The skeptical cardiologist has always had a fondness for push-ups. Therefore I read with interest a recent study published in JAMAOpen which looked at how many push-ups a group of 30 and 40-something male firefighters from Indiana could do and how that related to cardiovascular outcomes over the next ten years.
The British National Health Service pointed out that “The UK media has rather over exaggerated these findings:”
Both the Metro and the Daily Mirror highlighted the result of 40 push-ups being “the magic number” for preventing heart disease, but in fact being able to do 10 or more push-ups was also associated with lower heart disease risk.
What Was Studied?
The study involved 1,104 male firefighters (average age 39.6) from 10 fire departments in Indiana who underwent regular medical checks between 2000 and 2010.
At baseline the participants underwent a physical fitness assessment which included push-up capacity (hereafter referred to as the push-up number (PUN))and treadmill exercise tolerance tests conducted per standardized protocols.
For push-ups, the firefighter was instructed to begin push-ups in time with a metronome set at 80 beats per minute. Clinic staff counted the number of push-ups completed until the participant reached 80, missed 3 or more beats of the metronome, or stopped owing to exhaustion or other symptoms (dizziness, lightheadedness, chest pain, or shortness of breath). Numbers of push-ups were arbitrarily divided into 5 categories in increments of 10 push-ups for each category. Exercise tolerance tests were performed on a treadmill using a modified Bruce protocol until participants reached at least 85% of their maximal predicted heart rates, requested early termination, or experienced a clinical indication for early termination according to the American College of Sports Medicine Guidelines (maximum oxygen consumption [V̇ O2max]).
The main outcomes assessed were new diagnoses of heart disease from enrollment up to 2010.
Cardiovascular events were verified by periodic examinations at the same clinic or by clinically verified return-to-work forms. Cardiovascular disease–related events (CVD) were defined as incident diagnosis of coronary artery disease or other major CVD event (eg, heart failure, sudden cardiac death)
Here’s the graph of the probability of being free of a CVD event on the y-axis with time on x-axis.
The black line represents those 75 firefighters who couldn’t make it into double digits, the green those 155 who did more than 40 pushups.
Participants able to complete more than 40 push-ups had a significant 96% lower rate of CVD events compared with those completing fewer than 10 push-ups.
It is surprising that the push up number seemed a better predictor of outcomes than the exercise test, This should be taken with a grain of salt because although the investigators report out “VO2 max” the stress tests were not maximal tests.
The firefighters with lower push up numbers were fatter, more likely to smoke and had higher blood pressure, glucose and cholesterol levels.
What useful information can one take from this study?
You definitely cannot say that being able to do more than 40 pushups will somehow prevent heart disease. The PUN is neither causing nor preventing anything.
The PUN is a marker for the overall physical shape of these firefighters. It’s a marker for how these men were taking care of themselves. If you are a 39 year old fireman from Indiana and can’t do 11 push-ups you are in very sorry condition and it is likely evident in numerous other ways.
The <11 PUN crew were a bunch of fat, diabetic, insulin resistant, hyperlipidemic, out-of-shape hypertensives who were heart attacks in the waiting.
Push-ups Are A Great Exercise
Despite the meaningless of this study you should consider adding push-ups to your exercise routine. Doing them won’t save your life but it will contribute to mitigating the weakness and frailty of aging. Don’t obsess about your PUN.
I’ve always liked push-ups and highly recommend them. They require no special equipment or preparation. It’s a quick exercise that builds upper body muscle strength, adds to my core strength and gets my heart rate up a bit. For some reason my office in O’Fallon is always cold so several times during the day when I’m there I’ll do 100 jumping jacks and drop on the carpet and do some push-ups in an effort to get warm.
I don’t do them every day but the last time I tried I could do 50 in less than a minute and that has me convinced I will live forever!
Americans spend billions on useless supplements and vitamins in their search for better health but exercise is a superior drug, being free and without drug-related side effects
I’ve spent a lot of time on this blog emphasizing the importance of aerobic exercise for cardiovascular health but I also am a believer in strength and flexibility training for overall health and longevity.
As we age we suffer more and more from sarcopenia-a gradual decrease in muscle mass.
Scientific reviews note that loss of muscle mass and muscle strengh is quite common in individuals over age 65 and is associated with increased dependence, frailty and mortality
Push-ups are a great resistance exercise. For a description of the perfect form for a push up see here.
It is available online and through an app for Apple and Android (search in the app store on “MESA Risk Score” for the (free) download.)
The MESA tool allows you to easily calculate how the CACS effects you or your patient’s 10 year risk of ASCVD.
The Multi-Ethnic Study of Atherosclerosis (MESA) is a study of the characteristics of subclinical cardiovascular disease (disease detected non-invasively before it has produced clinical signs and symptoms) and the risk factors that predict progression to clinically overt cardiovascular disease or progression of the subclinical disease. MESA researchers study a diverse, population-based sample of 6,814 asymptomatic men and women aged 45-84. Approximately 38 percent of the recruited participants are white, 28 percent African-American, 22 percent Hispanic, and 12 percent Asian, predominantly of Chinese descent.
To use the score you will need information on the following risk factors:
age, gender, race/ethnicity, diabetes (yes/no), current smoker (yes/no), total and HDL cholesterol, use of lipid lowering medication (yes/no), systolic blood pressure (mmHg), use of anti-hypertensive medication (yes/no), any family history of heart attack in first degree relative (parent/sibling/child) (yes/no), and a coronary artery calcium score (Agatston units).
In many cases the CACS dramatically lowers or increases the risk estimate.
In this example a 64 year old man with no discernible risk factors has a CACS of 175 The 10 year risk of a CHD event almost doubles from 4.7% to 7.6% when the CACS is added to the standard risk factors and moves into a range where we need much more aggressive risk factor modification.
On the other hand if we enter in zero for this same patient the risk drops to a very low 1.9%.
It’s also instructive to adjust different variables. For example, if we change the family history of heart attack (parents, siblings, or children) from no to yes, this same patient’s risk jumps to 7.2% (2.6% with zero calcium score and to 10.4% with CACS 175.)
It can also be used to help modify risk-enhancing behaviors. For example if you click smoker instead of non-smoker the risk goes from 4.7% to 7.5%. Thus, you can tell your smoking patient that his risk is halved if he stops.
Discussions on the value of tighter BP control can also be informed by the calculator. For example, if our 64 year old’s systolic blood pressure was 160 his risk has increased to 6.8%.
How Does Your CACS Compare To Your Peers?
A separate calculator let’s you see exactly where your score stands in comparison individuals with your same age, gender, and ethnicity
The Coronary Artery Calcium (CAC) Score Reference Values web tool will provide the estimated probability of non-zero calcium, and the 25th, 50th, 75th, and 90th percentiles of the calcium score distribution for a particular age, gender and race. Additionally, if an observed calcium score is entered the program will provide the estimated percentile for this particular score. These reference values are based on participants in the MESA study who were free of clinical cardiovascular disease and treated diabetes at baseline. These participants were between 45-84 years of age, and identified themselves as White, African-American, Hispanic, or Chinese. The current tool is thus applicable only for these four race/ethnicity categories and within this age range.
