From Beaumont Physicians and Allied Health Professionals
S TAT E O F T H E
Spring Issue 2018
How do you heal a broken heart? 100 and she did not appear distressed. I made plans for her to return for an echocardiogram on Monday morning. Daniel Walsh, M.D. Her labs later that afternoon demonstrated findings consistent Staff Cardiologist with a recent myocardial injury. She was then admitted to the Beaumont Hospital, Royal Oak hospital for an echocardiogram and invasive heart catheterization. She was somewhat reluctant to go to the hospital as it was her 87th birthday and she had plans to attend her grandson’s graduation from Michigan State University the following day. A Case study: On a spring Thursday evening in 2011, I received Her heart catheterization the following Monday demonstrated a call from one of our patients. She had called because she was no significant coronary artery obstruction. worried her blood pressure was unusually low However, her ejection fraction (volume of (75/50 mmHg) and she was having some blood pumped out with each beat, normally shortness of breath. She initially denied any greater than 55 percent) was only 25 percent, chest pain but admitted to some vague chest with a large area of the left ventricle that discomfort. She had not eaten or had much lacked motion and was dilated. to drink during the day. She had what is known as Takotsubo's I told her to hold off on the only medication cardiomyopathy. Takotsubo is a Japanese that she took for hypertension. She was fishing pot used to trap octopus. It has a very encouraged to drink some fluids. Her narrow neck and a wide round bottom. This is symptoms of the vaguely described malaise the shape that the left ventricle assumes began during a talk she had given at a middle during systole (contraction) in this condition. school where her daughter is a speech Patients with this syndrome commonly pathologist. She had given this same lecture present with chest discomfort, shortness of for several years. breath and often with hypotension (low blood She called me back one to two hours later pressure) from an inadequate cardiac output. to report she felt a little better and her ECG changes suggestive of inadequate systolic blood pressure had risen to the mid blood and oxygen delivery to the heart 90's. She did not wish to go to the Emergency muscle or heart attack (myocardial infarction) Center. She reported no other new symptoms What is the relationship between are typical. Echocardiography images and was told to come into the office Friday our minds and our hearts? suggest a large myocardial infarction. morning to check her labs and Do our emotions affect the Laboratory studies of cardiac biomarkers electrocardiogram (ECG). function of our hearts? typically show small cardiac enzyme leaks. I saw her as my last patient just before the This syndrome was first described in a Can grief be measured? office would close. She was a delightfully series of elderly Japanese women in 1990. charming 87 year old woman, looking much Does time heal all wounds? The syndrome classically occurs in older younger than her stated age. Speak, memory? women who have had some stressful event Unfortunately, her ECG did indeed reveal in their life, such as the death of a spouse. The human family really a significant change from one recorded Another name for this syndrome is has remarkable stories of previously. She had had a negative workup for bravery, resilience, fortitude, “Broken Heart Syndrome.” coronary artery disease in the prior five years. courage and love. (continued on page 2) Her systolic blood pressure hovered around CLINICAL CARDIOLOGY
INSIDE THIS ISSUE 1
Cardio-resistance exercise training
EECP: A noninvasive approach to treating symptomatic heart disease
What’s the latest in cholesterol therapy? How low is too low?
Exercise wastes heartbeats: Fact or fallacy?
Exercise as a treatment for peripheral artery disease: A new covered benefit
Vitamin supplements and a healthy heart
Garrett Van Camp still road racing at 80
New guidelines for high blood pressure
How do you heal a broken heart?
Can physical exertion trigger an acute cardiac event?
Common Q & A
EECP: A noninvasive approach to treating symptomatic heart disease Anne Davis, RN Preventive Cardiology and Rehabilitation Beaumont Hospital, Royal Oak
The American Heart Association’s cornerstone treatment for patients with stable ischemic heart disease remains “optimal medical therapy,” specifically cardioprotective medications and lifestyle modification, including diet, regular exercise, smoking cessation and stress management. When this option fails, the health care team considers revascularization techniques such as bypass surgery or percutaneous coronary intervention (angioplasty), with or without stenting. The decision for determining the best plan of care is complicated. Many factors must be considered in evaluating overall surgical risk status, including the number and location of coronary artery blockages, heart function (e.g., ejection fraction), patient anatomy, previous attempts at revascularization, body habitus (e.g., obesity), related co-morbid conditions (e.g., diabetes) and of course, patient preference. In cases where surgical intervention is not advised and patients remain symptomatic with chest pain, chest
How do you heal a broken heart?
pressure or shortness of breath despite maximal medical therapy, enhanced external counterpulsation, or EECP®, is another treatment option to consider. There have been more than 190 reports published since 1992, including eight randomized controlled studies that support EECP as a safe, highly effective anti-anginal treatment. In a large study completed by The International EECP Patient Registry, 70 to 80 percent of patients that completed the prescribed number of EECP sessions, reported a decrease in their anginal symptoms, decreased nitroglycerin use and increased activity tolerance, lasting up to three years or more. EECP is a noninvasive outpatient therapy and consists of 35, one hour sessions, over the course of seven or eight weeks. Patients lie on a Fig. 1: Myocardial perfusion imaging pre and post EECP
comfortable treatment table, with pressurized cuffs to the legs and hips, which inflate sequentially from the ankles up, transiently increasing the pressure and blood flow to the coronary arteries (see photo above). Presumably, this physiologic cascade stimulates the formation of tiny new blood vessels that can more adequately supply oxygenstarved heart muscle (Fig. 1). Side effects are minimal and the treatment time commitment may, in some instances, be life changing. Most insurance companies, including Medicare, cover this treatment for patients with diagnosed angina. If you think you qualify, discuss this option with your physician. A cardiologist referral is required. Beaumont has treatment sites in Royal Oak and Farmington Hills. For more information, call 248-655-5750.
