cardiovascular event, such as a heart attack. Shoveling snow can cause excessive increases in heart rate and blood pressure that are comparable to maximal exertion on a treadmill. The upper-body movements involved in shoveling are more taxing on the heart than movements involving only the legs. Moreover, breathing cold air can acutely constrict the arteries that supply the heart. Holding one’s breath, muscle straining and mainly standing still while shoveling, all of which impair blood flow to the heart, also can increase cardiac demands. Preventive strategy: Don’t shovel snow if you’re generally sedentary or have been diagnosed with cardiovascular disease or have risk factors (such as high blood pressure or a family history of heart disease). Hire someone to do it for you. If you must shovel, work slowly and for only a few minutes at a time. If possible, push the snow or sweep it rather than lifting it or throwing it. Although using an electric snow thrower will decrease the demands on your heart, our research studies at Beaumont have documented nonfatal and fatal heart attacks, even during automated snow removal!
C A R D I O VA S C U L A R S U R G E RY
Coronary artery disease: The fork in the road Nicholas Tepe, M.D. Division of Cardiovascular Surgery Beaumont Hospital, Royal Oak
The treatment of coronary artery disease (CAD) has markedly improved over the last 25 years. New cholesterol medications and blood lubricants are now common. Coronary angioplasty has become far more effective with the routine use of drug-eluting stents, reducing the likelihood that the blood vessel will clog or narrow again, a condition known as restenosis. We are now able to offer coronary artery bypass grafting (CABG) to virtually any patient. Many CABG patients are well into their 80’s and today, operating on patients with renal failure on hemodialysis is routine. At one extreme are patients with limited CAD requiring only one or two stents. At the other extreme are patients with severe or advanced CAD requiring CABG and complex operations. Between these two black and white examples is a vast gray area of patients with CAD in multiple vessels and sites that
technically could have either multivessel angioplasty or CABG. Often the choice is made on the basis of the complexity of the CAD. Patients with easily accessible lesions may opt for staged angioplasty with procedures done over two or more visits. Patients with complex blockages such as at a branch point or right at the beginning of a vessel or who have completely occluded vessels are usually sent for CABG. For 17 years, the controversy has raged about staged angioplasty or CABG for the treatment of multivessel CAD. Which fork in the road should patients take? Studies have shown that in selected patient groups with multivessel CAD, angioplasty works just as well as CABG over the long term. However, most patients do not fall into this subset. Recently, the comparative effectiveness of these revascularization techniques was reported in patients with advanced CAD and diabetes mellitus. Investigators published the results of the FREEDOM trial (New England Journal of Medicine, Nov. 2012), which was a large randomized trial comparing multivessel angioplasty to CABG in coronary patients with diabetes.
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H E A LT H Y G I V I N G
$1M gift from Pam and Bob Rossiter names cardiac cath suite Richard Ryan Daly Vice President Development-Medical Education Beaumont Foundation
Pam and Bob Rossiter have always been connected to Beaumont. Mr. Rossiter’s parents received their care at Beaumont and his father had bypass surgery here. “As our family gets older, Pam and I wanted to help the hospital and help our community. We believe Beaumont to be the number one hospital in the world,” said Bob Rossiter. 4
The Pamela S. & Robert E. Rossiter Jr. Cardiac Catheterization Suite will be located on the second floor of the Heart and Vascular Center at Beaumont, Royal Oak. This state-of-the-art cardiac catheterization suite will treat patients requiring structural cardiovascular diagnostics and repairs. The suite will feature a collaborative approach to patient care delivered by a team of cardiologists, interventional radiologists and cardiovascular surgeons. “Without investments, you can’t keep pace with others. I want the best care available right here at Beaumont,” said Mr. Rossiter. (continued on next page)
Pam and Bob Rossiter
E X E R C I S E A P P L I C AT I O N S
Beaumont’s Cardiovascular Performance Clinic Justin Trivax, M.D. Staff Cardiologist Beaumont Hospital, Royal Oak
From a high school back-up pitcher to Justin Verlander, or a recreational runner competing in his next half-marathon to Usain Bolt, every athlete wants to perform at his or her best. And while performance may be a top priority for these individuals, physicians (and, oftentimes, family and friends) are more concerned about the health and safety of the athlete engaged in high-volume, high-intensity exercise. Over the last two decades, remarkable technological advances and increased knowledge of the effects of prolonged strenuous exercise, including marathon running, triathlons and long-distance cycling, have allowed us to provide athletes with an accurate assessment of their heart-lung fitness and give each individual a “prescription” to safely improve their physical performance.