The calculator tells us that 75% of 64 year old white males have a zero CACS and that the average CACS is 61.
Unlike SAT scores or Echo Board scores you don’t want your CACS percentile status to be high. Scores >75th percentile typically move you to a higher risk category, whereas scores <25th percentile move you to a lower risk category, often with significant therapeutic implications.
Scores between the 25th and 75th percentile typically don’t significantly change the risk calculation.
Exploring Gender Differences In CACS
If we change the gender from male to female on our 64 year old the risk drops considerably from 4.7% down to 3.3%. This graph demonstrates that over 20% of women between the ages of 75 and 84 years will have zero calcium scores.
The graph for men in that same range shows that only around 10% will have a zero CACS.
I’ve been asked what the upper limit is for CACS but I don’t think there is one. I’ve seen numerous patients with scores in the high two thousands and these graphs show individuals in the lowest age decile having scores over 2981.
If you want to be proactive about the cardiovascular health of yourself or a loved one, download the MESA app and evaluate your risk. Ask your doctor if a CACS will help refine that risk further.
The writer, Roni Rabin (who has a degree in journalism from Columbia University) struggles to support her sense that there is a “growing body of research” suggesting we should all modify our current dietary habits in order to eat a breakfast and make breakfast the largest meal of the day.
Many of us grab coffee and a quick bite in the morning and eat more as the day goes on, with a medium-size lunch and the largest meal of the day in the evening. But a growing body of research on weight and health suggests we may be doing it all backward.
Rabin’s first discussion is of an observational study of Seventh Day Adventists published in July which adds nothing to the evidence in this area because (as she points out):
The conclusions were limited, since the study was observational and involved members of a religious group who are unusually healthy, do not smoke, tend to abstain from alcohol and eat less meat than the general population (half in the study were vegetarian)
She then discusses experiments on mice from 2012 with a Dr. Panda, a short term feeding trial in women from 2013 and studies on feeding and circadian rhythm in a transgenic rat model from 2001.
There is nothing of significance in the NY Times piece that changes my previous analysis that it is perfectly safe to skip breakfast and that it will neither make you obese nor give you heart disease.
Finally, I’ll take a close look at a statment from the American Heart Association from earlier this year which Rabin quotes and which many news outlets somehow interpreted as supporting the necessity of eating breakfast for heart health when, in fact, it confirmed the lack of science behind the recommendation.
Feel Free To Skip Breakfast
It always irritates me when a friend tells me that I should eat breakfast because it is “the most important meal of the day”. Many in the nutritional mainstream have propagated this concept along with the idea that skipping breakfast contributes to obesity. The mechanism proposed seems to be that when you skip breakfast you end up over eating later in the day because you are hungrier.
The skeptical cardiologist is puzzled.
Why would i eat breakfast if I am not hungry in order to lose weight?
What constitutes breakfast?
Is it the first meal you eat after sleeping? If so, wouldn’t any meal eaten after sleeping qualify even it is eaten in the afternoon?
Is eating a donut first thing in the morning really healthier than eating nothing?
Why would your first meal be more important than the last?
Isn’t it the content of what we eat that is important more than the timing?
eat a nutrient-dense breakfast. Not eating breakfast has been associated with excess body weight, especially among children and adolescents. Consuming breakfast also has been associated with weight loss and weight loss maintenance, as well as improved nutrient intake
Eating a healthy breakfast is a good way to start the day and may be important in achieving and maintaining a healthy weight
Biased and Weak Studies on the Proposed Effect of Breakfast on Obesity (PEBO)
A recent study anayzes the data in support of the “proposed effect of breakfast on obesity” (PEBO) and found them lacking.
This is a fascinating paper that analyzes how scientific studies which are inconclusive can be subsequently distorted or spun by biased researchers to support their positions. It has relevance to how we should view all observational studies.
Observational studies abound in the world of nutritional research. The early studies by Ancel Keys establishing a relationship between fat consumption and heart disease are a classic example. These studies cannot establish causality. For example, we know that countries that consume large amounts of chocolate per capita have large numbers of Nobel Prize winners per capitaChocolate Consumption and Nobel Laureates
Common sense tells us that it is not the chocolate consumption causing the Nobel prizes or vice versa but likely some other factor or factors that is not measured.
Most of the studies on PEBO are observational studies and the few, small prospective randomized studies don’t clearly support the hypothesis.
Could the emphasis on eating breakfast come from the “breakfast food industry”?
I’m sure General Mills and Kellogg’s would sell a lot less of their highly-processed, sugar-laden breakfast cereals if people didn’t think that breakfast was the most important meal of the day.
My advice to overweight or obese patients:
-Eat when you’re hungry. Skip breakfast if you want.
-If you want to eat breakfast, feel free to eat eggs or full-fat dairy (including butter)
-These foods are nutrient-dense and do not increase your risk of heart disease, even if you have high cholesterol.
-You will be less hungry and can eat less throughout the day than if you were eating sugar-laden, highly processed food-like substances.
The “must eat breakfast” dogma reminds me of a quote from Melanie Warner’s excellent analysis of the food industry, “Pandora’s Lunchbox.”
“Walk down a cereal aisle today or go onto a brand’s Web site, and you will quickly learn that breakfast cereal is one of the healthiest ways to start the day, chock full of nutrients and containing minimal fat. “Made with wholesome grains,” says Kellogg’s on its Web site. “Kellogg’s cereals help your family start the morning with energy by delivering a number of vital, take-on-the-day nutrients—nutrients that many of us, especially children, otherwise might miss.” It sounds fantastic. But what you don’t often hear is that most of these “take-on-the-day” nutrients are synthetic versions added to the product, often sprayed on after processing. It’s nearly impossible to find a box of cereal in the supermarket that doesn’t have an alphabet soup of manufactured vitamins and minerals, unless you’re in the natural section, where about half the boxes are fortified.”
The Kellogg’s and General Mills of the world strongly promoted the concept that you shouldn’t skip breakfast because they had developed products that stayed fresh on shelves for incredibly long periods of time. They could be mixed with easily accessible (low-fat, no doubt) milk to create inexpensive, very quickly and easily made, ostensibly healthy breakfasts.
Unfortunately, the processing required to make these cereals last forever involved removing the healthy components.
As Warner writes about W.K. Kellogg:
“In 1905, he changed the Corn Flakes recipe in a critical way, eliminating the problematic corn germ, as well as the bran. He used only the starchy center, what he referred to as “the sweetheart of the corn,” personified on boxes by a farm girl clutching a freshly picked sheaf. This served to lengthen significantly the amount of time Corn Flakes could sit in warehouses or on grocers’ shelves but compromised the vitamins housed in the germ and the fiber residing in the bran”
This is a very familiar story in the world of food processing; Warner covers, nicely, the same processes occurring with cheese and with milk, among other things.