fellow Jews would be stacked floor to ceiling. Their job was to take the clothes apart seam by seam to find the jewelry that was often To understand more about the patient’s clinical presentation hidden in them as a potential bribe for survival. Every day they a more thorough social history needs to be provided. Her physical would fill boxes full of jewels. Men's coats would have diamonds examination outside of her cardiac exam was most notable for hidden in the linings. a tattoo on her left forearm. The tattoo included the following They had to uncover the buttons that could hide gold coins. characters: A-6733. It had been placed there by a German One of the coats she took apart belonged to her father and tattoo artist in 1944. The A stands for Auschwitz. that is how she knew he was gone. Nothing left of him but the She had given lectures to middle school students for several coat and the acrid smell of burning flesh that wafted over from years regarding the 13 months she spent in the crematorium. They were told they would Is it possible for such a 1944-1945 at a concentration camp in Poland. never survive since, “They had seen too much, memory to cause her heart After Dr. Josef Mengele chose her and her heard too much, knew too much.” to fail 76 years later? sister for a special group of women to have In January 1945, with the Russians closing in a particular job at the camp, she cajoled her mother from the East, she and her coworkers were to join the group − all three of whom survived the war. She would sent on a “Death March.” Those who could not go on walking often give her slice of bread for the day to her mother or sister. were shot and left by the side of the road. She managed to The job these 150 women had at the camp was to work in steal from her job a man's coat and shoes and somehow a large barn next to the crematorium. The clothes of their survived to the next camp. (continued on page 12)
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Barry A. Franklin, Ph.D.
FFRRO OM M TTH HEE EED DIITTO ORR
Director, Preventive Cardiology and Rehabilitation Beaumont Hospital, Royal Oak
Exercise wastes heartbeats: Fact or fallacy? The heartbeat bank notion ignores an important Recently, I read a common question (Q) posed to an elderly adaptation that occurs with regular exercise training: Chinese physician, but it was his perplexing response/answer The conditioned heart beats at a slower rate at rest and (A) that got my attention. during any level of exercise, pumping more blood with Q: Doctor, I’ve heard that cardiovascular exercise can each beat. Thus, being physically fit can actually save prolong life. Is this true? you thousands of heartbeats each day. A: “Heart only good for so many beats, and that it… To borrow an idea from economics, exercise is like an Don’t waste on exercise. Everything wear out eventually. investment. Yes, you spend money to invest, but the Speeding up heart not make you live longer; it like investment lasts a long time and pays you dividends. saying you extend life of car by driving faster. Want to For example, a vigorous daily one-hour live longer? Take nap.” exercise program may require an increase Along these lines, many years ago, Don’t worry about the of 5,000 heartbeats (investment) a day Peter J. Steinchron, M.D., author of old ticker “wearing out” compared to rest. But the cardiovascular several books and a syndicated prematurely as a result fitness (dividend) produced by the newspaper column on medical problems, of regular exercise. training will require fewer heartbeats for offered the theory of a “heartbeat bank.” Improved fitness will routine physical activities. On average, It holds that each of us is born with a actually save you the savings is 10 beats per minute. given number of heartbeats (generally approximately 3 million At day’s end you have performed your two to three billion) in his or her heartbeats each year! other activities with a savings of 13,800 heart bank. beats. The net savings is 8,800 beats a A person born with a small bank day and more than 60,000 beats a week. account “should not indiscriminately That’s an excellent return on your throw away those beats in unnecessary exercise investment. exertion known as exercise,” he said. The bottom line, as astute Steinchron suggested that one should physiologists say, is: Don’t worry about ration his/her heartbeats, taking the old ticker “wearing out” prematurely afternoon naps instead of exercise, as a result of regular exercise; improved because once heartbeats are withdrawn, fitness will actually save you they are lost forever. No doubt his advice approximately three million heartbeats comforted millions of inactive adults each year! Moreover, these data and at the time. other scientific reports (British Medical To my knowledge, however, no Journal, Feb. 2009; Mayo Clinic Proceedings, Dec. 2013) scientific evidence supports the notion that a person has a suggest that a lower resting heart rate serves as an limited bank account of heartbeats. But if one wished to prove independent predictor of health and longevity. The notion that regular exercise contributes to longevity, it would be nice that regular exercise wastes heartbeats is a fallacy. if there were a heartbeat bank.
Supervised exercise therapy for patients with peripheral artery disease Peripheral artery disease (PAD) is a circulatory condition caused by atherosclerosis that narrows and blocks arteries in various regions of the body, most notably the lower extremities. The most common symptoms of PAD involving the leg or hip muscles are cramping, pain or tiredness while walking or climbing stairs. PAD affects 12 to 20 percent of Americans age 60 and older. Recently, the Centers for Medicare and Medicaid decided that symptomatic patients with PAD will now be able to receive supervised exercise therapy as a covered benefit through Medicare. Why? Because recent evidence has shown that this therapy can improve quality of life for patients with PAD and enhance clinical outcomes. (Source: American Heart Association/American Stroke Association news release, May 2017)
N U T R I T I O N A L C O N S I D E R AT I O N S
Vitamin supplements and a healthy heart Steven Ajluni, M.D.