electrocardiogram (to examine the electrical activity in the heart), echocardiogram (to evaluate the pumping and valvular function of the heart), cardiopulmonary exercise testing (to determine one’s level of aerobic fitness) and coronary calcium scoring (to assess the likelihood of possible blockages in the arteries feeding the heart). In addition, initial testing may include measures of bone density and body fatness as well as related noninvasive and laboratory evaluations. Health care providers from multiple disciplines, such as dieticians, sports medicine/exercise physiologists and physicians specialized in adult and pediatric cardiology, internal medicine, pulmonary medicine, endocrinology, and rehabilitation, will provide counseling and specific recommendations. (continued on page 12)
Beaumont is pleased to introduce a new Cardiovascular Performance Clinic this fall, offering state-of-the-art diagnostic and physiologic testing and providing athletic counseling and training. All patients will undergo basic cardiovascular testing including an
(continued from page 4)
The purchase of additional diagnostic equipment, including a hemodynamic monitoring system and contrast injector will allow precise, detailed imaging and evaluation of the interior walls of coronary arteries. These diagnostic methods permit the physician to identify arterial plaques in order to develop the most appropriate individualized treatment plans for each patient. Their gift will have a direct impact on nearly 500 patients each year and will ensure that these patients have the safest, most effective cardiovascular therapies possible. “We are deeply grateful to the Rossiters for their spirit of community and their generosity. Their gift will mean
so much for heart and vascular patients at Beaumont,” said Margaret Casey, president, Beaumont Foundation. After 41 years, Mr. Rossiter retired in May 2012 from his position as chairman, CEO and president at the Lear Corporation. Happily retired, Mr. Rossiter said, “I did everything I needed and wanted to do at Lear. Now, Pam and I are so happy to help Beaumont and we’re proud to be part of the Beaumont family.” “We are extremely grateful to Pam and Bob Rossiter for their generous support of the Heart and Vascular Program at Beaumont. With their extraordinary gift, we will be able to build a state-of-the-art cardiac catheterization suite for treating
patients with complex coronary artery and vascular disease. Equipped with a leading edge imaging system as well as an innovative X-ray shielding device, this suite will greatly enhance the care of our patients for years to come,” said Simon Dixon, M.D., health system chair, cardiovascular medicine.
Your gift can also support Heart and Vascular Services at Beaumont Health System. Please give online at foundation.beaumont.edu or call Ryan Daly at 248-551-5318 to discuss your gift today. 5
O B E S I T Y A N D M E TA B O L I S M
Weight loss surgery reduces subsequent health risks Kerstyn C. Zalesin, M.D. Internist, Internal Medicine, Weight Control Center Beaumont Hospital, Royal Oak
Obesity rates have skyrocketed over the last several decades and projections indicate that by the year 2030, up to 42 percent of the U.S. population may be obese, with 11 percent of those suffering from severe obesity (American Journal Preventive Medicine, June 2012). Accordingly, the associated rate of new cases of diabetes and other health risks directly related to obesity has increased disproportionately. Historically, traditional treatment options for obesity, such as diet and exercise, have been generally ineffective and fraught with high rates of failure and weight regain. In recent years, weight loss or bariatric surgery has gained increasing acceptance by the medical community as a unique and powerful tool that favorably modifies digestive anatomy, appetite control and eating behaviors. This intervention enables patients to eat smaller meals and supports the individual in making proper dietary choices owing to intolerance for fatty, greasy or sugary foods. Consequently, weight loss surgery is now recognized by physicians and patients as an effective strategy for treating morbid obesity when used in conjunction with appropriate lifestyle changes. The Beaumont Weight Control Center conducted a study that assessed overall improvement in cardiovascular risk by
Prevention of heart disease with a Mediterranean diet According to a recent report, among persons at high cardiovascular risk, but with no cardiovascular disease at enrollment, a Mediterranean diet supplemented with extra-virgin olive oil or nuts reduced the incidence of major cardiovascular events by approximately 30 percent, as compared with a control group (advice to simply reduce dietary fat). These results support the benefits of the Mediterranean diet for the primary prevention of heart disease. (Source: New England Journal of Medicine, Feb. 2013)
evaluating Framingham 10-year scores on a cohort of obese patients before and after their weight loss surgery (American Journal of Cardiology, Jan. 2007). The Framingham score is a prognostic index that can be used to estimate the likelihood of developing cardiovascular disease over the next decade. Subjects who underwent surgical treatment for their obesity demonstrated significant health improvements, including high rates of remission of type 2 diabetes, as well as reductions in blood pressure and cholesterol. These collective health improvements resulted in a dramatic reduction in Framingham risk scores and demonstrate how surgicallyinduced weight loss can lead to an overall decreased risk for the development of heart disease. At present, weight loss surgery is indicated for persons with a body mass index (BMI) greater than 40 or those with a BMI between 35.0 and 39.9 who are afflicted by related health conditions such as type 2 diabetes, hypertension, heart disease, sleep apnea or advanced arthritis at a weight bearing joint. Nevertheless, surgical weight loss interventions should only be considered after traditional weight loss methods have proven ineffective. Longterm success is dependent on the patientâ€™s ability to adopt the necessary lifestyle changes, which challenges the population to achieve a lifelong commitment to behavior modification.