The AHA (Always Horribly Awry) Weighs In
I pick on the American heart Association (AHA) a lot in this blog but the AHA scientific statement on “Meal Timing and Frequency: Implications for Cardiovascular Disease Prevention” published earlier this year in Circulation is for the most part a balanced summary of research in the field.
Unfortunately, the media grossly distorted the statement and we ended up with assertive headlines such as this one from Reuters:
Reuters went on to say (red added by me for emphasis):
“Planning meals and snacks in advance and eating breakfast every day may help lower the risk of cardiovascular disease, new guidelines from U.S. doctors say.”
however, the AHA statement says nothing close to that.
This is the summary that was actually in the AHA paper:
“In summary, the limited evidence of breakfast consumption as an important factor in combined weight and cardiometabolic risk management is suggestive of a minimal impact. There is increasing evidence that advice related to breakfast consumption does not improve weight loss, likely because of compensatory behaviors during the day. …… Additional, longer-term studies are needed in this field because most metabolic studies have been either single-day studies or of very short duration”
The lead author of the paper, Marie-Pierre St-Onge, (Ph.D., associate professor, nutritional medicine, Columbia University, New York City) apparently very clearly told Reuters in an email:
“We know from population studies that eating breakfast is related to lower weight and healthier diet, along with lower risk of cardiovascular disease,” .
“However, interventions to increase breakfast consumption in those who typically skip breakfast do not support a strong causal role of this meal for weight management, in particular,” St-Onge cautioned. “Adding breakfast, for some, leads to an additional meal and weight gain.”
“The evidence, St-Onge said, is just not clear enough to make specific recommendations on breakfast.”
Health New Review published a nice summary of news reports on the AHA statement with a discussion on the overall problem of making broad public policy dietary recommendations from very weak evidence.
New York Times Gets It Right
The New York Times does have writers who can put together good articles on health. One of them, Aaron Carroll wrote a piece in 2016 entitled “Sorry, There’s Nothing Magical About Breakfast” which does a great job of sorting through weak evidence in the field.
Carroll is a professor of pediatrics at Indiana University School of Medicine and writes excellent articles on The New Health Care blog for the Times.
His conclusions are identical to mine from 2013:
“The bottom line is that the evidence of breakfast is something of a mess. If you’re hungry, eat it. But don’t feel bad if you’d rather skip, and don’t listen to those who lecture you. Breakfast has no mystical powers.”
Mindful and Intentional Eating
If you read the AHA statement completely you come across a lot of mumbo-jumbo on intermittent fasting, meal frequency and “mindful” eating. The abstract’s last sentence is
Intentional eating with mindful attention to the timing and frequency of eating occasions could lead to healthier lifestyle and cardiometabolic risk factor management.
and they reference this table:
Yikes! I have no idea what they are talking about.
For those of us who need to get to work early in the morning, breakfast is likely to be the worst time for “mindful” eating.
I have a cup of coffee first thing upon arising and only eat much later in the day when I feel very hungry.
Dinner, on the other hand we can plan for, prepare with loved ones and consume in a very mindful and leisurely fashion with a glass of heart healthy wine or beer while enjoying good conversation.
So, ignore what apparently authoritative sources like the New York Times, Reuters, and the AHA tell you about eating breakfast like a king, lunch like a prince, and dinner like a pauper, mindfully or otherwise.
After all, in the Middle Ages, kings likely didn’t eat breakfast as the Catholic church frowned on it. Per Wikipedia:
Breakfast was under Catholic theological criticism. The influential 13th-century Dominican priest Thomas Aquinas wrote in his Summa Theologica (1265–1274) that breakfast committed “praepropere,” or the sin of eating too soon, which was associated with gluttony.Overindulgences and gluttony were frowned upon and were considered boorish by the Catholic Church, as they presumed that if one ate breakfast, it was because one had other lusty appetites as well, such as ale or wine.
Image of king and pauper eating from the New York Times article created by Natalya Balnova.
As the skeptical cardiologist surveys the heart health information available to his patients and the lay public, he sees two broad categories of misinformation.
First we have the quacks and snake oil salesman. These are primarily characterized by a goal of selling more of their useless stuff online.
I’ve described this as the #1 red flag of quackery. Usually I’m inspired to investigate these charlatans because a patient asks me about one of their useless supplements.
The second category is more insidious: the magazine or internet news site seems to have as its legitimate goal, promoting the health of its readers. There is no clear connection to a product.
Web MD, which I wrote about here, is an example of this second type. Hard copy versions of these types of media frequently make it into doctor’s waiting rooms: not because doctor’s have read and approved what is in them. These companies send their useless and misleading magazines for free to doctor’s offices, and the staff believe it to be legitimate.
How does glaringly inaccurate and often dangerous information get into media that ostensibly has as its goal promoting its readers health? Most likely, it is a result of media’s need to constantly produce new and interesting ways for readers to improve their health.
Clearly, readers will not continue subscribing, clicking and reading such sources of information if there isn’t something new and exciting that might prolong their lives: gimmicks, miracles cures, and “natural” remedies are more alluring than the well-known advice to exercise more, watch your weight, stop smoking and get a good night’s sleep.
Reader’s Digest was a staple of my childhood. My parents subscribed to it consistently and I would read parts of it. It was small and enticing. Allegedly its articles were crafted so that they could be read in their entirety during a session in the bathroom.
To this day it has a wide circulation. Per Wikipedia”
Global editions of Reader’s Digest reach an additional 40 million people in more than 70 countries, via 49 editions in 21 languages. The periodical has a global circulation of 10.5 million, making it the largest paid circulation magazine in the world.
Reader’s Digest used to run a recurring educational feature on the various body parts and organs of Joe and Jane which intrigued me.
I am certainly no beauty. I weigh 340 grams, am red-brown in color and have an unimpressive shape. I am the dedicated slave of Joe. I am Joe’s heart.
The health information in this series was generally accurate but the presentation lacks the kind of sizzle that apparently attracts today’s readers.
The article my patient brought to my attention is typical of the mix of good and bad information and fluff that mainstream media can produce to attract followers:
Not So Bad But Not Clearly True Medical Advice
#1. I keep a gratitude journal. An internist “at NYU” is quoted as saying: “Studies have recently shown that expressing gratitude may have a significant positive impact on heart health.”
Fact Check: following the links provided provides no evidence to support this claim.
#2 I get 8 hours of sleep a night, every night. This cardiologist seems to have been misquoted, because her comment is actually “getting a good night sleep is essential. I make a point of getting seven to eight hours of sleep every night…Poor sleep is linked to higher blood pressure.”
