From Beaumont Physicians and Allied Health Professionals
Spring Issue 2012
Statin drugs: Benefits versus risks? CLINICAL CARDIOLOGY
Steven B.H. Timmis, M.D. Staff cardiologist, Beaumont Hospital, Royal Oak
Over the past three decades, few medical developments have been as important as the emergence of statin therapy to both treat and prevent cardiovascular disease. Statin drugs are familiar to most patients, with names like Lipitor, Zocor and Crestor, all of which have been aggressively advertised on television. They derive their nickname “statin” from their generic names atorvastatin, simvastatin and rosuvastatin, respectively. Despite their tremendous benefit, few medications have been more difficult to convince patients to start taking. Patients are often fearful of potential side effects, whether real or perceived. Why does your cardiologist (and primary care doctor) prescribe these drugs? What are the concerns regarding these drugs? This article explores these questions and attempts to provide a ‘fair and balanced” overview of their benefits and risks. Benefits of statin therapy Statin therapy has been studied in a broad range of patients in a wide variety of clinical situations. Patients with and without coronary artery disease who are taking these drugs have consistently demonstrated a significant reduction in adverse health outcomes, including death, heart attack and stroke.
INSIDE THIS ISSUE
Statin drugs: Benefits versus risks?
Sudden cardiac death in young athletes
New frontiers: The bioabsorbable stent
Getting the most value from a cardiovascular appointment
Novel strategies to reduce atrial fibrillation related stroke
Caloric expenditure during exercise is often overestimated
Whose heart is it anyway?
A potentially lifesaving ‘walk test’
Shedding some light on vitamin D
Cardiac ultrasound: A window into the heart
Common Q & A
Patients at the greatest risk of these adverse events are those with known coronary artery disease, including individuals who have had a previous heart attack, angioplasty procedure, or heart bypass surgery, people who experience anginal chest pain or those who have had heart disease confirmed by cardiac catheterization or coronary computed tomographic scanning. People who have peripheral arterial disease, abdominal aortic aneurysms, carotid artery disease and previous stroke, diabetes mellitus or chronic kidney disease are also at substantial risk of similar outcomes. Those who have There is nothing multiple risk factors including more potent than an elevated LDL cholesterol a statin in lowering (bad cholesterol), a low HDL bad cholesterol. cholesterol (good cholesterol), hypertension, tobacco use and a family history of premature cardiovascular disease are at risk, as well. In each of these patient groups, statin drugs have resulted in a profound reduction in major adverse cardiovascular events, approximating 25 to 35 percent. Statins produce these effects by lowering LDL cholesterol. Every study that has looked at lowering cholesterol levels has demonstrated a reduction in adverse cardiovascular outcomes that is proportionate to the degree of LDL cholesterol lowering. There is nothing more potent than a statin in lowering bad cholesterol. There is no diet, drug or supplement that comes close to the potency of statins. But statins don’t just lower bad cholesterol. They have a favorable effect on good cholesterol and triglyceride levels (the other bad fat in the bloodstream). Statins also work on the blood vessels, where plaque develops and causes heart attack and stroke. Oxidation and inflammation aggravate plaque in the arteries, accelerating its development. Statins inhibit these processes, stabilizing the plaque. Long-term studies have shown that plaque progression slows and sometime even stops with statin therapy. One study showed that plaque regression, or shrinkage, actually occurred. These effects are not seen with other cholesterol lowering strategies.
(continued on page 11)
CLINIC AL C ARDIOLOGY
Sudden cardiac death in young athletes Kim Bonzheim, M.S.A. Pioneer of Beaumont’s Healthy Heart Check, Student Heart Screening Program Beaumont Hospital, Royal Oak
We’ve all heard the tragic stories of young student athletes who die suddenly while playing sports. Invariably, a post mortem examination revealed an underlying, and previously undetected, structural heart abnormality. At least four student athletes in Michigan died in 2011. Approximately one in 200,000 high school athletes will die during or immediately after vigorous physical exertion, most without any prior symptoms. Fortunately, using simple noninvasive tests, many of these conditions can be detected to help prevent catastrophic events. Several years ago, Italian researchers reported that mandatory pre-participation screening of athletes in their country decreased their rates of sudden cardiac death by almost 90 percent. These findings spurred a Beaumont team of cardiologists, nurses and clinical staff to create our Healthy Heart Check student heart screening program. We launched our free screening program in 2007. Using portable beds, equipment and lots of volunteers, we set up heart screenings at local high school gyms, hospitals, the Oakland University recreational center, various classrooms, and even on a tennis court. The screening includes a heart history questionnaire, blood pressure check, an electrocardiogram to evaluate the heart’s electrical activity, and a focused physical exam by a physician and if necessary, a quick-look echocardiogram is also obtained to better visualize the heart’s function and structure. To date, we’ve screened 8,106 students; 49 were counseled to stop exercise immediately and follow up with a cardiologist. Another 754 were advised to continue exercise, but to follow up with their physician. Of those told to stop sports, four students were diagnosed with hypertrophic cardiomyopathy, known as HCM, the single most common cause of death in U.S. athletes. Male athletes are 10 times more likely to die suddenly as a result of HCM. Other students screened by Beaumont were diagnosed with conditions such as an enlarged heart, abnormal heart valves and heart rhythm irregularities. 2
Mass screening of students prior to sports participation is controversial in the medical community due to excessive costs and the high number of “stop sports” recommendations based on abnormal ECGs. Data from our screening program presented at the recent American Heart Association Scientific Sessions, showed that by adding a “quick-look” echocardiogram to the evaluation in some cases, we could reduce the number of students falsely told to stop sports by 90 percent, based on ECG findings alone. In addition, by using physician volunteers and paid technical staff, we have developed a rapid, low-cost, individualized model to effectively screen large numbers of high school students for potentially lifethreatening and other heart conditions. We have successfully shared our heart screening model with Michigan hospitals located in Chelsea, Kalamazoo, Muskegon and Flint using a free-of-charge franchise kit. Media sponsors, including WXYZ-TV-7, the Detroit ABC affiliate, and CBS radio station 97.1 The Ticket, have helped to promote the screenings. The student heart screenings are offered free of charge several times a year at community locations, such as schools or recreational centers. If you are unable to attend a free community screening, you can make an appointment for a screening at Royal or Troy, for $25.