Vitamin E, selenium) may even be harmful with reports of increased bleeding risk and carcinogenic effects (Nature Reviews Endocrinology, July 2016). While supplementation above and beyond our bodyâ€™s needs is unsubstantiated, it is reasonable that if someone is vitamin Many patients use vitamin and mineral supplements in the or mineral deficient, due to unhealthy dietary habits and/or hope of living healthier, longer lives. Our patients frequently metabolic derangements, they may benefit by taking adjunctive come to their office visits with a list of supplements that they agents to normalize these insufficiencies. Vitamins and minerals take or plan to use to either complement their medication in adequate quantity are essential for healthy living. Examples regimen or serve in lieu of prescribed medications. It is not include vitamins B12, A and D. In our society, uncommon for patients to seek â€œnaturalâ€? however, deficiencies are typically uncommon alternatives to pharmaceutical agents. with a normal diet. Exceptions may include Although the medical community supports individuals who are malnourished the goal of minimizing medications, one or unable to absorb necessary vitamins Most supplements have needs to remember a few important secondary to a metabolic or digestive not been evaluated by facts when considering this strategy. anatomic anomaly, for example, colitis rigorous scientific trials The first is that this approach is already or gastrointestinal bypass. It is also known to validate that they highly prevalent. The vitamin/mineral that taking vitamins and minerals through actually provide all the supplement industry involves over an endogenous diet (i.e., consumption benefits that they $30 billion in sales annually and more than of food) is preferable to exogenous vitamin claim to do. half of all adults report using at least one supplements (due to limitations in the supplement. In addition, over 10 percent of adults absorption of exogenous supplements use more than 4 supplements (Journal of the compared with food ingestion). American Medical Association, Oct. 2016 and Feb. 2018). To summarize, among United States adults While most supplements (in reasonable quantities) convey consuming a normal diet with no abnormalities of little risk to the patient, only limited data are available on their gastrointestinal function, it is exceedingly unlikely to be deficient potential benefits. Part of the information gap relates to how in vitamin and mineral intake. The salutary impact of extra supplements are marketed and sold under the auspices of the supplementation, if any, is largely unknown. Sometimes potential Food and Drug Administration (FDA). Efficacy (the validation cardioprotective benefits such as those previously ascribed to of benefit in using a particular additive) is not typically a vitamin E, folic acid, beta carotene and, more recently, fish oil, requirement placed on manufacturers of supplements which have failed in controlled studies to show the benefit that was are classified by the FDA as essentially a food. The only burden anticipated. There may be other as yet unknown benefits in as such before they can be sold is the need to prove safety in taking supplements (theoretical benefits on boosting immune ingestion of reasonable quantities. In fact, most supplements function or functioning as antioxidants) but only time and further have not been evaluated by rigorous scientific trials to validate research will define their therapeutic effects. For now, focusing that they actually provide all the benefits that they are on supplementation only when there is proven deficiency seems purported to do. A few agents (e.g., folic acid, beta carotene, to be the most prudent strategy. Interventional Cardiologist Beaumont Hospital, Troy
Alcohol drinking patterns and risk of diabetes Recently, researchers reported on alcohol consumption and the risk of developing diabetes in a large cohort of men and women from the general Danish population over a five year follow-up. They found that light to moderate alcohol consumption was associated with a lower risk of diabetes, as compared with no alcohol consumption. Interestingly, frequent consumption of alcohol was associated with the lowest risk of diabetes. Similarly, another recent analysis of 13 different studies reported that wine consumption was associated with a significantly lower risk (~20 percent) of Type 2 diabetes. (Source: Diabetologia, July 2017; Journal of Diabetes Investigation, Jan. 2017)
FFRRO OM M TTH HEE ECD HIITEO FR
Simon R. Dixon, MBChB
Chair, Department of Cardiovascular Medicine; Professor, OUWB School of Medicine Dorothy Susan Timmis Endowed Chair of Cardiology
New guidelines for high blood pressure Management of hypertension
Over the past decade, the management of high blood pressure (hypertension) has been one of the most hotly contested subjects in the field of cardiovascular medicine, especially regarding the threshold to treat, best drugs and optimal treatment goals. In November 2017, the American College of Cardiology and American Heart Association released new guidelines for the prevention, diagnosis and management of hypertension. Because you should be aware of these new recommendations, let’s review a few of the key changes.
1. High blood pressure needs to be treated earlier. 2. Lifestyle changes are critical to the effective management of hypertension. This includes a heart healthy diet (such as the Dietary Approaches to Stop Hypertension [DASH] diet), limiting sodium intake (<1500 mg daily), regular exercise, limiting alcohol consumption and weight loss. For example, a 10 pound weight reduction can achieve a similar decrease in blood pressure to some medications.
Diagnosis of Hypertension 1. The new definition for high blood pressure is ≥130/80 millimeters of mercury (mmHg) instead of ≥140/90 mmHg and the term pre-hypertension is no longer used. 2. The new blood pressure categories are (Table 1): normal=systolic <120 mmHg and diastolic <80 mmHg elevated=systolic 120-129 mmHg and diastolic <80 mmHg stage I hypertension=systolic 130-139 mmHg, or diastolic 80-89 mmHg stage II hypertension=systolic 140 mmHg or higher, or diastolic 90 mmHg or higher hypertensive crisis=systolic >180 mmHg and/or diastolic >120 mmHg 3. The use of home blood pressure monitoring is emphasized for diagnosis of hypertension. This new definition means that 46 percent of the U.S. population has high blood pressure. However, there will only be a small increase in the number of people who need medications – for many patients lifestyle changes are all that will be required. Table 1: Blood Pressure Categories
3. The need for blood pressure lowering medications depends on the stage of hypertension and patient’s estimated risk of cardiovascular disease. Most people with stage II hypertension will need medication. Some patients with stage I hypertension will also need medications including those who have had a heart attack or stroke or patients with diabetes or chronic kidney disease. 4. Many patients will need two or more medications to control their blood pressure. 5. The treatment target for most patients with hypertension is now <130/80 mmHg. Indeed, the SPRINT (Systolic Blood Pressure Intervention Trial), randomized, controlled study which evaluated non-diabetic, hypertensive patients older than 50 years of age who were at high cardiovascular risk, showed that aggressively treating patients to a systolic blood pressure of less than 120 mmHg was superior to the former goal of 140 mmHg in further reducing fatal and nonfatal cardiovascular events and death from any cause (New England Journal of Medicine, Nov. 2015). In summary, hypertension is a silent disease and a major cause of congestive heart failure, stroke and heart attack. These new guidelines are the most significant change in the field since 2003 and strongly emphasize the importance of earlier diagnosis and more aggressive intervention to prevent long-term complications of this disease. For additional information, see your cardiologist or primary care physician. The American Heart Association website is also a useful resource.