Too little or too much sleep are associated with adverse health outcomes, including total mortality, type 2 diabetes, hypertension, and respiratory disorders, obesity in both children and adults, and poor self-rated health.
Another broke down mortality according to number of hours of sleep.
A J-shaped association between sleep duration and all-cause mortality was present: compared with 7 h of sleep (reference for 24-h sleep duration), both shortened and prolonged sleep durations were associated with increased risk of all-cause mortality (4 h: relative risk [RR] = 1.05; 95% confidence interval [CI] = 1.02–1.07; 5 h: RR = 1.06; 95% CI = 1.03–1.09; 6 h: RR = 1.04; 95% CI = 1.03–1.06; 8 h: RR = 1.03; 95% CI = 1.02–1.05; 9 h: RR = 1.13; 95% CI = 1.10–1.16; 10 h: RR = 1.25; 95% CI = 1.22–1.28; 11 h: RR = 1.38; 95% CI = 1.33–1.44; n = 29; P < 0.01 for non-linear test)
Thus, in comparison to those who sleep 7 hours, those who sleep 5 hours have a 5% increase in mortality and those who sleep 11 hours have a 38% increase in mortality.
These data are based entirely on observational studies so it is impossible to know if the shortened sleep is responsible for the increased mortality or if some other (confounding) factor is causing both.
My advice: Some people do fine with 6 hours and 45 minutes of sleep. Some require 8 hours 15 minutes for optimal function. Rather than obsessing about getting a specific amount of sleep time, it makes more sense to find our through your own careful observations what sleep time works best for you and adjust your schedule and night time patterns accordingly.
#3. I do CrossFit.
Fact Check. There is nothing to support CrossFit as more heart healthy than regular aerobic exercise (which the vast majority of cardiologists recommend and perform).
#4. I meditate. “Negative thoughts and feelings of sadness can be detrimental to the heart. Stress can cause catecholamine release that can lead to heart failure and heart attacks.”
Fact Check. There is a general consensus that stress has adverse consequences for the cardiovascular system. Evidence of meditation improving cardiovascular outcomes is very weak.
Participation in meditation practices has been shown to reduce depression, anxiety, and negative mood and thus may have an indirect positive effect on CV health and well-being. This possibility has led the American Heart Association to classify TM as a class IIb, level of evidence B alternative approach to lowering BP.32
Non randomized, non blinded studies with small numbers of participants have suggested a reduction in CV death in those performing regular TM.
However, we need better and larger studies before concluding there is a definite benefit compared to optimal medical therapy.
Thus far, the recommendations have been pretty mundane: exercise, stress reduction and a good night’s sleep is good advice for all, thus boring.
Seriously Bad Advice From Quacks Mixed In With Reasonable Advice
In order to keep reader’s interest (and reach 45 things) Reader’s Digest is going to need to add seriously bad advice.
My patient had circled #34. “I mix magnesium powder into my water. If sufficient magnesium is present in the body, cholesterol will not be produced in excess.”
This bizarre and totally unsubstantiated practice was recommended by Carolyn Dean MD, ND.
What do we know about Dr. Dean?
-She was declared unfit to practice medicine and her registration revoked by the College of Physicians and Surgeons of Ontario in 1995. From quackwatch.org :
After being notified in 1993 that a disciplinary hearing would be held, Dean relocated to New York and did not contest the charges against her.
Dean had used unscientific methods of testing such as hair analysis, Vega and Interro testing, iridology and reflexology as well as treatment not medically indicated and of unproven value, such as homeopathy, colonic irrigations, coffee enemas, and rotation diets.
-The initials after her name (ND, doctor of naturopathy) should be considered the second red flag of quackery. See quackwatch.org (here) and rational wiki (here) and the confessions of a former naturopath (here ) for discussions of naturopathy. As noted at science-based medicine:
“Go ahead, try them at home: Experts swear by these nondrug cures for back pain, nausea, hot flashes, and other common ailments.”
Who are these “experts”? Let the reader beware because the first quote comes from “Amy Rothenberg, past president of the Massachusetts Society of Naturopathic Doctors.”
Finding The Truth
It’s getting harder and harder for the lay public to sort out real from fake health stories and advice.
When seemingly legitimate news media and widely followed sources like Reader’s Digest and Prevention Magazine either consciously or inadvertently promote quackery, the truth becomes even more illusive.
Readers should avoid any source of information which
Profits from selling vitamins and supplements.
Utilizes or promotes naturopaths or other obvious quacks as experts in health advice.
“The Monday following spring time changes was associated with a 24% increase in daily AMI counts (p=0.011), and the Tuesday following fall changes was conversely associated with a 21% reduction (p=0.044). No significant difference in total weekly counts or for any other individual weekdays in the weeks following DST changes was observed.”
Our data argue that DST could potentially accelerate events that were likely to occur in particularly vulnerable patients and does not impact overall incidence. There is considerable controversy over the health and economic benefits of DST, and some authorities have argued that this practice should be abandoned.17 Although we are unable to comment on the merits of these arguments, our data suggest that while such a move might change the temporal fluctuations in AMI, it is unlikely to impact the total number of MIs in the broader population.
Mondays, in general, are the days of the week on which most MIs occur. This has been attributed to an abrupt change in the sleep–wake cycle and increased stress in relation to the start of a new work week
Manipulations of the sleep–wake cycle have been linked to imbalance of the autonomic nervous system, rise in proinflammatory cytokines and depression so presumably the additional disruption created by DST adds to this effect.
However, the data suggest that this very weak effect means only that if you were going to have an MI in the next week, after DST it is more likely to occur on the Monday of that week than on another day. Your overall risk of MI is not changed.
From a public health standpoint the major conclusion is that emergency rooms and cath labs should consider increasing staffing by 24% on the Monday after the spring DST time change.
I don’t think this is a significant factor for my patients. We have to deal with events and stressors that influence our sleep-wake cycle constantly. Good planning and sleep hygiene are the keys to success and reducing stress.
So, fear not the grim reaper as you set your clocks forward tonight.
The most popular skeptical cardiologist post is one written a year ago concerning over-the-counter (OTC) cold medications.
Little has changed in the 8 billion dollar world of useless and confusing OTC cold, flu, and sinus medications since then.
I still advise avoiding them and utilizing specific medications for specific symptoms.
I’m updating the article with additional comments on two frequently encountered drugs that I did not cover originally.
Alka-Seltzer Plops Into The OTC Cold Market
I had always viewed Alka-Seltzer as an effervescent tablet which was a treatment for acid reflux, a.k.a. upset stomach, but the brand (now owned by Bayer) has moved aggressively into the bewildering morass of over the counter OTC cold meds. Indeed, when Alka-Seltzer began in 1931 it was a combination of aspirin and sodium bicarbonate (baking soda) marketed for upset stomachs. Popular commercials from the 1960s featured the catchy jingle (still stuck in my head) “Plop, Plop, Fizz, Fizz. Oh What a Relief It Is” often sung by Speedy, an odd anthropomorphic creature with an Alka-Seltzer thorax and cap.