Register today to attend our FREE seminar about Beaumontâ€™s bariatric surgery program. Call 888-899-4600 or register online.
Simon R. Dixon, MBChB, FACC, FRACP
FROM THE CHIEF
Chair, Department of Cardiovascular Medicine, Beaumont Hospital, Royal Oak
Promising new heart attack treatment: “Supersaturated oxygen” A heart attack is caused by sudden blockage in one of the coronary arteries that supply the heart muscle with oxygenated blood. Prolonged interruption in blood flow causes the muscle cells to die which may weaken the pumping ability of the heart and result in congestive heart failure or death. The most common cause for myocardial infarction (heart attack) is formation of a blood clot at the site of an inflamed atherosclerotic plaque inside the coronary artery tree.
Over the past two decades, we have explored numerous additional treatments that might help prevent permanent damage after a heart attack. One promising new treatment is supersaturated oxygen (SSO2). This therapy is based on the known beneficial effects of hyperbaric oxygen in patients with burns and wounds. The technology (which was developed in Detroit) provides the equivalent of a hyperbaric oxygen chamber, but just to the heart.
MRI of the heart after a large heart
Emergency coronary attack. There is extensive injury in angioplasty and stenting is the front wall of the heart (arrow) the most effective method for relieving the obstruction in the coronary artery and abating the course of the heart attack. The faster the occluded artery can be opened the better, since the longer the heart is starved of blood flow, the more extensive the muscle injury. The amount of muscle damage is the most important factor that will influence a patient’s recovery and future well-being. Occluded LAD artery
SHEATH SSO2 DELIVERY CATHETER
The treatment is delivered after the cardiologist has opened the occluded coronary artery with a stent. Using a small circuit, the patient’s blood is supersaturated with oxygen, and then returned directly into the main coronary artery through a small catheter for 60 minutes. The high level of oxygen appears to improve healing, and has been shown to reduce the size of the heart attack by 25 percent! Beaumont has been one of the few centers in the U.S. pioneering SSO2 therapy and is now leading a new clinical trial with this innovative technology. However, the therapy is not FDA-approved at this time and may not be suitable for all heart attack patients. Nevertheless, for those with large heart attacks, the treatment looks extremely promising.
Memorable heart-healthy quote
“Diabetes and heart disease go hand in hand. Once you’ve got diabetes, you’re going to have heart disease.” – Tim Church, M.D., Ph.D., M.P.H.
Chronic disease and sitting time A recent study of 63,048 men aged 45 to 64 years found that those who sat less than four hours per day were much less likely to report any chronic disease (cancer, diabetes, heart disease, high blood pressure) as compared with those who sat more. Men who sat at least six hours per day had a greater risk for diabetes. Take home message? If you have a desk job, make the effort to take frequent walk breaks – stand while you’re on the phone, and wear a pedometer to motivate yourself to increase daily step totals. (Source: International Journal of Behavioral Nutrition and Physical Activity, Feb. 2013)
PRE VENTIVE C ARDIOLOGY
Preventing your next heart attack: Know your numbers! procedures and/or cardioprotective medications as a first-line strategy to stabilize or favorably modify established risk factors and the course of coronary disease. These therapies do not address the root of the problem, which are the underlying heart disease lifestyle factors such as poor dietary practices, physical inactivity and cigarette smoking.