BLOOD PRESSURE CATEGORY
SYSTOLIC mm Hg (upper number)
DIASTOLIC mm Hg (lower number)
LESS THAN 120
LESS THAN 80
LESS THAN 80
HIGH BLOOD PRESSURE (HYPERTENSION) STAGE 1
HIGH BLOOD PRESSURE (HYPERTENSION) STAGE 2
140 or HIGHER
90 OR HIGHER
HYPERTENSIVE CRISIS (consult your doctor immediately)
HIGHER THAN 180
HIGHER THAN 120
E X E R C I S E A P P L I C AT I O N S
Cardio-resistance exercise training Kirk D. Hendrickson, M.S.
during CWT, which can last up to 24 hours or more, depending on the intensity and duration of exercise. Although CWT has advantages over traditional aerobic endurance training, it may not be for everyone. Individuals with orthopedic limitations may not tolerate the resistance exercises. Additionally, those with balance problems may be at risk for falls due to the frequent changing of exercises and varied The American College of Sports Medicine (ACSM) recommends movements. With CWT, the hemodynamic response to exercise that adults participate in a minimum of 150 minutes per week of may also be exaggerated, eliciting higher heart rates and blood moderate-intensity aerobic exercise and/or 75 minutes per week of pressures than expected. vigorous exercise to maintain good health (Medicine and Science For those who want to attempt cardio-resistance exercise, in Sports and Exercise, July 2009). The ACSM also recommends a qualified exercise professional is recommended to demonstrate two to three days per week of strength training exercises for the proper form and techniques. A gradual aerobic warm-up of major muscle groups (see Activity Pyramid). Strength training 10 to 15 minutes should precede the circuit. Participants should can minimize the effects of aging and reduce the likelihood of assess their heart rate to remain within the functional impairment by countering the loss Circuit weight training (CWT) prescribed training zone and monitor for of muscle mass, strength and endurance over combines resistance exercise signs or symptoms of exercise intolerance time. Although regular exercise has been interspersed with short such as chest discomfort, shortness of shown to improve health, less than 25 percent breath, palpitations or lightheadedness. of the adult population in the U.S. achieves bouts of aerobic exercise Start slow and progress gradually over time these recommendations. One way to potentially using the treadmill, to allow your body to become acclimated enhance exercise adherence is to design stationary cycle ergometer to CWT. Accordingly, the duration of rest physical conditioning programs that are both or elliptical machine. breaks between exercises can be initially effective and efficient. lengthened. Finally, take time to get on and off aerobic exercise A method of training that has gained popularity is cardioequipment safely between resistance exercises. resistance exercise, also known as circuit weight training (CWT). Cardio-resistance exercise training is a novel way to obtain This approach combines resistance exercise interspersed with concomitant improvements in muscle strengthening and aerobic short bouts of aerobic exercise using the treadmill, stationary cycle endurance, while simultaneously reducing risk factors for heart ergometer or elliptical machine. Resistance exercises are disease, including high blood pressure, elevated cholesterol and performed in a series or circuit employing different muscle groups obesity. The added variety may also serve to combat while using oneâ€™s own body weight or light dumbbells. Exercisers boredom and enhance adherence. are advised to complete 15 to 20 repetitions (reps)/set, or a timed set with a short rest between exercises, alternating between upper and lower body or push and pull movements such as the chest press or rowing. This allows for recovery Occasional of one muscle group while another is completing the TV, next exercise. The load chosen should be lighter in computer games order to complete the 15 to 20 reps/set or a timed set of 20 to 30 seconds. Short bursts of aerobic exercise lasting three to five minutes can be completed intermittently between resistance exercises. Sports Active Leisure In addition, core exercises, such as crunches Squash, Swimming, 2-3 days/week or planks, can be added to the routine. touch football, weight lifting, Some studies have reported greater tennis, etc. gardening increases in endurance, decreases in resting blood pressure and reductions in body weight and fat stores during CWT as compared with traditional Do planned aerobic activities aerobic training programs such as Accumulate a total of 30 minutes: walking or biking. The mechanism Walk 3-4 km (total). Bike 12-16 km (total). that may be responsible, Row. Stair climb. Ski (cross country). Paddle. at least in part, is the increase in metabolism that occurs Exercise Physiologist, Preventive Cardiology and Cardiac Rehabilitation Beaumont Hospital, Royal Oak
Increase incedental activity
Regard movement as an opportunity not an inconvenience; Take extra steps in the day. Take the stairs. Mow the lawn. Walk the dog. Park the car and walk. Donâ€™t use remote controls.
What’s the latest in cholesterol therapy? How low is too low? Aaron Berman, M.D. Associate Chief Medical Officer and Clinical Chief, Cardiovascular Medicine Beaumont Hospital, Royal Oak
In 1982, the treatment of coronary artery disease (CAD) was revolutionized with the Food and Drug Administration (FDA) approval of the first statin drug to lower cholesterol in patients, lovastatin. Since then, numerous statins have been approved and there is incontrovertible evidence that these medications decrease the risk of heart attack and cardiac death in patients with CAD. Although severe complications of statin therapy are rare, some patients develop troublesome muscle pains on these agents. In addition, and perhaps more importantly, there is still residual risk of heart attack even in patients on statin therapy with cholesterol considered to be “well controlled.” Contemporary recommendations include maintaining the low-density lipoprotein (LDL) less than 70 mg/dl in high risk patients, and less than 100 in lower risk patients. Is this low enough? In recent years a new class of cholesterollowering drugs, called PCSK9 inhibitors, have been extensively evaluated. This class of drug works by binding the enzyme which breaks down the LDL receptor, so that more LDL receptors remain on cell surfaces. More surface LDL receptors equals less circulating LDL, which is considered a main culprit in the progression of plaque buildup in coronary arteries. These drugs had already been approved for use in patients with familial hypercholesterolemia. However, on Dec. 1, 2017, the FDA approved the use of these medications alone or in combination with other cholesterol-lowering medications to reduce the risk of heart attack in patients with CAD. This approval came on the strength of the FOURIER trial (New England Journal of Medicine, May 2017), a study of over 27,000 patients with CAD. Half of the patients were treated with