Healthy Heart Check Student Heart Screening Program
For more information, to check future community events, or make an appointment, visit heart.beaumont.edu or call 800-633-7377.
FROM THE CHIEF
Simon R. Dixon, M.D., MBChB Chair, Department of Cardiovascular Medicine, Beaumont Hospital, Royal Oak
New frontiers: The bioabsorbable stent In 1994, the first coronary artery stent was approved for use in the United States. The concept of stenting arose in the early days of coronary angioplasty to overcome recoil of the artery after balloon dilation. Coronary stents are essentially a metal frame designed to prop open the narrowing like a scaffold, and maintain blood flow to the heart muscle. Over the past decade many new generations of stents have been developed to improve the ease of insertion and long term results for our patients. While we often take it for granted, modern stents are remarkable pieces of engineering technology, and have revolutionized the treatment of coronary artery blockages, enabling many patients to avoid open heart surgery. More recently, it has become apparent that the “scaffolding” effect of a coronary stent is really only needed for a few months after implantation, while the artery wall is healing. Accordingly, there has been escalating interest in developing stents that are fully absorbed by the body, rather than leaving behind a permanent implant. The goal is for the stent to be gradually resorbed by the body over six to 12 months. The idea of the “disappearing stent” has several theoretical benefits such as restoring the artery to its natural function, minimizing the need for long-term medications such as clopidogrel (Plavix), and improving the accuracy of subsequent diagnostic testing with techniques such as coronary computed tomographic angiography.
made by Abbott Vascular, and has two layers of a biodegradable polymer (Figure). One layer contains the drug everolimus to limit scar tissue formation, and the other layer provides the structural backbone. This stent, which was first tested in New Zealand and the Netherlands, was approved for use in Europe last year. In 2012, Beaumont will be one of a select number of centers in the United States to conduct a clinical trial with this novel stent platform. Although it could be several years before the stent is commercially available in the United States, initial results in Europe look very promising. Stay tuned for more information in future editions of State of the Heart.
Several bioabsorbable stents are currently being studied. One type uses a biodegradable polymer; another is a made of a magnesium-alloy. The technology that is most promising is
Marathons pose modest risk to heart To clarify the cardiac risk associated with long-distance running races, researchers assessed the incidence and outcomes of cardiac arrest associated with marathon and half-marathon races in the U.S. from January 1, 2000 to May 31, 2010. Among nearly 11 million runners who participated, only 59 went into cardiac arrest during a race, for an incidence rate of just 0.54 per 100,000 participants. Forty-two of these were fatal. Men were more likely than women to have cardiac arrest and sudden death. Although the authors concluded that long distance running races are associated with a low overall risk of cardiovascular complications, they suggested that preparticipation exercise testing may be useful for identifying some persons at high risk.