Georges Ghafari, M.D. Staff Cardiologist Beaumont Hospital, Grosse Pointe
Most patients ask after surviving a heart attack, “What can I do to prevent the next one?” To begin the process of healing and recovery, one must understand the causes of heart disease and the risk factors that contribute to it. need to purchase A heart attack occurs when a coronary artery (about the size of cooked spaghetti) suddenly becomes blocked or obstructed. Oftentimes, this is a result of acute injury to the inner layer of these vessels due to inflammation and blood clotting. Over time, multiple risk factors contribute to the development of heart disease, and most of these risk factors are modifiable. This means a patient can favorably influence their long-term outcomes by aggressively modifying their lifestyle. Unfortunately, many patients as well as the medical community continue to rely on costly heart bypass or angioplasty
It’s been said that, “It takes a village to raise a child.” The same applies to heart disease – it takes a knowledgeable and committed team to prevent and treat heart disease. This includes internal medicine physicians and cardiologists, exercise physiologists, dieticians, pharmacists, spiritual counselors and nurses. However, you (the person you see in the mirror every day) probably have the single greatest influence on your destiny after a heart attack, bypass surgery or balloon angioplasty/ stenting. In addition to medical management, favorably modifying the risk factors shown below will help
decrease your likelihood of having another cardiac event. It’s also recommended that patients with cardiovascular disease have an annual influenza vaccination. Major modifiable risk factors and goals: • blood pressure less than 140/90 • cholesterol numbers: – LDL less than 70 – HDL greater than 40 • obesity – body mass index less than 25 • sedentary lifestyle – regular exercise, four to five days/week • diabetes mellitus – hemoglobin A1c less than seven • s tress reduction – positive attitude/ outlook – respond rather than react to stressful situations • smoking cessation, if appropriate Don’t be afraid to ask questions about the benefits and risks of varied treatment options with your team of caregivers. The key is to ‘know you numbers’ and to favorably modify your risk factors with aggressive lifestyle modification and cardioprotective medications (e.g., aspirin, cholesterol-lowering statins, beta-blockers), if necessary. The challenge is YOURS.
Caloric intake from fast food is decreasing Cardiac rehabilitation: implications regarding patient benefit A recent study clearly demonstrated that cardiac patients with low heart-lung fitness can especially benefit from exercise-based cardiac rehabilitation to improve functional capacity and survival. (Source: Mayo Clinic Proceedings, May 2013)
During 2007 to 2010, fast food from restaurants such as McDonald’s, Burger King and Wendy’s accounted for 11 percent of American adults’ daily calories. That’s lower than it was between 2003 and 2006, when fast food accounted for nearly 13 percent of adults’ daily caloric intake. (Source: National Center for Health Statistics, Feb. 2013)
C ARDIOLOGY BRIEFS
Varicose veins: The blue epidemic Amr Abbas, M.D. Director, Interventional Cardiology Research; Co-Director, Echocardiography Lab
Varicose veins are the most common cardiovascular disease manifestation, exceeding the incidence of heart disease, peripheral artery disease and stroke combined. The condition affects both men and women; however, it is more frequently found in women. Normally, veins have Normal Vein Varicose Vein one-way valves that direct the flow of blood from the feet upward, toward the heart, and from the skin inward, preventing it from Valve Valve Leaky Valve Open Closed leaking backward due to gravity. If these valves become defective, blood may leak backward causing swelling at the ankle, spider and varicose veins and, in advanced stages, skin discoloration and ulcers in the leg. This is known as venous insufficiency.
People who are overweight, work in occupations that require prolonged standing, including physicians, nurses, police officers and teachers, as well as individuals with a family history of varicose veins, are more likely to develop this condition. Treatment is initially directed at wearing compression stockings and decreasing the intake of dietary salt. If this approach fails, leaking veins can be Before Ablation After Ablation collapsed with a long tube that is advanced through them with laser or radiofrequency energy. The procedure is known as endovenous ablation, requires only local anesthesia, takes 30 to 45 minutes and is relatively painfree. The large varicose veins are then either removed through very small incisions or injected with a chemical substance to collapse them.
