29
November
2008
Congestive heart failure: acute decompensation causes shortness of breath. Fluids builds up in the lung. Usually CHF from left ventricle disease so doesn’t pump well. Also from fluid overload (like in blood transfusions or IV fluids), severe high blood pressure, severe kidney disease, renovascular HTN. CHF from acute heart attack. Atrial fibrillation with fast heart beat can cause it. Shortness of breath is main symptoms. blood pressure can drop and kidneys function drops. Legs can become very swollen. From fluid build up, there is acute weight gain. Often requires hospitalization to improved blood pressure, reduce fluid, improve heart function, help oxygenation.
drjohnhong 
cardiovascular 
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19
November
2008
JUPITER: Randomized Clinical Trial, double blinded, placebo controlled. 1315 sties in 26 countries. To see if cardiovascular naïve people with high hsCRP will have less CV events on Crestor.
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15
November
2008
Caffeine stimulates the brain. Commonly found in coffee, tea, cola, chocolate. But it also stimulates the nervous system and can cause shakiness, nervousness, and fast heart beat. Nervousness, overly excited, irritable, insomnia. Has been consumed since ancient history. 80% the world consumes caffeine.
5oz of the following drinks have caffeine: drip coffee 146mg, percolated coffee 110mg, instant coffee 53mg, espresso (1-2oz) 45-100mg, Starbuck Venti 415-550mg. 1 min brew tea 9-33mg, 3min brew tea 20-46mg, Canned ice tea 12oz 22-36mg. 12oz diet or regular cola 46mg. Chocolate: milk 1oz 6mg, 6oz cocoa mix 10mg, baking 1oz is 35mg.
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7
August
2008
Myocardial Infarction (MI) is a “heart attack” in which heart muscle doesn’t get enough blood/oxygen and dies. Main cause is from a coronary artery getting blocked by a clot that forms on an atherosclerotic plaque (called acute coronary syndrome (ACS) that occurs abou 1,200,000 times a year). 38% die each year from ACS (450,000 people). That is 1 in every 5 deaths making coronary heart disease (CHD) #1 cause of death in USA. 16 million Americans have CHD. ½ millions new cases of stable angina a year.
ACS: Chest pains aren’t pain – squeezing of the chest, heaviness like an elephant standing on the chest. Under the sternum more than 15 minutes. 20min heart muscles die. Radiation of discomfort like a numbness to neck, jaw, shoulder, down left arm, maybe back. N, SOB, palpitations, lightheadness, sweating. Often occurs with exertion though can occur at rest especially with h/o angina.
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28
March
2008
Edema is swelling, such as in the legs, face, abdomen, etc. Edema occurs from leakage of fluid in the blood vessels (arteries and veins) into the soft tissue. Sodium in table salt is responsible for many cases of edema if the kidneys don’t excrete enough of it out. So kidney insufficiency can lead to edema, as well as congestive heart failure. Kidney diseases can cause edema. Cirrhosis of the liver in particular causes edema in the abdomen. Low protein drops the osmotic pressure in the vessels so fluid leaks out into soft tissue. Varicose veins and lymphatic obstruction are causes. Pulmonary edema means fluid leaks into the lungs, making it hard to breathe. Bad COPD can increase pressure back to the legs and liver to cause edema there. Women with PMS very well understand edema. Idiopathic edema means we don’t know what is causing the edema.
Pitting edema is a sign in which you push the fluid the side. So like on the legs pushing on the tibia for 10 seconds leaves a dent/imprint. If the edema does not pit, it might mean hypothyroidism or lymphatic obstruction. Lymphatic damage can occur after surgery, like after a mastectomy that causes arm swelling.
Varicose veins are pretty common, but it is important to make sure the edema is not from a blood clot (DVT) or infection of the vein (thrombophlebitis). DVT tends to occur in only one leg so one leg is swollen compared to the other, and is usually a rapid onset.
Treatment: occupational therapy can help with lymphatic massage for those with lymphedema. Compression hose on the legs is a mainstay of treatment to “squeeze” the fluid up the veins, and in turn the fluid from soft tissue goes back into the veins. Diuretics are often used but they can make things worse in some cases due to depleting too much fluid from the body, dropping sodium and potassium, driving the pH up in the blood, and increasing the blood urea nitrogen. Those with cirrhosis have ascites (edema in the belly) and often the fluid has to be drained using a needle. And a low sodium diet is pretty key to reduce edema. Elevation of the legs often help reduce edema of the legs, as many people notice their leg swelling improves after a night in bed.