Mini-stroke increases risk for heart attack Patients who have suffered a mini-stroke are twice as likely to suffer a heart attack within the next five years. If you have had a mini-stroke: Reduce your risk for heart attack by achieving healthy blood pressure and cholesterol levels. Many men and women may also benefit from prophylactic aspirin therapy. Check with your physician. (Source: Stroke, April 2011)
(Source: New England Journal of Medicine, Jan. 2012)
HELPFUL MEDICAL ADVICE
Getting the most value from a cardiovascular appointment David H. Forst, M.D. Director, Clinical Operations Department of Cardiovascular Medicine Beaumont Health System
In our expensive health care environment and with many people still uninsured, it is increasingly important for patients not only to maximize the quality of their medical visit, but also to minimize cost. Too often, the entire process is left in the hands of the cardiologist or cardiac surgeon, but every patient can play an important role in ensuring that the best possible outcome from a doctor’s visit. Communication It is amazing how many tests are generated and how many prescriptions are written because of a lack of information. To minimize this, every patient should bring an accurate list of medications and appropriate test results when available. It’s also important to ask the doctor to sit down; this creates an environment for more comfortable communication, which is necessary for a successful visit. Don’t leave the office until you feel certain that you fully understand the test or treatment being prescribed: Taking a few extra minutes can prevent future problems. Also, don’t hesitate to ask for handout materials or written directions; and always ask the doctor to clarify or repeat something if you still have questions. Cost Ask about different diagnostic and therapeutic options. A stress echocardiogram may cost less than a nuclear stress study, but oftentimes similar information can be obtained from either study. In many instances, generic drugs may be equally effective, but much less expensive. The cost of different pacemaker devices or coronary stents may also vary substantially with similar results as many other procedures. 4
Do your homework before coming into the office and don’t be afraid to ask about the financial implications of your proposed treatment. Treatment options Be sure to ask your doctor about the expected results of treatment. Many times a surgical or medical intervention may have similar outcomes, but very different recovery times and costs. This is also true of drug prescriptions. Always ask about side effects, drug interactions and therapeutic options. An allergic reaction is not only uncomfortable; but it also increases the cost of treatment and puts your overall health at risk. For those who are employed, always ask about recovery time from a procedure and when you can reasonably return to work. This may make the difference when selecting a therapeutic option with similar risks and outcomes. Insurance coverage Always bring your insurance card with you. The last thing you want to happen is to get stuck with a large bill, especially if a different approach was possible had the insurance information been known. It is perfectly reasonable to ask the staff to explain deductibles and co-pays for different services. Also, note what insurance is accepted in a physician’s office. You may wish to go elsewhere if an insurance plan is not accepted. Clinical information Always bring a list of diagnoses, past procedures, allergies and medications. This can save time and reduce errors. Likewise, know which hospital or clinic provided your service. The year or date may also be helpful. Today, even though electronic medical records are readily available, they may not be compatible among different hospitals or clinics. Hunting for records can waste time and delay decision-making and failing to note a past procedure or a medication may result in a medical error. Summary Providing appropriate information in your doctor’s office can pay big dividends. Health care is collaboration between a doctor and a patient. Often, the better the information exchange, the better the outcome. Don’t be afraid to ask about or even challenge a proposed diagnostic or treatment option. Communicating effectively increases the likelihood that you will receive the best possible care at the lowest possible cost, the outcome for which we all strive.
INTERVENTIONAL C ARDIOLOGY
Novel strategies to reduce atrial fibrillation related stroke George S. Hanzel, M.D. Director, Cardiac Catheterization Laboratory Beaumont Hospital, Royal Oak
Atrial fibrillation, know as AF, is a common medical condition affecting more than 6 million adults in the United States. This heart rhythm irregularity can cause palpitations, fatigue, and shortness of breath. However, the greatest threat of AF is clot formation within the heart, leading to stroke. On average, AF increases a person’s risk of stroke five-fold, and 20 to 25 percent of all strokes are due to AF. The standard strategy to reduce AF related stroke is anticoagulation treatment with either warfarin (Coumadin) or dabigatran (Pradaxa). However, approximately 50 percent of patients with AF are unable to tolerate anticoagulant therapy. There are many reasons for this, but the main one is
risk of bleeding complications. Accordingly, there is great interest in reducing the dreadful complication of stroke without increasing the risk of major bleeding. Interestingly, 90 percent of all clots in AF arise in an outpouching of the upper left heart chamber (atrium), called the left atrial appendage. Because of stagnation of blood flow within this structure, clots are prone to develop there. If this structure could be occluded or sealed off, it is thought that AF related strokes could be significantly reduced, eliminating the need for longterm anticoagulation therapy, and it’s associated bleeding complications. Physicians at Beaumont are involved with two novel devices to achieve left atrial appendage occlusion. The first device is called the WATCHMAN device. This device is placed into the left atrial appendage to “plug” it. The procedure is
performed via a small tube placed in the vein in the groin and takes approximately one hour to complete. This therapeutic option is available through an investigational trial. Currently patients who are candidates for anticoagulation therapy are randomized to warfarin or the WATCHMAN device. Preliminary data suggest that the WATCHMAN device is as effective as warfarin at reducing stroke. The second method is called the LARIAT device. This procedure is also performed in the catheterization laboratory and uses a suture to tie off the left atrial appendage. This procedure also takes approximately one hour to perform and patients are kept in the hospital for 24 to 48 hours. This procedure is mainly used for patients who are not good candidates for anticoagulation therapy. Beaumont is the only hospital in Michigan evaluating both of these new technologies.
Caloric expenditure during exercise is often overestimated Allison Poremba Exercise Specialist, Preventive Cardiology and Rehabilitation Beaumont Hospital, Royal Oak
We know the importance of exercise for energy expenditure contributing to weight loss, but how many calories are you actually burning while exercising and how much does the exercise alone contribute to the calories burned? Simply put, a calorie is a metabolic unit, used to measure the amount of energy we consume through food and expend through physical activity and bodily functions, such as breathing and digestion. The body burns a certain number of calories to maintain vital processes, but when we consume more calories than our body can burn, it tends to store it as fat, resulting in obesity or higher weight.