Disguise your exercise…Work out with your canine companion! Angela Fern, MS Exercise Physiologist, Preventive Cardiology and Rehabilitation Beaumont Hospital, Royal Oak
Looking for ways to spruce up your summer activities? Consider including your dog in your exercise plan and you will both reap the benefits of cardiovascular conditioning and calorie burning. According to the Centers for Disease Control, 35.7% of adults are obese in the United States. Additionally, one fifth of dogs (and cats) are obese per the Association for Pet Obesity Prevention. So, if you and/or your pooch haven’t been very active, check with your physician and your dog’s veterinarian first. Then, start with walking short bouts (e.g., 10-15 minutes) and gradually building up to longer durations. A recent Michigan based study found that “dog walking was associated with more walking and leisure time physical activity” in adult dog owners (Journal of Physical Activity & Health, March, 2011). While exercising outdoors in warm weather, keep in mind these tips from the Humane Society of the United States and the Michigan Humane Society: exercise in the early morning or late evening, bring water for both of you to be well hydrated, and avoid pavement or asphalt that is too hot for your dog’s pads. If you are looking for more variety or a challenge activity with your four legged friend, ponder the following suggestions from the web site Petside.com: hill walking, trail running (ideally on dirt or grass), stair climbing, swimming, disc/Frisbee, rollerblading, cycling, Doga (yoga inspired), and agility/obstacle training. Always keep safety a priority in choosing the right exercise for you and your dog. Enjoy the summer and have fun! 9
COMMON Q & A
Robert N. Levin, M.D. Medical Director Coronary Care Unit Beaumont Hospital, Royal Oak
I am on warfarin (Coumadin) for atrial fibrillation due to a leaking mitral valve. I saw an advertisement for Pradaxa on TV. Can I take Pradaxa in place of warfarin? Although several new agents have been approved and are being investigated as “replacements” for warfarin, there are still some potential pitfalls with the new drugs. The new class of drugs works by blocking a clotting protein known as factor X. The problem with the currently approved drugs is that they are approved only for nonvalvular atrial fibrillation, meaning they are not FDA approved for atrial fibrillation due to valvular heart disease. A positive finding was that all of these drugs had a lower rate of hemorrhagic (bleeding) stroke compared to warfarin. The initial studies with dabigatran (Pradaxa) showed efficacy similar to warfarin, with some excess heart attacks.
One potential drawback to these drugs is the inability to reverse them if there is a bleeding problem. This is currently being addressed with further research, but has not yet been solved. Other drugs in this class include rivaroxaban (Xarelto), which has been studied in both heart attacks and in nonvalvular atrial fibrillation and is FDA approved. An even more promising agent was recently approved, and this drug is called apixaban (Eliquis). In a large study known as the ARISTOTLE trial, apixaban was found to be superior to warfarin in preventing stroke or embolism (clot which travels to the brain), caused less bleeding and resulted in a lower mortality rate. At this point, anti-X or anti-Xa agents are not a viable alternative for patients with mechanical (metallic) heart valves; these patients should remain on warfarin. I’d suggest you have a discussion with your cardiologist regarding the optimal blood thinner in your situation.
CLINIC AL C ARDIOLOGY
Renovascular hypertension: Causes and lifestyle treatment strategies Dinish Shah, M.D. Staff Cardiologist Beaumont Hospital, Royal Oak
Over time, cholesterol and calcium deposition (plaque) may slowly narrow or even block the renal (kidney) arteries. Renal artery stenosis (RAS) involves a narrowing or blockage of the artery that supplies blood to the kidneys, reducing its blood supply. The kidneys mistakenly respond as if the blood pressure is low and release hormones that result in the body retaining salt and water. This causes your blood pressure to rise.
• hypertension at a young age • high blood pressure that suddenly worsens • evidence of acute kidney malfunction • sudden buildup of fluid in the air sacs of the lungs (pulmonary edema)
Another cause of RAS is fibromuscular dysplasia. It is often observed in women under age 50 and tends to run in families. It is due to abnormal growth of cells in the walls of the arteries leading to the kidneys.
Your doctor may hear a “whooshing” noise, called a bruit, when placing Artery a stethoscope over your belly area and/or order a variety of blood tests when RAS is suspected. Imaging tests may also be performed to detect if the kidney arteries have narrowed. These may Artery include doppler ultrasound Plaque of the renal arteries, magnetic resonance studies Kidney and renal arteriography.