(The jingle was written by Tom Dawes of The Cyrcle (Red Rubber Ball) and not by the father of Juliana Margulies)
Recently, I received a request from an out-of-town guest who was suffering from a cough and upper respiratory infection (URI) to purchase Alka-Seltzer plus in the form of a tablet that dissolves in hot water .
At his request, Alka-Seltzer Plus Day Multi-Symptom Cold and Flu was purchased at the local Walgreen’s.
The ingredients are typical for many of the Alka-Seltzer products:
-dextromethorphan (promoted for cough but ineffective with considerable side effects, see my initial post)
-acetaminophen (Tylenol, for pain and fever)
-phenylephrine (decongestant )
Phenylephrine: Ineffective Substitute for Pseudoephedrine
I didn’t cover phenylephrine in my previous post. It has taken the place of pseudoephedrine in on the shelf over the counter URI (OTSOTCURI) medications.
Like pseudoephedrine, phenylephrine is a sympathomimetic drug, meaning it stimulates receptors of the sympathetic nervous system. Unlike pseudoephedrine, phenylephrine is useless as a decongestant when taken in the dosages available over the counter.
A study published in february, 2015 confirmed what previous studies had suggested: phenylephrine in dosages of 10 to 40 mg daily was no more effective than placebo in reducing symptoms of nasal congestion.
An accompanying editorial called on OTSOTCURI manufactures to remove this useless drug from their products.
Alas, all of the Alka-Seltzer preparations that claim to treat congestion utilize phenylephrine as the decongestant.
The transition to useless phenylephrine took place when pseudoephedrine was taken off the shelves and put behind the counter to reduce its usage in making methamphetamine.
Therefor, Alka-Seltzer plus multi-symptom cold and flu contains two useless ingredients plus acetaminophen (Tylenol).
You can buy a large bottle of cheap generic acetaminophen and take exactly the right dose you need for relieving fever or body aches without paying for two useless accompanying drugs which have the potential for giving you unwanted side effects.
Nighttime Sleep Aids In OTC Cold Meds
I covered the most common drug found in OTC cold meds that are promoted for nighttime use, diphenhydramine/benadryl, in my previous post.
Nighttime Alka-Seltzer products contain a similar sedating antihistamine called doxylamine succinate. For example , Alka-Seltzer Severe Cold and Cough Liquid Night (ASCCLN) contains:
-Acetaminophen 650 mg
-Dextromethorphan hydrobromide 30 mg
-Doxylamine succinate 12.5 mg
Doxylamine is the active ingredient in the brand name sleep aid Unisom and the “ZZquil” products from the Nyquil brand that are promoted for inducing sleep. It is available in cheap, generic form at a cost of 7.90$ for 96 25 mg tablets. According to drugbank.ca:
“It is also the most powerful over-the-counter sedative available in the United States, and more sedating than many prescription hypnotics. In a study, it was found to be superior to even the barbiturate, phenobarbital for use as a sedative.”
Note that the effective dosage recommended in separate sleep aids is 25 mg not the 12.5 mg found in Alka-Seltzer OTC cold meds, Thus, if you want an effective dosage of doxyylamine to help you sleep, you must double the recommended dosage of Alka-seltzer SCCLN which gives you too much acetaminophen and dextromethorphan.
Doubling these drugs raises the potential for side effects. Common dextromethorphan side effects include nausea/vomiting, dizziness, diarrhea, nervousness. Too much acetaminophen can damage the liver.
In addition, both dextromethorphan and acetaminophen interact with multiple other medications. Dextromethorphan is known to interact with 76 medications.
Acetaminophen can increase the INR (measure of blood thinning) in patients taking warfarin and increase the risk of dangerous bleeding.
“I think you are much better off avoiding these brand name mixtures of different active ingredients.
Instead, you should take what you need for a specific symptom in the appropriate dosage and time interval.
Thus, if you have pain, take the minimal dose of tylenol that relieves it and repeat when it comes back.
If you have a cough, recognize that the OTC ingredients are no better than placebo and are being abused as recreational drugs. Most coughs go away shortly but if one is particularly troublesome and persistent get a cough suppressing drug from your physician.
If you have a really runny nose with a lot of sneezing it is probably OK to take pseudoephedrine even if you are a heart patient or have high blood pressure. Take it as I described above. Start with 30 mg of the little red pseudoephedrine pills , wait an hour to see how you feel. Take a second if it has not been effective. Repeat at 4-6 hour intervals as needed. Take your blood pressure at least once after starting it.
Don’t buy the multi-symptom multiple ingredient combinations which are simply a marketing tool to get you to spend more money on something from which you won’t benefit.”
Why is death from coronary heart disease declining in the US at the same time that obesity and diabetes rates are climbing?
Two editorials recently published in The Lancet show the widely varying opinions on the optimal diet for controlling obesity , diabetes and coronary heart disease that experts on nutrition, diabetes and heart disease hold.
The first paper contains what I would consider the saturated fat “traditionalist” viewpoint. This is a modification of the misguided concept that was foisted on the American public in the 1980s and resulted in the widespread consumption of industrially produced trans-fats and high sugar junk food that was considered heart healthy.
The traditionalists have shifted from condemning all fats to vilifying only saturated and trans fats. They would like to explain at least part of the reduction in coronary heart mortality as due to lower saturated fat consumption and the accompanying lowering of LDL (“bad”) cholesterol.
The SFA traditionalists fortunately are in decline and more and more in the last five years, prominent thinkers, researchers and scientists working on the connection between diet and the heart believe saturated fats are neutral but sugar and refined carbohydrates are harmful in the diet.
Darius Mozzafarian, a highly respected cardiologist and epidemiologist, who is dean of the School of Nutrition Science and Policy at Tufts, wrote the second editorial and is what I would term a saturated fatty acid (SFA) progressive.
He makes the following points which are extremely important to understand and which I have covered in previous posts. I’ve included his supporting references which can be accessed here.
Fat Doesn’t Make You Fat, Refined Starches And Sugar Do
"Foods rich in refined starches and sugars—not fats—seem to be the primary culprits for weight gain and, in turn, risk of type 2 diabetes. To blame dietary fats, or even all calories, is incorrect
Although any calorie is energetically equivalent for short-term weight loss, a food's long-term obesogenicity is modified by its complex effects on satiety, glucose–insulin responses, hepatic fat synthesis, adipocyte function, brain craving, the microbiome, and even metabolic expenditure Thus, foods rich in rapidly digestible, low-fibre carbohydrates promote long-term weight gain, whereas fruits, non-starchy vegetables, nuts, yoghurt, fish, and whole grains reduce long-term weight gain.1, 2, 3
Overall, increases in refined starches, sugars, and other ultraprocessed foods; advances in food industry marketing; decreasing physical activity and increasing urbanisation in developing nations; and possibly maternal–fetal influences and reduced sleep may be the main drivers of obesity and diabetes worldwide".