Weight loss occurs from decreasing the amount of calories you consume while increasing the amount of calories you expend. Structured, aerobic exercise is one way to help burn off some of those extra calories, but we can’t depend on exercise alone if our goal is weight reduction. Regular exercise is a great start to a weight loss plan, but just because you exercise for 30 minutes it does not necessarily entitle you to unlimited desserts. Walking on a level treadmill at three miles per hour for 30 minutes will burn 125 to 150 calories, but that piece of apple pie you assumed was okay to have at dinner was about 400 calories. Therefore, you’re consuming an extra 250 to 275 calories, with a food that provides little nutritional value. Diet and lifestyle physical activity (e.g., the total number of steps you take each day), in addition to structured (continued on page 11) 5
P S YC H O S O C I A L I S S U E S
Whose heart is it anyway? Daniel C. Stettner, Ph.D. Licensed Psychologist
The fact that you are reading this newsletter is very important. It speaks to the fact that you are thinking about heart disease. Isn’t it great to be alive? Isn’t it something to think about all that you have been through and all that has happened in the recent past? It’s great that you have come this far, but the reality is that this is a new beginning.
(and your family), and a real eye opener. Now that your body has gotten your attention, the question is what to do now.
problems you have, there really are simple, workable ways to move more and improve your fitness.
There are professionals waiting to review your usual food choices and make helpful suggestions that will improve your overall health, including heart health. Perhaps you were one who ‘lived to eat’ or even ‘ate like there was no tomorrow.’ Well there just could have been no tomorrow if it weren’t for the physicians and others
Perhaps you were someone who thought when you left the hospital, and survived what could have been a lifethreatening event or series of events, that the story had a good ending. Not so fast… yes, you are alive and reading this, but what about the future? What about next year? What about five years from now? Beaumont’s Cardiac Rehabilitation program is really a team effort. You have the option to be an important member of that team – actually you are the ‘star’, the key player on the team. Everybody else on the treatment team are like coaches. Their job is to help you develop optimal health, wellness, fitness, and behaviors for a meaningful future.
Perhaps you took your heart for granted, didn’t worry too much about annual check-ups, cholesterol, fitness, and those kinds of things. Maybe in your past, it was all about being in the moment – eating for now, being too busy for fitness, too involved to think about the inner workings of your body. Well… as you know, things have caught up with you. But fortunately you are invited to participate in a very special program – Cardiac Rehabilitation. By now you have met a variety of people from the hospital – healthcare professionals who are waiting for you to join them in a common commitment – to aggressively treat your heart disease and potentially prevent future cardiac events. What you have already been through was very likely scary, upsetting to you
So the answer to “whose heart is it?” – it’s really everybody that has an investment in your heart! who were there when you needed them most. Now…it’s about eat to live. Yes, you can do this! Others are there to help you develop a simple and progressive exercise plan that will work for you now and further protect your future health. Increasing scientific evidence now supports the adage, “Fitness for life.” Despite what orthopedic
Insomnia raises heart disease risk People who have trouble falling asleep or staying asleep have a higher risk of developing heart disease. Possible reason? Insomnia may be linked to increased stress hormones, blood pressure and inflammation, all of which increase the risk for heart disease. (Source: Circulation, Nov. 2011)
It’s all about we and us and team. You can’t do as well alone without the team’s support; and the team exists for you! Join the team and live more fully, healthier, and with confidence. Welcome to the rest of your life as a team player for the most important activity in your life – being your own best friend, and being an active, assertive part of your healthy future.
Sexual activity is safe for most heart patients If a heart patient can achieve two minutes or more during a conventional treadmill test (1.7 miles per hour, 10 percent grade), without experiencing adverse signs or symptoms, the risk of cardiac events during sexual activity with one’s spouse or regular partner is extremely low. (Source: Circulation, Jan. 2012)
FROM THE EDITOR
Barry A. Franklin, Ph.D. Director, Preventive Cardiology and Rehabilitation, Beaumont Hospital, Royal Oak
A potentially lifesaving ‘walk test’ The 109 passengers and nine crewmen of a British Airways jet were not so fortunate at London’s Heathrow Airport in June of 1972, when their plane crashed on takeoff, killing all aboard. A subsequent investigation established the accident’s cause – a massive heart attack shortly after takeoff killed the plane’s 51-year old captain. His condition, said the report, “must have been developing for 30 years or more,” yet the gradual narrowing of his coronary arteries had gone undetected in routine annual physical exams, including resting electrocardiograms, known as ECGs. The report went on to recommend exercise stress testing for all airline pilots. What does an exercise stress test measure? Exercise testing involves a medical evaluation of heart-lung fitness; heart rate and blood pressure responses to progressive exercise; abnormal clinical signs or symptoms (anginal chest pain); and associated changes in electrical functions of the heart, especially heart rhythm abnormalities and ECG signs of myocardial ischemia (inadequate blood flow to the heart). During incremental exercise, significant blockage of the coronary arteries (generally considered to be 75 percent or more) may cause anginal chest pain, a change in the ECG pattern (called ST-segment depression), or both. There is one limitation, however: Exercise stress tests are unable to detect mild-to-moderate coronary blockages, where most heart attacks occur. Consequently, an exercise stress test can be normal despite the presence of coronary plaque that may rupture. Sometimes exercise tests suggest underlying heart disease when it does not exist; this is called a false-positive result and is associated with women in particular. Nevertheless, these tests provide enormously powerful prognostic information, especially when taking heart-lung fitness into account, expressed as metabolic equivalents or METs. A low exercise capacity of 4 METs or less indicates a higher mortality group. On the other hand, a MET capacity of 8 METs or higher designates a cohort with excellent long-term survival (Journal of the American Medical Association, May 2009).