People with renovascular hypertension may have a history of extremely high blood pressure that is difficult to control with conventional medications. Adverse signs or symptoms may include:
In patients with RAS, medications are often needed to help control blood pressure. There are numerous high blood pressure medications that are currently available. Your doctor will decide which
type is best for you. Oftentimes, more than one medication may be needed. Lifestyle changes are also critically important in favorably modifying blood pressure. Eat a heart-healthy diet; exercise regularly, at least 30 minutes a day (check with your doctor before starting); and, if you smoke, Kidneys quit. Limit the amount of alcohol you drink: one and two drinks a day for women and men, respectively. Also, restrict the amount of sodium (salt) you consume; aim for less than 1,500 mg per day. Try to avoid situations that create stress. Meditation or yoga may be helpful in this regard. Finally, if you are overweight or obese, recognize that blood pressure may be adversely affected. Sensible caloric restriction, structured exercise and increased lifestyle activity may have antihypertensive effects.
E X E R C I S E A P P L I C AT I O N S
Women Exercising to Live Longer: Beaumont’s WELL Program Megan Donnelly, B.S. Exercise Specialist, Preventive Cardiology and Rehabilitation Beaumont Hospital, Royal Oak
Thanks to the efforts of national awareness campaigns, most women understand their increased risk of developing breast cancer. Yet, more women die every year from heart disease than from all cancers combined. According to the National Institute of Health, one in 30 women dies of breast cancer in the United States every year, whereas one in four dies from heart disease (The Healthy Heart Handbook for Women, 2007). Unfortunately, heart disease is still widely considered a man’s disease. Women who seek to improve their own heart health should consider adding a moderate intensity exercise regimen into their weekly routine. Exercise is a key intervention in reducing the risk of developing heart disease or preventing potentially fatal cardiovascular events, such as a heart attack or stroke. Regular aerobic exercise can modestly decrease cholesterol, blood pressure, fasting blood glucose
and weight, as well as increase energy levels, walking, biking, jogging, rowing, rollerblading) for at least 30 minutes per self-confidence and sound sleep. Moreover, session. If too taxing, the exercise can be it appears that women who are generally broken up into shorter inactive and/or unfit Remember: bouts of about 10 stand to gain the “A journey of 1,000 miles minutes each, until 30 or greatest benefit begins with the first step.” more minutes has been from implementing completed. At the end of (and maintaining) an your exercise, gradually cool down for five exercise program. However, if you are a to10 minutes by continued slow novice exerciser, you should consult your movement, until your heart rate returns to physician before implementing a vigorous within 10 beats of your resting heart rate. physical activity regimen. The American College of Sports Medicine recommends exercising at least 30 minutes, five or more days per week (Medicine & Science in Sports & Exercise, July 2011). Exercise should begin with a preliminary warm-up of five to 10 minutes to stretch muscles, enhance range of motion and gradually increase your heart rate for the aerobic or endurance phase. Warm up can be performed on a stationary bicycle or treadmill, but at a lower intensity than you normally use for the aerobic phase. If you are walking outside or in a mall, start slowly, gradually increasing your pace. Once the body is warmed up, engage in moderate-to-vigorous cardiovascular exercise (i.e.,
Oftentimes, women are afraid to begin an exercise routine because they don’t know where to start. However, taking action is the key to success. If you’re at risk for heart disease (e.g., overweight, high blood pressure, elevated blood cholesterol, diabetic) and want to improve your heart health, consider enrolling in Beaumont’s WELL program. This free program empowers selected women to exercise at least three days per week under the supervision of our cardiac rehab staff.
For more information about the W.E.L.L. program, call 248-655-5781.
Walking versus running for reducing coronary risk Using data from the National Runners’ and Walkers’ Health Study, investigators recently reported that equivalent energy expenditures by moderate-intensity exercise (walking) and vigorous exercise (running) produced similar risk reductions for the development of high blood pressure, elevated cholesterol and diabetes mellitus. These results should be used to encourage physical activity in general, regardless of its intensity. However, walkers would be required to devote more than twice the exercise duration (time) to achieve comparable risk factor reductions. (Source: Arteriosclerosis, Thrombosis, and Vascular Biology, Apr. 2013)
The fork in the road
STATE OF THE HEAR T LINE-UP
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When followed for five years, the CABG group demonstrated a 30 percent greater reduction in death and heart attack, when compared with the angioplasty group. CABG showed a clear advantage over angioplasty in this large patient subset; however, stroke was more frequent in the CABG group. The accompanying editorial suggested that cardiologists discuss these findings with their coronary patients with diabetes before performing a diagnostic and interventional cardiac catheterization. So, which fork? CAD is a chronic disease. Angioplasty and CABG are not mutually exclusive. You may need both over the long course of treatment for CAD. Early on, your treatment may be medications alone. Later, as blockages appear, one or more angioplasties may be done. If the disease progresses, CABG may be your best choice. If you are diabetic, the option for CABG should be offered earlier. In any event, talk to your cardiologist. Heed warning signs or symptoms suggesting progression of your heart disease, and keep your options open.