There Are Many Different Kinds of Saturated Fats With Markedly Different Health Effects: It Makes No Sense to Lump Them All Together
"SFAs are heterogeneous, ranging from six to 24 carbon atoms and having dissimilar biology. For example, palmitic acid (16:0) exhibits in vitro adverse metabolic effects, whereas medium-chain (6:0–12:0), odd-chain (15:0, 17:0), and very-long-chain (20:0–24:0) SFAs might have metabolic benefits.4 This biological and metabolic diversity belies the wisdom of grouping of SFAs based on a single common chemical characteristic—the absence of double bonds. Even for any single SFA, physiological effects are complex: eg, compared with carbohydrate, 16:0 raises blood LDL cholesterol, while simultaneously raising HDL cholesterol, reducing triglyceride-rich lipoproteins and remnants, and having no appreciable effect on apolipoprotein B, 5 the most salient LDL-related characteristic. Based on triglyceride-lowering effects, 16:0 could also reduce apolipoprotein CIII, an important modifier of cardiovascular effects of LDL and HDL cholesterol. SFAs also reduce concentrations of lipoprotein(a) ,6 an independent risk factor for coronary heart disease."
The Effects of Dietary Saturated Fats Depend on Complex Interactions With The Other Ingredients in Food
"Dietary SFAs are also obtained from diverse foods, including cheese, grain-based desserts, dairy desserts, chicken, processed meats, unprocessed red meat, milk, yoghurt, butter, vegetable oils, and nuts. Each food has, in addition to SFAs, many other ingredients and characteristics that modify the health effects of that food and perhaps even its fats. Judging the long-term health effects of foods or diets based on macronutrient composition is unsound, often creating paradoxical food choices and product formulations. Endogenous metabolism of SFAs provide further caution against oversimplified inference: for example, 14:0 and 16:0 in blood and tissues, where they are most relevant, are often synthesised endogenously from dietary carbohydrate and correlate more with intake of dietary starches and sugars than with intake of meats and dairy.4"
Dietary Saturated Fat Should Not Be a Target for Health Promotion
"These complexities clarify why total dietary SFA intake has little health effect or relevance as a target. Judging a food or an individual's diet as harmful because it contains more SFAs, or beneficial because it contains less, is intrinsically flawed. A wealth of high-quality cohort data show largely neutral cardiovascular and metabolic effects of overall SFA intake.7 Among meats, those highest in processing and sodium, rather than SFAs, are most strongly linked to coronary heart disease.7Conversely, higher intake of all red meats, irrespective of SFA content, increases risk of weight gain and type 2 diabetes; the risk of the latter may be linked to the iron content of meats.2, 8 Cheese, a leading source of SFAs, is actually linked to no difference in or reduced risk of coronary heart disease and type 2 diabetes.9, 10 Notably, based on correlations of SFA-rich food with other unhealthy lifestyle factors, residual confounding in these cohorts would lead to upward bias, causing overestimation of harms, not neutral effects or benefits. To summarise, these lines of evidence—no influence on apolipoprotein B, reductions in triglyceride-rich lipoproteins and lipoprotein(a), no relation of overall intake with coronary heart disease, and no observed cardiovascular harm for most major food sources—provide powerful and consistent evidence for absence of appreciable harms of SFAs."
Dietary Saturated Fats May Raise LDL cholesterol But This Is Not Important: Overall Effects On Obesity and Atherosclerosis Are What Matters
"a common mistake made by SFA traditionalists is to consider only slices of data—for example, effects of SFAs on LDL cholesterol but not their other complex effects on lipids and lipoproteins; selected ecological trends; and expedient nutrient contrasts. Reductions in blood cholesterol concentrations in Western countries are invoked, yet without systematic quantification of whether such declines are explained by changes in dietary SFAs. For example, whereas blood total cholesterol fell similarly in the USA and France between 1980 and 2000, changes in dietary fats explain only about 20% of the decline in the US and virtually none of that which occurred in France.11Changes in dietary fats11 simply cannot explain most of the reductions in blood cholesterol in Western countries—even less so in view of the increasing prevalence of obesity. Medication use also can explain only a small part of the observed global trends in blood cholesterol and blood pressure. Whether decreases in these parameters are caused by changes in fetal nutrition, the microbiome, or other unknown pathways remains unclear, thus highlighting a crucial and greatly underappreciated area for further investigation."
Dietary Saturated Fats Are Neutral For Coronary heart Disease Risk
Finally, SFA traditionalists often compare the effects of SFAs only with those of vegetable polyunsaturated fats, one of the healthiest macronutrients. Total SFAs, carbohydrate, protein, and monounsaturated fat each seem to be relatively neutral for coronary heart disease risk, likely due to the biological heterogeneity of nutrients and foods within these macronutrient categories.7Comparisons of any of these broad macronutrient categories with healthy vegetable fats would show harm,12 so why isolate SFAs? Indeed, compared with refined carbohydrates, SFAs seem to be beneficial.7
The overall evidence suggests that total SFAs are mostly neutral for health—neither a major nutrient of concern, nor a health-promoting priority for increased intake.
Focusing On Reducing Saturated Fats Leads To Unhealthy Dietary Choices
"Continued focus on modifying intake of SFAs as a single group is misleading—for instance, US schools ban whole milk but allow sugar-sweetened skim milk; industry promotes low-fat foods filled with refined grains and sugars; and policy makers censure healthy nut-rich snacks because of SFA content.13 "
It is extremely hard to change most people’s opinions on dietary fat.
My patients have been hearing the SFA traditionalist dogma for decades and thus it has become entrenched in their minds.
When I present to them the new progressive and science-based approach to fat and saturated fat some find it so mind boggling that they become skeptical of the skeptical cardiologist!
Hopefully, in the next few years, the progressive SFA recommendations will become the norm and maybe , some day in the not too distant future, the inexplicable recommendations for low-fat or non fat dairy will disappear.
As more data accumulates we may become SFA enthusiasts!
For another viewpoint (?from an SFA enthusiast) and a detailed description of both editorials see Axel Sigurdsson’s excellent post here.
It’s the cold and flu season here in St. Louis. That means the beds in my hospital are filling up with people who have upper respiratory infections of one kind or another and have developed complications. Not uncommonly, the skeptical cardiologist is asked to consult on one of his heart patients who has developed worsening heart failure or atrial fibrillation as a consequence of the pulmonary issues.
In the office it seems like every other patient has recently had a flu-like illness and is still dealing with lingering symptoms, most commonly a persistent cough.
At this time of year I get a lot of questions from patients which come down to “What over the counter medication can I take for my cold/flu/cough symptoms that is safe for my heart?”
My answer prior to writing this post has always been “Take anything that does not contain pseudoephedrine.”