What happens during an exercise stress test? During an exercise stress test, an ECG is obtained during exercise, usually on a treadmill. The standard exercise stress test evaluates the heart when it’s beating more rapidly than when it’s at rest. The workload gradually increases as the test progresses (i.e., the treadmill speed and/or grade are increased every three minutes), and blood pressure readings are taken at intervals to assess the heart’s pumping power. The test typically progresses to the point of volitional fatigue (the patient is too tired to continue) or to the point of adverse signs or symptoms, which suggest the test should be discontinued. These tests are often used to evaluate symptoms such as shortness of breath or chest pain, sometimes in conjunction with nuclear imaging or echocardiographic studies. Are there any risks? Several years ago we evaluated the complication rate of exercise testing in our laboratories. We reviewed more than 58,000 consecutive exercise stress tests and reported a mortality rate of 0.3 per 10,000 tests and a total complication rate of 2.4 per 10,000 tests. Thus, the test is associated with an extremely low risk of complications. Experts generally agree that the ability to maintain a high degree of safety depends on knowing when not to perform the test, when to terminate the test (i.e., recommended end points), and being prepared for adverse responses that may arise. What does an abnormal result mean? An abnormal result may suggest clogged coronary arteries, manifested as chest pain/pressure, ECG evidence of ischemia, or both. In some individuals, heart disease may be heralded by heart rhythm irregularities that develop during and immediately after exercise stress, or by a decreasing systolic blood pressure response to increasing workloads. The peak heart rate response to exercise or the decrement in heart rate after maximal exercise testing can also serve as important predictors of mortality. (continued on page 12)
H E A LT H Y N U T R I T I O N
Shedding some light on vitamin D Anne Davis, R.N. Preventive Cardiology and Rehabilitation Beaumont Hospital, Royal Oak
Vitamin D has gained a lot of attention over the last few years. In 2010, the Food and Drug Administration, or FDA, increased the previous recommended daily allowances, known as RDA, of vitamin D. Recognize that the FDA does not make changes like this without considerable research and evidence. Is vitamin D the “wonder vitamin” of the decade? Let’s look at some of the facts. Vitamin D is a fat-soluble vitamin that can be stored in the body. It’s most well known function is to support calcium absorption to aid in building strong bones. This was discovered in the early 1900s when rickets was a major epidemic in children. Why the recent hype? Adding vitamin D levels to routine blood chemistry studies has created a huge database of information, which scientists have now used to link low levels of this vitamin with many chronic diseases and medical conditions, including heart disease, asthma, depression and some cancers. The cardioprotective benefits of vitamin D may be related to reduced levels of inflammatory markers, like C-reactive protein (American Journal of Cardiology, Jan. 2012). Natural sources of vitamin D are limited. The sun’s ultraviolet or UVB rays enable our skin to make vitamin D. Moreover, fatty fish, such as salmon, tuna or mackerel are the best natural food sources. Orange juice, milk, some cereals and eggs are also fortified with vitamin D, but require four to six servings of each to meet minimal RDA requirements. Several factors potentially increase our risk of vitamin D deficiency. Our geographical location is key. At least six months of the year, the sun’s UVB rays, in latitudes north of Atlanta,
Georgia, are not strong enough for vitamin D synthesis. As we age, our body is less able to convert the sun’s UVB rays to vitamin D and while sunshine is truly our best option, most physicians prefer we limit our sun exposure, due to the increased risk of skin cancer. Adequate dietary intake of vitamin D is also challenging, due to the limited number of natural and fortified food options. Some people are more susceptible to vitamin D deficiency, including individuals with darker skin pigments, obesity, At least six months of the year, liver and kidney the sun’s UVB rays, in latitudes north disease. Certain of Atlanta, Georgia, are not strong medications, such enough for vitamin D synthesis. as steroids, dilantin, phenobarb and some cholesterol lowering drugs, also increase the risk of vitamin D deficiency.