Cardiovascular Performance Clinic
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Our experienced physicians will provide pre-participation physicals for student, amateur, and professional athletes with and without known heart disease or structural cardiovascular abnormalities, as well as individuals with a pacemaker or implantable defibrillator who want to continue to play sports. Our physicians will also serve as a resource for other cardiologists to provide the safest exercise recommendations for our patients. By providing these services, the Cardiovascular Performance Clinic aims to assist the escalating number of recreational athletes seeking to improve their performance, while maximizing the benefits and reducing the associated risks of vigorous and high-intensity competitive exercise. We look forward to bringing this exciting new resource to you later this year.
Warning: erectile dysfunction drugs and nitroglycerin may be hazardous to your health Drugs used for the treatment of erectile dysfunction (such as Viagra or Cialis) taken along with nitroglycerin (spray or tablet) can lead to extreme relaxation of blood vessels and, in some patients, a dangerous drop in blood pressure. Thus, nitroglycerin use in conjunction with these medications is strictly prohibited. (Source: Circulation, June 2013)
Editor-in-chief: Barry Franklin, Ph.D. Co-editor: Simon Dixon, M.D. Associate editor: Robert Levin, M.D. Managing editor: Brenda White PANEL OF EXPER TS Clinical Cardiology: Aaron Berman, M.D.; Terry Bowers, M.D.; William Devlin, M.D.; Harold Friedman, M.D.; Andrew Hauser, M.D.; Robert Levin, M.D.; Steven Timmis, M.D.; Douglas Westveer, M.D.; David Forst, M.D. Interventional Cardiology: Steven Almany, M.D.; Nishit Choksi, M.D.; Phillip Kraft, M.D.; George Hanzel, M.D.; Dinesh Shah, M.D. Nursing: Steve Albertus, R.N.; Kathy Faitel, R.N. Pharmacology: Heidi Pillen, PharmD. Exercise Physiology/Fitness: Angela Fern, M.S.; Kirk Hendrickson, M.S.; Amy Fowler, B.S.; Jenna Brinks, M.S. Geriatrics: Michael Maddens, M.D.; Cindy Haskin-Popp, M.S.. Psychosocial Issues: Dan Stettner, Ph.D.; Gene Ebner, Ph.D. Electrophysiology: David Haines, M.D. Diagnostic Testing/Nuclear Medicine: Darlene Fink, M.D.; Ralph Gentry, R.T. (R) (MR) (CT); Gilbert Raff, M.D. Cardiovascular Surgery: Marc Sakwa, M.D.; Frank Shannon, M.D.; Nicholas Tepe, M.D. Obesity, Diabetes, Metabolism: Wendy Miller, M.D.; Kerstyn Zalesin, M.D. Enhanced External Counterpulsation Therapy: Anne Davis, R.N.; Joyce Said, M.S.
Excess salt blamed for cardiovascular deaths worldwide Salt intake worldwide is at least twice what it should be, with a negative impact on global cardiovascular health, researchers reported. Daily sodium intake averaged 3,950 milligrams (mg) in 2010, according to an analysis covering all of the worldâ€™s population. The recommended daily intake is 2,000 mg by World Health Organization standards and 1,500 mg by American Heart Association guidelines. The impact of the excess dietary sodium: an estimated 2.3 million deaths from cardiovascular disease in 2010 alone. These findings highlight both the tremendous disease burden caused by sodium as well as the need for food industry and policy makers to take rapid and decisive actions to reduce sodium in the food supply. (Source: American Heart Association Nutrition, Physical Activity and Metabolism and Cardiovascular Disease Epidemiology and Prevention meeting, March 2013)
Womenâ€™s Issues: Pamela Marcovitz, M.D.; Melissa Stevens, M.D.; Megan Donnelly, B.S. To receive the State of the Heart e-newsletter, opt in at heart.beaumont.edu or scan our code below.
From Beaumont Physicians and Allied Health Professionals