Pseudoephedrine (brand name Sudafed)is a decongestant, so often OTC cold meds that contain it will add a D to the title.
It is a sympathomimetic drug meaning that it stimulates the part of the autonomic nervous system that is responsible for “flight and fight” activation. This system kicks in the heart rate goes up, the blood pressure goes up and the heart beats stronger. Blood vessels constrict to nasal passages, thereby reducing fluid build up and resulting in the decongestant properties of the drug.
You won’t find it on the shelves in your local pharmacy because methamphetamine can be produced from it. Laws vary from state to state but at a minimum you will have to present your driver’s license and you will be allowed to purchase a limited amount from the pharmacist.
A related drug, phenylpropanolamine,(which was used in OTC cold remedies and for weight loss) was removed from the market in 2000 after the FDA warned of an increased risk of hemorrhagic stroke in young women
I use the little red 30 mg Sudafed pills when my nose is really running badly (think 30 tissue/ hour) and I’m sneezing frequently and it dries me up pretty effectively. After I take it I feel like I’ve consumed a really highly caffeinated (think Starbucks) cup of coffee for about 4 hours. For this reason, I don’t take it within 6 hours of going to bed.
Sudafed is often combined with other cold , sinus and flu OTC remedies with names like:
Allegra-D, Alka-Seltzer Plus Cold Medicine Liqui-Gels, Aleve Cold and Sinus Caplets, Benadryl Allergy and Sinus Tablets, Claritin-D Non-Drowsy 24 Hour Tablets, Contac Non-Drowsy 12 Hour Cold Caplets, Robitussin Cold Severe Congestion Capsules, Sudafed 24 Hour Tablets, Triaminic Cold and Cough Liquid, Thera-Flu Cold and Cough Hot Liquid, Tylenol Sinus Severe Congestion Caplets, and Vicks 44M Cough, Cold and Flu Relief.
Adverse Effects of Pseudoephedrine: Stroke, Blood Pressure, Heart Rate
A 2003 paper from Mexico identified 22 cases of stroke (out of 2500 stroke cases at their center) that were associated with taking agents like pseudoephedrine within 24 hours. The majority were with phenylpropanolamine but there were 4 cases associated with pseudoephedrine. Given how often pseudoephedrine is taken and how few strokes were reported, it is difficult to draw any conclusions that pseudoephedrine causes stroke
In 2005, a review of all studies looking at oral pseudoephedrine concluded
This analysis demonstrates that pseudoephedrine causes a small but significant mean (1–mm Hg) increase in SBP, with no significant effect on DBP and a slight increase in HR (3 beats/min)
On average, these are very minor changes in blood pressure and heart rate and would be unlikely to cause any problems in the vast majority of patients with significant heart disease or hypertension.
The study found NO increased rate of adverse effects (such as heart attacks or strokes) in the patients taking pseudoephedrine.
Coridicin Hbp, A Typical Mixture Of OTC Ingredients
One of my patients pulled from her purse an OTC cold remedy that appeared to have the American Heart Association seal of approval.
The HBP refers to high blood pressure and the blurb on the front claims this is cold relief for people with High Blood Pressure.
This is really just marketing hype to get patients to buy a more expensive combination of otherwise cheap ingredients.
Let us look closely at the benefits and side effects of this typical and common OTC cold/sinus/flu remedy
-Acetaminophen (tylenol)- helps with aches, pain, headache and fever.
-Dextromethorphan (look for DXM or DM) is commonly found in these kinds of multi-ingredient brand name products and is promoted as reducing cough (as an antitussive). However, there is very little evidence to support its efficacy. This study found 30 mg dextromethorphan no better than placebo at reducing cough. The Cochran Database Review in 2012 concluded :
There is no good evidence for or against the effectiveness of OTC medicines in acute cough.
In addition to lacking evidence for efficacy, dextromethorphan is used as a recreational drug due to its side effect as a dissociative hallucinogen in very high doses. Per Wikipedia:
It may produce distortions of the visual field – feelings of dissociation, distorted bodily perception, and excitement, as well as a loss of sense of time. Some users report stimulant-like euphoria, particularly in response to music
-Chlorpheniramine is an antihistamine. It’s one of the oldest antihistamines and as such is “sedating”. This means it almost certainly is going to make you drowsy. I remember trying to function on medical wards 30 years ago when it was the only antihistamine available and it turned me into a zombie for 24 hours.
. Since newer non-sedating antihistamines (like loratadine which is available OTC and generic) have become available I cannot fathom how something like Coricidin has survived.
What is the antihistamine in this hodgepodge of drugs doing for your cold symptoms? Nothing, other than making you drowsy. Antihistamines are useful for allergically related runny nose or sneezing.
What Are the Downsides of Multiple Medication Cold Remedies
I think you are much better off avoiding these brand name mixtures of different active ingredients.
Instead, you should take what you need for a specific symptom in the appropriate dosage and time interval.
Thus, if you have pain, take the minimal dose of tylenol that relieves it and repeat when it comes back.
If you have a cough, recognize that the OTC ingredients are no better than placebo and are being abused as recreational drugs. Most coughs go away shortly but if one is particularly troublesome and persistent get a cough suppressing drug from your physician.
If you have a really runny nose with a lot of sneezing it is probably OK to take pseudoephedrine even if you are a heart patient or have high blood pressure. Take it as I described above. Start with 30 mg of the little red Sudafed pills , wait an hour to see how you feel. Take a second if it has not been effective. Repeat at 4-6 hour intervals as needed. Take your blood pressure at least once after starting it.
Don’t buy the multi-symptom multiple ingredient combinations which are simply a marketing tool to get you to spend more money on something from which you won’t benefit.
I see no reason to ever take coricidin. In the late 1960s, however, legend has it that Duane Allman had a cold on his birthday. His brother Greg gave him two gifts: a glass bottle of coricidin pills and Taj Mahl’s debut album. From this he learned how to play slide guitar by listening to Statesboro Blues.
And the rest is history.
I “Ain’t Wastin’ Time no More” on OTC Cold Meds…. Super Bowl is approaching.
Important findings from the IMPROVE-IT trial were presented at the American Heart Association meeting yesterday. They demonstrate for the first time that the cholesterol lowering drug ezetimibe (brand name Zetia) lowers the risk of heart attack and stroke when added to a statin drug in high risk patients (those who have sustained a heart attack or had unstable angina) over a statin drug plus placebo.
That study showed
The primary endpoint of CV death/MI/UA/coronary revascularization beyond 30 days/stroke was significantly lower in the ezetimibe/simvastatin arm compared with the simvastatin arm over the duration of follow-up (32.7% vs. 34.7%, hazard ratio [HR] 0.94, 95% confidence interval [CI] 0.89-0.99; p = 0.016).
Prior to this study, Zetia had been prescribed to millions of patients since 2002 garnering Merck, its maker, profits of 30 billion dollars despite there being no evidence that it reduced heart attack or stroke.