statins, and the other half received a PCSK9 inhibitor called evolocumab added to usual therapy. The achieved LDL value in the study group was very low, in the 30’s, much lower than that usually attained with statins (mean LDL in the statin arm of the study was 92 mg/dl). At a 2.2 year follow-up, patients on evolocumab demonstrated a 27 percent reduction in the risk of heart attack, a 21 percent decrease in stroke risk and had fewer coronary revascularization procedures (stent or bypass surgery) than patients in the conventional therapy arm. Given this information, the FDA moved forward and approved these medications. It appears that the additional reduction in LDL cholesterol further decreases the “residual risk” left over by statin therapy. Side effects of the PCSK9 inhibitors were modest, including occasional irritation at the injection site, with rare reports of more generalized allergy. One common concern among patients is the risk of cognitive impairment. Although never proven, some patients on statins complained of impaired thinking. A detailed assessment of patients in earlier high dose statin trials as well as an evaluation of patients in the FOURIER trial showed no change in cognitive function in patients with very low LDL levels. There continues to be controversy about “how low to go” with LDL cholesterol. A lot of it depends on your personal burden of cardiac risk factors. One point of interest is that there are patients with genetic variants in the PCSK9 enzyme wherein the enzyme functions poorly; these individuals have very low LDL cholesterol levels and have very low cardiovascular risk and are otherwise healthy. The PCSK9 inhibitors mimic this genetic variant by destroying PCSK9. In many trials, there do not seem to be any safety signals suggesting harm in very low LDL values. So, what’s the downside? These drugs are taken by injection, either every other
week or once a month and there can be some injection site irritation. The injection syringe itself is pre-filled and relatively easy to use. A bigger concern is the cost, which is currently in the $1,200 dollar per month range, depending on your insurance. If you have CAD and cannot tolerate statin therapy, these drugs may be lifesavers. Also, if you have CAD and tolerate statins but have additional risk factors such as diabetes, or cannot get your LDL to target goals, additional benefit may be obtained by complementing your statin therapy with a PCSK9 inhibitor. A frank discussion with your physician to review your risk and whether the current cost of these drugs is warranted should be undertaken. The answer to “how low can you go” may not be available for years. Based on current information, it seems that lower is better, and PCSK9 inhibitors, perhaps in conjunction with statins and a heart healthy lifestyle, may be the way to go (Trends in Cardiovascular Medicine, Dec. 2017). Cost remains a major barrier, but hopefully as the merits of these drugs continue to emerge, insurance coverage will likely improve.
Worldwide trends in children and adolescent obesity Mean body mass index (BMI) and the prevalence of obesity increased worldwide in children and adolescents from 1975 to 2016. The trend in children’s and adolescents’ mean BMI has plateaued, albeit at high levels, in many high income countries since 2000, but has accelerated in Asia. (Source: Lancet, Oct. 2017)
E X E R C I S E A P P L I C AT I O N S
Exercise as a treatment for peripheral artery disease: A new covered benefit Taylor Ollanketo, M.S.
evaluation called the ankle-brachial index or ABI. This noninvasive test compares the blood pressure in the arms versus the ankles. The normal range of ABI values is between 0.90 and 1.30. An ABI value greater than 1.3 is also considered abnormal and suggests calcification of the walls of the arteries and non-compressible, calcified vessels, reflecting severe PAD (Table 1). Doctors may confirm these results with other tests, as well. Once a patient is One in 20 adults over the age of 50 and one in five over the age diagnosed with PAD, he/she may be prescribed medications to of 70 has peripheral artery disease, or PAD (AACVPR 2016). PAD lower high cholesterol and/or blood pressure and prevent blood is typically caused by plaque build-up in the arteries of the lower clots. PAD, when severe, can also be treated with surgical extremities (Fig. 1). The lack of blood flow causes activity-limiting interventions. Fortunately, there is one and sometimes painful muscle cramping therapy that is highly effective, readily when walking, climbing stairs or exercising Fig. 1 accessible and free, that many doctors because there is inadequate oxygen supply now prescribe as an initial treatment to feed the working muscles (Fig. 2). strategy. Exercise, especially walking, can This cramping pain is called “intermittent be one of the most effective treatments claudication.” Many people with PAD may for mild-to-moderate PAD. It can lead to not have any symptoms or may mistake decreased pain when walking, increased their symptoms for muscular stress or ability to perform activities of daily living, strain. In fact, only about 10 to 15 percent enhanced quality of life and decreased of patients with PAD have this classic risk of CAD. Although walking is the symptom (Journal of Applied Physiology, Atherosclerosis Normal Narrowed artery Artery preferred way to treat PAD, for selected Nov. 2013). Other symptoms of PAD blocked by the patients who are severely limited in their include foot or toe wounds that won’t heal blood clot ability to walk, even arm-crank ergometry or heal slowly, gangrene, a decrease in has been shown to improve walking temperature of the lower leg or foot and capacity when compared to participants poor nail growth on the toes or hair loss receiving usual care (Vascular Medicine, or slower growth on the legs. Aug. 2009). People with PAD often have coronary artery Fig. 2 When patients with PAD walk, they are disease, or CAD. Both PAD and CAD are often limited by pain in their legs. While caused by atherosclerosis that gradually patients should reduce exercise intensity narrows and blocks blood vessels in the legs or stop exercising if they experience and heart, respectively. About 40 to 60 increasing chest discomfort, tolerating percent of patients with PAD are eventually pain in the lower extremities is not only diagnosed with CAD or cerebrovascular safe but a necessary requisite for disease (Journal of Vascular Surgery, Jan. achieving the maximal therapeutic 2007). CAD may be difficult to diagnose in benefit from walking. Patients should patients with PAD because they are often walk to a moderate pain level and then limited in their activities and may not exert rest until the pain subsides. This interval themselves strenuously enough to elicit training approach is repeated for a total anginal chest pain or discomfort. of 30 to 60 minutes, preferably most In order to lower the risk of PAD, patients days of the week. Eventually, patients should follow the same “heart healthy” advice are able to walk further, faster and longer given to those wanting to lower their risk of Table 1: Interpretation of the without pain. A systematic review of CAD. Controlling blood pressure and diabetes, Ankle-Brachial Index (ABI) 20 scientific trials showed an increase quitting smoking, eating a healthy diet and in overall walking ability of 50 to 200 being physically active can reduce the risk of ABI Interpretation percent in those patients with PAD who developing PAD and delay progression in those 0.90−1.30 Normal exercised regularly (Cochrane Database patients already diagnosed. Smoking and of Systematic Reviews, July 2014). diabetes are the two major risk factors for PAD. 0.70−0.89 Mild In exciting news, exercise treatment for Smokers are four times more likely to develop 0.40−0.69 Moderate PAD has been shown to be so beneficial PAD and it’s associated symptoms as compared that Medicare is now covering this with nonsmokers (National Heart, Lung, and Less than 0.40 Severe treatment for patients with symptomatic Blood Institute, Aug. 2006). Greater than 1.30 Non-compressible PAD, with some other insurers recently Diagnosing PAD is fairly simple once the vessels adopting this covered benefit. disease is suspected. Patients often undergo an Exercise Physiologist Preventive Cardiology and Cardiac Rehabilitation Beaumont Hospital, Royal Oak