Obviously, dietary and natural sources are preferred, but if the sun isn’t a consistent or recommended source and our dietary options are limited, what is our next best option? For some people, a dietary supplement may be recommended. It is always best to check with your primary care physician, when considering any dietary supplement. A simple blood test can be done to determine your level of serum 25(OH)D or vitamin D. The following table lists the National Institute of Health’s recommendations for vitamin D or 25(OH)D levels and provides a good starting point in gauging your need for supplementation. nmol/L or ng/mL
Associated with vitamin D deficiency, leading to rickets in infants and children and osteomalacia in adults
30 - 50
12 - 20
Generally considered adequate for bone and overall health in healthy individuals
Emerging evidence links potential adverse effects to such high levels, particularly > 150 nmol/L or > 60 ng/mL
Generally considered inadequate for bone and overall health in healthy individuals
If your levels are less than 50 nmol/L or 20 ng/mL, a supplement will probably be recommended. There are a few options. (continued on page 9) 8
CLINIC AL C ARDIOLOGY
Cardiac ultrasound: A window into the heart Nathan Kerner, M.D. Staff cardiologist Beaumont Hospital, Royal Oak
There are many imaging methods to assess heart function, although none used more than cardiac ultrasound. Ultrasound is an established, safe, and readily available modality that gives unparalleled data in terms of cardiac anatomy and function. Cardiac ultrasound, or echocardiography, begins with two-dimensional imaging of heart structures. With 2-D imaging, we are able to visualize and measure abnormalities in the valves, pericardium surrounding the heart, and particularly the pumping function of the left ventricle, the main pumping chamber of the heart. This
imaging modality is often coupled with treadmill stress testing to allow assessment of left ventricular function at rest and during exercise. Echocardiography is also helpful in detecting wall motion abnormalities, which may signify the presence of coronary artery disease (blocked arteries in the heart). In addition to 2-D imaging, all current cardiac ultrasound equipment can also measure blood flow through the heart using Doppler ultrasound techniques. This allows the measurement of sound waves coming from red blood cells themselves as they travel through the heart. Being able to measure blood flow through the heart gives us the ability to identify abnormal pressures within the cardiac chambers and leaking or blocked valves in the heart.
in the heart. Contemporary echocardiographic methodologies are critical during procedures such as those used in the investigational Partner II Trial, a trial in which Beaumont Health System is a regional center. This technique involves a transcutaneous prosthetic aortic valve implantation for the treatment of aortic stenosis (a narrowed aortic valve) without “open heart” surgery.
A newer modality in echocardiography is three-dimensional imaging of the heart. Viewing the heart in this manner is performed using sophisticated computerized algorithms. Modern technology allows us to view cardiac structures from many different angles, which is extremely helpful to interventional cardiologists and surgeons performing valvular repair or replacement procedures, or correcting structural defects
Cardiac ultrasound is an imaging modality that has been around for many years. It is proven as a safe and noninvasive means of imaging the heart. This relatively straightforward and constantly evolving tool yields a tremendous amount of information which can be of paramount importance in a physician’s assessment and management of numerous and diverse cardiovascular conditions.
Vitamin D (continued from page 9) Cod liver oil provides 1360 international units (IU) per tablespoon and also comes in capsule form. This is the most natural supplement and also provides beneficial omega 3 fatty acids. Vitamin D3 (cholecalciferol) or vitamin D2 (ergocalciferol) come in tablet form and appear to be equally effective in raising serum vitamin D levels. Most multivitamins contain 400 IU of vitamin D. Because it is fat soluble, caution must be taken to avoid toxicity. Excessive sun exposure and food intake are highly unlikely to create toxic levels; however, inordinate amounts of vitamins D3 or D2 could be problematic. The threshold for vitamin D toxicity is high. The Institute of Medicine recommends a tolerable upper limit of 2500 IU per day for ages 1 to 3 years, 3000 IU per day for ages 4 to 8 years and 4000 IU per day for ages 9 to 71+ years. Talk to your physician about assessing your serum vitamin D level, and then decide on a treatment plan together. By correcting vitamin D deficiency, improved cardiovascular health outcomes may occur. If you ‘toast’ to that objective, make it orange juice or vitamin D fortified skim milk.
Food sources with vitamin D: Salmon Tuna Mackerel Orange juice Milk Cereal Eggs 9
COMMON Q & A
Robert N. Levin, M.D. Medical Director Coronary Care Unit Beaumont Hospital, Royal Oak
I’ve had atrial fibrillation (AF) for many years and I take Coumadin without any problems. I have no symptoms and I’m able to regularly play golf. I have a friend who had an ablation procedure to get rid of his AF. Am I a candidate for this procedure?