Dr. Melissa Walton-Shirley wrote an excellent article on the status of Zetia at the beginning of 2014, summarizing thusly:
Perhaps the lesson to be learned is that starting in 2014, let’s not put compounds on the market for human ingestion without knowing if they help or hurt. Let’s make it unacceptable for a company to make tens of billion dollars from the sale of a compound without knowing if it lowers mortality or improves quality of life
I have previously bashed Zetia on this site and I only prescribe it in very rare cases. These new data may change my approach.
Before embracing Zetia, though, I want to see the full paper in published form and examine the data in detail. Many questions need to be answered. For example, the addition of the drug to simvastatin lowered heart attack and stroke compared to simvastatin alone but there was no difference in overall death rates or cardiovascular death rates. That raises a red flag.
In addition, this study does not support the use of Zetia in patients who have not had heart attacks or near heart attacks (primary prevention).
Science moves slowly but inexorably toward the truth if done properly. It’s important that public policy and drug prescribing not get in front of the science as it did with this drug.
The skeptical cardiologist was in Atlanta recently visiting his Life Coach (LCOSC). Oddly enough, the wife of the LCOSC (who I’ll call Lisa) had just undergone a coronary calcium scan and it came back with a high score. Most women her age (58 years old) have a zero score but hers came back at 208 .
What is the significance of a calcium score of 208 in this case?
The CT scan for calcium (discussed by me in more detail here) focuses entirely on quantifying the intense and very specific kind of x-ray absorption from calcium. The three-dimensional resolution of the scan is such that the coronary arteries which supply blood to the heart can be accurately located and the amount of calcium in them very accurately and reproducibly added up. Calcium is not in the arteries normally and only accumulates as atherosclerotic plaque builds up over time. The build up of fatty plaque (atherosclerosis) is the major cause of coronary artery disease (CAD, sometimes termed coronary heart disease (CHD)) which is what causes most heart attacks and most death in both men and women in the U.S.
We can enter Lisa’s numbers into the online MESA calculator to see how she compares to other white 59 year old women. The calculator tells us that 72% of her peers have a zero calcium score and a score of 208 is higher than 95% of her peers. Although the 95th percentile is a good place to be for SAT scores it is not for atherosclerosis. This means substantial amount of fatty atherosclerotic plaque has built up in the arteries and puts the individual at significantly greater risk for heart attack and stroke. A calcium score of 100-300 confers a 7.7 times increased risk compared to an individual with similar risk factors with a zero calcium score.
Most of the risk factors that we can measure to assess one’s risk of heart attack (blood pressure, diabetes, smoking) were absent in Lisa. Her cholesterol levels had risen in the last 10 years but when I entered her numbers (total cholesterol 221, HDL 68) into the ASCVD risk estimator her 10 year risk came back at 2.5%. This is considered low and no treatment of cholesterol would be advised by the new guidelines.
The only clue that her cardiologist would have that Lisa has advanced premature atherosclerosis is that her mother had coronary heart disease at an early age, something we call premature CAD. Her mom at the age of 62 suffered a heart attack and had a stent placed in one of her coronary arteries. The occurrence of significant premature CAD in a parent or sibling substantially increases the chances that a patient will have premature CAD and the earlier it occurred in the parent or sibling the higher the risk.
Some of this excess risk is transmitted by measurable risk factors such as hypertension and hyperlipidemia and some through lifestyle factors but the majority of it is through genetic factors that we haven’t fully identified.
How much of an individual’s risk for heart attack is determined by genetics versus lifestyle?
A large Swedish study found that adopted men and women with at least one biological parent with CHD were 1.5 times more likely to have CHD than adoptees without. In contrast, men and women with one adoptive parent were not at increased risk.
Since 2007 an intense project to identify genetic factors responsible for CAD has been underway at multiple academic centers. Thus far 50 genetic risk variants have been identified. According to Dr. Robert Roberts
” All of these risk variants are extremely common with more than half occurring in >50% of the general population. They increased only minimally the relative risk for coronary artery disease. The most striking finding is that 35 of the 50 risk variants act independently of known risk factors, indicating there are several pathways yet to be appreciated, contributing to the pathogenesis of coronary atherosclerosis and myocardial infarction. All of the genetic variants seem to act through atherosclerosis, except for the ABO blood groups, which show that A and B are associated with increased risk for myocardial infarction, mediated by a prolonged von Willebrand plasma half life leading to thrombosis”
How well do the standard risk factors capture the individuals risk for heart attack?
The standard approach to estimating risk fails in about 25% of individuals as it does not accurately convey the high risk of the patient with family history and it overestimates risk in many elderly individuals who have an excellent family history.
It is in these patients that testing for the actual presence of atherosclerosis, either by vascular screening or coronary calcium is helpful.
Reducing The Excess Risk of Premature CAD
For many individuals there are clear-cut lifestyle changes that can be implemented once advanced CAD is identified: cigarette smoking cessation, weight loss through combinations of diet and exercise with resulting control of diabetes, However, many patients like Lisa, are non-smokers, living a good lifestyle, eating an excellent diet with plenty of fresh fruit, vegetables, fish and healthy oils and without obesity or diabetes. There is no evidence that modifying lifestyle in this group is going to slow down an already advanced progression of atherosclerosis.
Patients like Lisa have inherited predisposition to CAD, it is not due to their lifestyle.
Lisa’s cardiologist suggested she get a copy of Dr. Esselstyn’s book “Prevent and Reverse Heart Disease”. This book, based on the author’s experience in treating 18 patients with advanced CAD espouses an ultra low fat diet. The author declares that “you may not eat anything with a face or a mother (meat/poultry/fish)” and bans full fat dairy products and all oil (“not even a drop”)
Such “plant-based diets” (codeword for vegan or vegetarianism) lack good scientific studies supporting efficacy and are extremely hard to maintain long term. There is nothing to suggest that Lisa’s long term risk of heart attack and stroke would be modified by following such a Spartan dietary regimen.
Her cardiologist did recommend two things proven to be beneficial in patients with documented advanced CAD: statins and aspirin.
Taking a statin drug will arrest the atherosclerotic process and reduce risk of heart attack and stroke by around 30% as I’ve discussed here and here.
An aspirin is now indicated since significant atherosclerosis has now been documented to be present as I’ve discussed here.
We can blame a lot of heart disease on lifestyle: poor diets and lack of exercise are huge factors leading to obesity, diabetes, hypertension and hyperlipidemia, but in many patients I see who develop heart disease at an early age, lifestyle is not the issue, it is the genetic cards that they have been dealt.
Until we develop reliable genetic methods for identifying those at high risk it makes sense to utilize methods such as vascular screening or coronary calcium to look for atherosclerosis in individuals with a family history of premature CAD.
Once advanced atherosclerosis is identified, we have extremely safe and effective medications that can help individuals like Lisa deal with the cardiovascular cards they have been dealt.