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C A R D I A C R E H A B I L I TAT I O N : A T E S T I M O N I A L
Garrett Van Camp still road racing at 80 Bob Capps and Garrett Van Camp*
and built the car in my garage. In the car’s first outing at Road America in Wisconsin, I blew the engine. From a bad start I went on to win the ’69 Waterford Hills Formula Vee championship. *Cardiac Rehabilitation Participant I also ran some SCCA Trans Am races at Marlborough, Maryland and Michigan International Speedway driving a Porsche 911 owned by Detroit-area BMW dealer Erhard Dahm. In 1970, I won the SCCA Central Division Formula Vee Championship and the For the past five years I have been involved in the cardiac next year I was the SCCA Formula Vee National Champion. rehabilitation (rehab) program at the Beaumont Health and In 1971, with growing family responsibilities, I decided to sell my Wellness Center. During this time, staff and program participants Vee, but still did some racing in borrowed Lynx Formula Vee’s. learned that I drive race cars for a hobby. Members of the rehab Then in May of ’99, something interesting happened. I received staff seemed interested in this and often the question arose a call from the car’s current owner wanting to know if I would be about whether there was a relationship between good physical interested in buying the car. I had always had a special fondness condition and driving a race car. Since I have been racing for over for the car so the decision to repurchase it fifty years, I thought I might be able to shed some light on the question. Let me explain. Exercising at a moderate- was not difficult. I brought the car back from The fact of the matter is – driving a race car is to-vigorous intensity has Oklahoma and did a complete ground-up restoration bringing it back to the way it was physically demanding. First, you are completely made a big difference clothed in fire-proof Nomex long John in my life, but participation when I built it in ’69. Since the restoration, I have raced eighteen seasons with VSCDA (Vintage underwear and a quilted driver’s suit. Nomex in Phase 3 cardiac rehab Sports Car Drivers Association) plus eleven doesn’t breathe. In addition, you’re wearing on a regular basis is Waterford Hills weekends and have won VSCDA’s a full-coverage crash helmet. There is no air what is really beneficial Vintage Vee championship several times. conditioning in the cockpit of a race car and as for everyone with In 2010 and 2011, I began experiencing a driver you’re constantly working hard, turning shortness of breath while racing. In 2012, I was right and left while simultaneously managing heart disease. racing two cars at Waterford Hills and the throttle, clutch and brake pedals. So, if the experienced extreme fatigue during and after the final afternoon temperature is in the high 70’s or 80’s outside, it’s even hotter race. My daughter took me to the Emergency Center at in an open cockpit, rear-engine race car. Beaumont Royal Oak where I was admitted for two days of tests Now let me share with you how I got involved in the sport and and observation. I was told that I probably suffered a mild how it led me to the Beaumont Health and Wellness Center. It all cardiac event during the race. I was released on Tuesday with a started in 1965. I was working for Ford as a chassis engineer and stress test scheduled for the following Monday. During the stress one weekend decided to attend a road race at Waterford Hills test I suffered a cardiac arrest and was admitted to Beaumont Raceway near Clarkston. I came away thinking I would like to give Royal Oak where I underwent triple-vessel heart bypass surgery road racing a shot so I bought a ’58 Porsche Speedster. Now that as well as aortic valve replacement. I owned a car I figured I needed to learn how to drive it so I went Following Phase 2 cardiac rehab, to date I have completed five to competition drivers’ schools at Waterford and Mid-Ohio. years of Phase 3 rehab at the Beaumont Health and Wellness After that I was able to run a full schedule of SCCA (Sports Car Center with excellent results. I have more energy, lost weight and Club of America) Regional and National races plus club races feel great. The staff is friendly, helpful and supportive. I highly at Waterford. Then in ’68 I won Waterford’s E Production recommend transitioning to Phase 3. Exercising at a moderatechampionship. Following this, I sold the Speedster. to-vigorous intensity has made a big difference in my life, but In 1966, while on a Ford Ski Club trip to Aspen, I met Maggie participation in Phase 3 on a regular basis is what is really Michalski. We dated for two years and were married in 1968. beneficial for everyone with heart disease. I highly recommend it! We have two children, Jason and Alison, and five grandchildren. Throughout my racing career, Maggie has been my racing NOTE: Bob Capps writes vintage race reports and articles manager and chief pit crew lady. for Victory Lane Magazine and is a Red Coat Volunteer After selling the Speedster my interests at Beaumont, Royal Oak. turned to Formula Vee’s. The Formula Vee class was founded in 1963 by the SCCA to promote and encourage low-cost, single-seat, open-wheel racing. The car, then and now, uses power trains and running gear from 1964 to 1967 Volkswagen Beetles. My first formula Vee, a Lynx B, was designed by Bob Riley, another Ford engineer. I knew Bob from Ford so in ‘69 I bought one of his Lynx kits 9
E X E R C I S E A P P L I C AT I O N S
Can physical exertion trigger an acute cardiac event? Ashish Chaddha, M.D. Cardiovascular Fellow Beaumont Hospital, Royal Oak