Atrial fibrillation, known as AF, is a condition characterized by erratic, irregular beating activity of the left atrium (upper chamber) of the heart. There are several issues to consider in treating AF, including controlling the heart rate (i.e., giving drugs that prevent the heart from beating too fast) and preventing clots from forming in the heart; the latter problem is usually addressed with drugs such as warfarin (Coumadin) or dabigatran (Pradaxa). On some occasions, your cardiologist may attempt to “convert” AF to a normal heart rhythm with medications or with a controlled electric shock (cardioversion). In patients who do not tolerate AF (i.e., have cardiac symptoms despite appropriate medical therapy), ablation is an option. There are both surgical and catheter-based procedures to abolish, or “ablate,” AF. A surgeon or cardiologist delivers a radiofrequency stimulus to the left atrium or to the pulmonary veins, which in many cases results in return to a normal heart rhythm. In the “robotic maze” procedure, the surgeon performs the ablation procedure through a small incision in the chest. However, most patients who have these procedures still need to take bloodthinning medications for some period of time, sometimes permanently.
Other novel strategies to reduce the potential consequences of AF are detailed in the article by Dr. Hanzel in this issue (see page 5). Check with your cardiologist regarding the varied treatment approaches to AF. If you are tolerating your AF and are able to take blood-thinners and rate control medicines without any problems, there is probably no pressing need for you to pursue the option of ablation.
I recently had an implantable cardioverter/defibrillator (ICD) implanted by my cardiologist after I had loss of consciousness due to a serious heart rhythm irregularity. The device shocked my heart while I was exercising, and my cardiologist started me on a drug called amiodarone. Why do I need to take medications if I already have an ICD?
An implantable cardioverter defibrillator (ICD) is a pacemaker-like device that is implanted under the skin on the chest, and shocks or “defibrillates” the heart in order to restore a normal rhythm. The analogy that I use for my patients is to consider an ICD as a “fire extinguisher,” in that the device will not activate unless there is a “fire.” What many patients don’t realize is that the ICD is really not doing anything other than monitoring your heartbeat, unless a dangerous rhythm problem arises, in which case it will shock your heart back into a normal rhythm. Approximately 36 percent of patients who have ICDs implanted never require a shock; however, if a patient does develop a recurrent electrical rhythm problem that causes the device to repeatedly fire, your cardiologist may opt to start you on a rhythm-stabilizing medication to prevent recurrence of the rhythm problem, so that you hopefully will not require another “shock” by your ICD (an unpleasant experience).
Value of generic cholesterollowering statins Approximately 80 percent of patients can achieve the recommended levels of low-density lipoprotein cholesterol (LDL) by taking the cheaper generic statins, including lovastatin, simvastatin or pravastatin. (Source: Bottom Line Personal, Nov. 2011)
Most sodium comes from processed and restaurant foods Home cooking
5% Processed and restaurant foods
Strategies to reduce sodium intake Americans average a daily intake of more than 3,400 mg of sodium. This substantially exceeds the maximum intake level (1,500 mg/day) recently recommended by the American Heart Association. Dietary sources of sodium are plentiful, are derived largely from processed and restaurant foods, and include many foods not commonly perceived as high sources of sodium. Recent studies also dispel the notion that excess salt intake is due primarily to salt added by the consumer at the table. Such use appears to account for only about 5 percent of sodium consumed. (Source: National Academy of Sciences, Institute of Medicine, 2012)
Statin drugs (continued from page 1) The problem with statins The answer is easy â€“ side effects. While the concern for side effects is warranted, the likelihood of experiencing them is quite low. The most common side effect is muscle aches, which tend to be felt throughout the body. These muscle aches, also known as myalgias, can be uncomfortable, but are harmless. Further, they resolve quickly after stopping the medication. Often muscle and joint aches that occur from exercise, hard work, tendinitis or arthritis are mistakenly attributed to statin drugs. It may, therefore, be reasonable to restart statin therapy among patients who previously developed these symptoms while on treatment. In addition, a patient who is truly intolerant to one statin drug can often tolerate a different statin medication without side effects. On rare occasion, patients taking a statin may develop inflammation of the muscle, a condition known as myositis or myopathy. Myositis is confirmed by a blood test that measures an enzyme called creatine kinase, or CK. If myositis occurs, the statin should be discontinued. The inflammation and muscle symptoms will gradually resolve. Again, like myalgias, myositis can be overdiagnosed. Patients can often have a brief increase in the CK that is unrelated to the medication. If symptoms are mild or absent when the CK is mildly increased, it is reasonable to wait and recheck the CK in about one week. If the CK returns to normal, statin therapy can continue. If, on the other hand, symptoms are more significant or weakness occurs, statin therapy should be immediately stopped. An extremely rare side effect is rhabdomyolysis, which is an intense inflammation of the muscle. When this occurs, the muscles are usually painful and weak, and CK levels are severely elevated. The kidneys can be injured or fail while trying to handle the protein released from the inflamed muscle. Early detection is crucial to prevent the most severe
outcomes. Accordingly, for patients who are taking a newly prescribed statin drug, new muscle discomfort should be promptly reported to your physician. A CK can be drawn to exclude this condition. Fortunately, rhabdomyolysis occurs in less than one out of ten thousand people taking a statin drug. Patients also worry about liver damage from statin therapy. Indeed, persistent minor elevations in liver enzymes can occur. However, this problem is seen in less than one percent of patients taking statins. These elevations are detected with a blood chemistry profile that measures the liver enzymes, aspartate aminotransferase (AST) and alanine aminotransferase (ALT). If a mild increase in liver enzymes is seen, it can safely be rechecked one to two weeks later. Usually the increases in AST and ALT occur without symptoms. Unless the increase in liver enzymes rises to more than three times the normal level, statin therapy can safely continue. Even when a significant statin-induced increase in liver enzymes occurs, it simply resolves when the medication is discontinued. As for liver failure, it is so rare that it is controversial whether statin-induced liver failure even exists. Nevertheless, it is appropriate that if unexplained abdominal discomfort or nausea occurs, an AST and ALT test should be done. Guidelines for cholesterol treatment also suggest these blood tests be routinely checked when monitoring cholesterol levels. The â€˜take homeâ€™ message Statin drugs are tremendously important in preventing heart attacks, strokes and death. Further, they are incredibly safe. There is no class of medication that has been as thoroughly studied as statins. Although side effects can and do occur, they are uncommon and generally harmless. Serious side effects are exceedingly rare. Routine follow up and monitoring are an important part of any medical strategy, including statin therapy. In summary, the benefits of statin therapy in patients with known or suspected cardiovascular disease far outweigh the potential risk of these medications.