What is the risk of experiencing a heart sports are greater than six METs (Table 1). attack, sudden cardiac death or stroke The risk of cardiovascular events during during or soon after exercise and does light or moderate intensity activity is the benefit outweigh the potential risk? comparable to that by chance alone, The short answer is, “yes.” However, it is irrespective of whether one has heart important to consider the intensity of disease or not. In individuals with heart exercise, one’s baseline level of habitual disease, the risk of exercise-related physical activity and cardiorespiratory cardiovascular events increases with fitness, exertional symptoms, increasing exercise intensities, and electrocardiographic especially during The overall risk of a unaccustomed, vigorous responses to incremental exercise and whether or not cardiac event is up to physical activity. Still, the 50 percent lower in absolute risk that an acute one has known or suspected heart disease when estimating cardiovascular event will occur individuals who the risk of exercise-related during vigorous exertion is perform regular acute cardiovascular events. exercise as compared estimated to be between one A metabolic equivalent with their sedentary in 500,000 and one in (MET) is a standard measure 2,600,000 hours of exercise counterparts. of oxygen consumption at (Journal of Cardiopulmonary rest and multiples of this are used to Rehabilitation, Aug. 2005). estimate the intensity of physical activity. Despite the risk-paradox of exercise, Light activities such as slow walking are there is a clear net benefit of regular less than three METs, moderate activities aerobic exercise. For example, the overall such as brisk walking and light bicycling risk of a cardiac event is up to 50 percent are three to six METs, and vigorous lower in individuals who perform regular activities such as jogging, snow shoveling, exercise as compared with their sedentary deer hunting, racket and competitive counterparts. Moreover, it appears that
A sedentary lifestyle is detrimental to health and contributes to the development of obesity, diabetes, hypertension (high blood pressure) and cardiovascular disease. Regular aerobic exercise is an effective intervention for improving health and lowering the risk of heart disease and other chronic medical conditions. The American College of Sports Medicine, American College of Cardiology and American Heart Association recommend at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise per week (Circulation, Aug. 2007). Although aerobic exercise and improved cardiorespiratory fitness reduce the risk of experiencing an initial or recurrent heart attack, it appears that sporadic, vigorous physical activity in persons with known or occult heart disease can trigger cardiovascular events, including a heart attack, sudden cardiac (continued on page 12) death or stroke (Physician and Table 1: Energy expenditure of common housekeeping and recreational activities Sportsmedicine, Nov. 2011). Accordingly, exertion-related Light Moderate Vigorous deaths have been reported <3.0 METs 3.0-6.0 METs >6.0 METs in recreational, amateur • Walking/hiking • Walking – slowly • Walking – very brisk (4 mph) and professional athletes, and •C leaning – heavy (washing windows, • Jogging at 6 mph • Sitting – using computer in occasional “weekend vacuuming, mopping) warriors.” As a result, •S tanding – light work • Shoveling exercise has increasingly been (cooking, washing dishes) • M owing lawn (walking power mover) • Carrying heavy loads maligned in the mainstream •B icycling – light effort (10-12 mph) • Fishing – sitting •B icycling fast – (14-16 mph) media, with sensationalized adminton – recreational • Playing most instruments • B • Playing basketball headlines such as “Exercise •T ennis – doubles • Playing soccer can kill you; details at eleven.” • Tennis – singles
Surprising ways to prevent a heart attack Five things you can do to reduce your heart attack risk include: avoid secondhand smoke; practice healthy lifestyle habits (i.e., no smoking, avoid obesity, regular aerobic exercise, eat a healthy diet) to cut your cardiovascular risk by nearly 50 percent; get a flu shot (adults over 65 years of age should discuss the pros and cons of high-dose flu vaccines with their physician); don’t stop taking a beta-blocker drug abruptly; and lower your resting heart rate. One analysis of heart patients taking beta-blockers found that each 10-beat reduction in resting heart rate reduced the risk for cardiac death by 30 percent! (Source: BottomLine, Nov. 2017)
COMMON Q & A
Robert N. Levin, M.D. Staff Cardiologist Beaumont Hospital, Royal Oak
I am a 34 year-old male in pretty good health. My doctor heard a heart murmur on my last exam and referred me for an echocardiogram. The echocardiogram showed that I have a bicuspid aortic valve. What is this, and what type of follow-up do I need?
Bicuspid aortic valve is a congenital condition whereby the aortic valve, which is the main valve channeling blood out of the heart, is defective. A normal aortic valve is configured as a Mercedes-Benz emblem or “peace symbol,” consisting of three thin leaf-like structures (“leaflets”) which open and close. A bicuspid aortic valve is a congenital abnormality whereby there are only two semicircular leaflets rather than the normal three leaflets. There are certain clinical entities Normal aortic valve
that can accompany this disorder, such as a “pinch” (coarctation) of the aorta, or a small brain aneurysm. Certain complications can occur with this disorder over many years and your cardiologist will monitor you for these. Complications can include calcification, Bicuspid aortic valve thickening, narrowing of the valve opening and possible development of valve leakage. The key parameter for your cardiologist to measure is the size of the ascending aorta (main artery conducting blood out of the heart) just above the valve (measured by an echocardiogram or by a computed tomography [CT] angiogram). Patients with bicuspid aortic valves often develop enlargement of this part of the aorta. If the ascending aorta shows signs of abnormal widening, the aortic root and/or aortic valve may need to be surgically replaced. It is likely that your cardiologist will follow you with serial echocardiograms over time and monitor your symptoms, particularly shortness of breath.
I have had intermittent heart palpitations for a number of years and have been told by my cardiologist that these are atrial premature complexes. There are some days that I experience palpitations and others that I do not. I don’t understand what I might be doing that makes my palpitations so unpredictable. Other than taking medications, what can I do differently to avoid palpitations?
Let us review several of the factors that can precipitate or exacerbate palpitations, regardless of the type of electrical rhythm problem involved. The predominant factor that seems to exacerbate palpitations is sleep deprivation; people who are sleep deprived are much more likely to experience palpitations. Another factor could be untreated sleep apnea, alcohol consumption, nicotine intake, caffeine and tobacco use; all of these will make you much more likely to have palpitations. Even a cola product or unsweetened soda can worsen your palpitations. It is likely your physician will also want to rule out any possible metabolic abnormalities, such as a deficit or excess of certain chemicals in the blood, such as potassium, calcium and magnesium. There are also certain sleep aids, such as melatonin, which can precipitate or exacerbate palpitations. You should discuss your individual circumstance with your cardiologist.
Endurance athletes, vigorous exercisers: One-stop shopping The Cardiovascular Performance Clinic at the Beaumont Health & Wellness Center in Royal Oak offers comprehensive diagnostic and physiologic testing to endurance athletes, recreational exercisers and highly active individuals. The battery of tests include: echocardiogram; a cardiopulmonary exercise test with direct measures of aerobic fitness and the anaerobic threshold; a coronary calcium score (optional); and consults with a cardiologist and physiologist. Staff works with clients to help design training programs to improve athletic performance and screen for conditions associated with exerciserelated cardiac events, including underlying atherosclerotic heart disease and/or structural cardiovascular abnormalities (e.g., hypertrophic cardiomyopathy). To learn more or schedule an appointment call, 248-655-5750. 11
How do you heal a broken heart? (continued from page 2) Is it possible for such a memory to cause her heart to fail 76 years later? This patient presented with a classic case of Takotsubo’s cardiomyopathy. This represents one to two percent of patients who present with evidence of acute cardiac syndromes (i.e., heart attack or unstable anginal chest pain). However, coronary angiography typically finds no significant obstructive coronary artery disease to account for the impaired left ventricular function. With the advent of readily available noninvasive cardiac imaging, this type of stress induced cardiomyopathy is recognized much more frequently. It was first described in older women under emotional stress such as the death of a spouse and disproportionately affects postmenopausal women. It is generally associated with both physical and/or emotional stress. The pathophysiology is thought to be related to excessive catecholamine or adrenaline output, causing blood vessel constriction and transient impairment in the heart’s pump function. The syndrome is classically thought to be related primarily to emotional triggers such as grief/ loss, panic/anxiety, interpersonal conflict, anger or financial problems. However, obvious triggers in some series have been reported in only about a third of the cases. Physical stressors such as an acute medical illness may account for 30 to 35 percent of the other cases. In some cases, no obvious triggers are found. Syncope has occasionally been a symptom, perhaps related to left ventricular outflow tract obstruction due to the excessive contraction of the base of the heart with limited or no movement in the other segments. Ventricular arrhythmias have also been reported. Approximately 10 percent of patients may present with signs of cardiogenic shock including hypotension, abnormal mental status, cool extremities, renal insufficiency and respiratory distress. Fortunately, the vast majority of patients with Takotsubo’s syndrome return to normal heart function within several days to weeks — often within seven days. So what happened to our patient in the above case? She had told her story of the horrors of the Holocaust to school children for many years. However, on that particular day she was asked to repeat her story to a second classroom of children. Two hours of reliving her memories was simply too much for her heart to bear. Fortunately, she continues to live a full life at age 93.
STATE OF THE HEAR T LINE-UP Editor-in-chief: Barry Franklin, Ph.D. Co-editor: Simon Dixon, MBChB Associate editor: Robert Levin, M.D. Managing editor: Brenda White Designer: Paul Murch
PANEL OF EXPER TS Clinical Cardiology: Aaron Berman, M.D.; Terry Bowers, M.D.; Allan Chernick, M.D.; Harold Friedman, M.D.; Andrew Hauser, M.D.; Robert Levin, M.D.; Steven Timmis, M.D.; David Forst, M.D. Interventional Cardiology: William Devlin, M.D.; Steven Almany, M.D.; Abdul Halabi, M.D.; Phillip Kraft, M.D.; George Hanzel, M.D.; Steven Ajluni, M.D. Nursing: Kathy Faitel, RN 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.;
Exercise as a treatment for peripheral artery disease (continued from page 8) Beaumont is now offering Supervised Exercise Therapy for Peripheral Artery Disease (SET for PAD). In a SET for PAD program, qualified healthcare professionals (e.g., nurses, exercise physiologists) guide patients through a structured exercise program while educating them on healthy nutrition and reducing risk factors. If you have symptoms of PAD or have been diagnosed with this condition, talk with your doctor to see if you may qualify for this exercise program. For more information on the program, call: Dearborn: 313-561-6400; Farmington Hills: 248-471-8342; Saint Clair Shores: 586-498-4575; Royal Oak 248-655-5651; Trenton: 734-671-3894; Troy: 248-964-8521; and, Wayne: 734-467-4291.
Gene Ebner, Ph.D. Electrophysiology: David Haines, M.D. Diagnostic Testing/Nuclear Medicine: Darlene Fink, M.D.; Gilbert Raff, M.D. Cardiovascular Surgery: Marc Sakwa, M.D.; Frank Shannon, M.D.; Nicholas Tepe, M.D. Obesity, Diabetes, Metabolism:
Can physical exertion trigger an acute cardiac event? (continued from page 10) exercise-related cardiovascular complications can be reduced by performing regular aerobic exercise, achieving an average to good level of cardiorespiratory fitness and by including a preliminary warm-up and post exercise cool-down. Sedentary individuals should start with light-to-moderate intensity exercise such as mild or brisk walking, initially avoid vigorous activities like jogging/running and competitive sports, and progressively increase the intensity of exercise over the first few months, provided they remain asymptomatic. In closing, there are three very important points to remember about exercise. First, the individual who benefits most from aerobic exercise is the one who currently falls in the least fit, least active cohort (i.e., the bottom 20 percent). Second, more intense exercise is not invariably better. Because the health benefits appear to plateau at higher exercise volumes and intensities, we do not recommend high intensity interval training for middle-aged and older adults with known or suspected heart disease. Finally, don’t ignore warning signs or symptoms that are brought on by exercise, including chest pain/ pressure, dizziness, unusual shortness of breath and erratic heart rhythms or frequent palpitations. Stop exercising and seek medical clearance, as these may be harbingers of exercise-related acute cardiac events. 12
Wendy Miller, M.D.; Kerstyn Zalesin, M.D. Enhanced External Counterpulsation Therapy: Anne Davis, RN; Joyce Said, M.S. Women’s Issues: Pamela Marcovitz, M.D.; Melissa Stevens, M.D.; Megan Bowdon, B.S.
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Heart and vascular stories from Beaumont physicians and allied health professionals