Caloric expenditure (continued from page 5) aerobic exercise, are important factors that contribute to weight loss as well. The key to losing weight is not only to incorporate structured exercise and more physical activity into your daily routine, but also to be conscious of what you eat. A modest exercise regimen will not drop the extra pounds you want to lose. Being physically active is just as important as the structured exercise you get because it helps you burn additional calories throughout the day. So, take the stairs instead of the elevator, park further away from store entrances when shopping, and walk or ride your bike instead of driving. Diet, exercise and daily physical activity are all modulators of body weight and burning calories. The bottom line? Eat right, move more and sit less. Take action. A 1,000 mile journey begins with the first step.
Eat right, move more and sit less.
Faster walk in elderly may predict longer lifespan Older men who walk at a three-mile per hour or faster pace tend to outlive their counterparts who move along at slower speeds. The researchers suggest that older individuals who can pick up the walking pace are likely healthier and fitter than adults who move more slowly. (Source: British Medical Journal, Dec. 2011)
STATE OF THE HEAR T LINE-UP 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
Exercise stress test (continued from page 7)
By incorporating several exercise test responses into a mathematical formula or treadmill score, conventional exercise testing can often outperform the newer, more costly, noninvasive studies. According to Victor Froelicher, M.D., treadmill scores can help determine the type and advisability of further diagnostic testing. Low-risk patients could be spared from additional diagnostic studies, whereas high-risk patients would be referred for cardiac catheterization. Thus, for these patient subsets, treadmill scores would make additional noninvasive testing unnecessary. If I get an abnormal result, what’s next? An abnormal result may suggest the likelihood of underlying heart disease, especially major blockage of one or more arteries. Depending on the abnormality, you may be directly referred for cardiac catheterization or coronary angiography, to obtain pictures of your heart’s arteries and potential blockages. More likely, however, would be additional noninvasive tests (e.g., exercise echocardiography, exercise testing with cardiac imaging, computed tomography to detect calcium deposits in the coronary arteries, or electron-beam computed tomography to
visualize the coronary arteries). Patients who are limited in their ability to exercise may benefit from pharmacologic stress testing, which uses medications to increase heart rate or dilate coronary arteries. This form of testing is associated with an accuracy of up to 90 percent in detecting significant coronary blockages. If the results of these additional noninvasive tests are abnormal, cardiac catheterization may be recommended.
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.
If heart disease is diagnosed, your doctor may recommend a number of options including medications (such as statin drugs to lower cholesterol or aspirin therapy), a low-fat diet, an exercise-based cardiac rehabilitation program, and smoking cessation. In addition, depending on your symptoms and/or the severity of the disease, you may be a candidate for an angioplasty procedure. For persons with multiple major blockages, typical in individuals suffering from severe heart disease, coronary artery bypass surgery may be recommended.
Exercise Physiology/Fitness: Angela Fern, M.S.; Kirk Hendrickson, M.S.; Amy Fowler, B.S.
Epilogue By ultimately identifying underlying, unrecognized coronary artery disease, an exercise stress test can change, or even save, your life – as it may have saved the lives of the unlucky 118 people on the British Airways jet, who died because of someone else’s heart attack.
Preventive Cardiology: Steve Korotkin, M.D.
To make an appointment for an exercise stress test, go to www.beaumont.edu/secure/request-anappointment, or call 800-328-8542. 12
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.
Geriatrics: Michael Maddens, M.D.; John Voytas, M.D. 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.
Obesity, Diabetes, Metabolism: Wendy Miller, M.D.; Kerstyn Zalesin, M.D. Enhanced External Counterpulsation Therapy: Anne Davis, R.N. Women’s Issues: Pamela Marcovitz, M.D.; Melissa Stevens, M.D.