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12
March
2008
Raynaud Phenomenon (RP) is when arteries clamp down inappropriately, because of oversensitive response to cold or emotional stress. So the arteries go haywire and over constrict. Occurs mostly in fingers and toes. First the skin color changes to white due to lack of arterial blood flow. Then turns blue because the period of time without oxygen. Blood flow usually takes 15-20min to return and then the skin is red. RP is primary if there is no underlying cause. It is secondary if associated with disease, medications, etc and called Raynaud Syndrome. Everyone can get cold fingers, but RP means the severe color changes, and it hurts (or feels like pins and needles if not so painful)
Risk Factors: Probably 3-5% of people have RP. Family history, women, younger people. Usually starts between ages 15-30.
Fingers are most affected: usually index to ring finger. Starts normally with one finger and then spreads to the other fingers – on both hands. Toes can also be affected, as well as face, ears, nose, nipples, and even knees. Going from warm to cold suddenly is often the precipitating factor, like grabbing ice cream out of the freezer. Even if the whole body is cold, it can precipitate it. Nervousness/stress can do it to.
On the body, like the torso and legs, it is livido reticularis – a spiderweb like pattern of blue skin. It is also associated with antiphospholipid syndrome, vasculitis, and occlusive vascular disease.
Secondary causes: there are a lot. ANA and ESR elevation by blood test can indicate a rheumatologic disease: scleroderma, SLE (systemic lupus erythematosus), polymyositis, rheumatoid arthritis, cryoglobulins (like in Hepatitis B & C patients). Mechanical injuries can cause it such as in vibration syndrome (like a jack hammer), frostbite, not using crutches right and causing vascular damage in the armpit. Migraine patients can have it. Vascular disease in atherosclerosis or emboli. Hypothyroidism, pheochromocytoma. Some meds and cocaine.
If blood flow is poor enough from an extended attack or frequent attacks, tissue can die. That can lead to ulcers or even loss of part of the finger.
Diagnosis is made with a rheumatologist usually. A simple look in the fingernail with oil and an ophthalmascope can see if further workup is needed. Checking the blood pressure of the finger in cold water can confirm RP.
Treatment: keep warm! Wearing gloves and avoiding touching cold objects. Hand warmers. Avoid tobacco, caffeine & stimulants. Biofeedback might help some. If secondary RP, then treating the underlying disorder.
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26
September
2007
Trans Fatty Acids are talked about a lot because it is associated with a higher risk of cardiovascular disease. What are they? Organic chemistry means carbon has to be involved because it is the base of the molecule, such as fatty acids. Fatty acids consist of a string of carbons (like a string of pearls) with oxygen and hydrogen towards the end of the chain. If the fatty acid is saturated, that means the carbons’ free bonding sites are all bonded to hydrogen atoms (saturated with hydrogens). In general saturated fats are not healthy for you. Unsaturated fatty acids mean some of the carbon atoms double bond to each other – and therefore let go of some hydrogen atoms (so not saturated with hydrogen atoms). When two carbon atoms are double bonded, there are 2 formations possible: cis and trans. Cis means in the 2 carbons that are double bonded, their 1 remaining hydrogen atoms are on the same side of the chain. Trans means in the 2 carbons that are double bonded, their 1 remaining hydrogen atoms are on the opposite sides of the chain.
Saturated fats are linked to heart disease. Cis fats are unsaturated and tend to be a healthy type of fat. However, Trans fatty acids are considered to be worse than saturated fats because of it appears to increase the risk coronary heart disease (CHD) events, such as heart attacks. Trans fats are called partially hydrogenated oils because once there were 2 double bonded carbons, and it was changed to only 1 double carbon – so the other double bonded carbon because single bonded and 2 hydrogen were added (i.e. hydrogenated)
Saturated fats have no health benefits, so why are they used? Taste and the palatable nature of it, that is why. Trans fats are stable in fried cooking, and they have a long shelf life. They are often used in deep-fried fast foods, margarine, baked goods, packaged snacks, crackers, though naturally found as well in meat and dairy. Such fun foods that have a high percentage of trans fats include: French fries, breaded fish burgers, breaded chicken nuggets, enchildas, pies, danishes, doughnuts.
Americans average 2-3% of total calories to trans fatty acids, which is about 2-7grams a day. It appears if trans fats are virtually eliminated from the American diet and replaced by cis fatty acids, CHD events would be reduced by 22%.
There aren’t any randomized clinical trials because it would be unethical to study this since there is enough evidence to show trans fatty acids increases CHD events. How does CHD go up? Lipids are negatively affected by trans fats, so good cholesterol HDL goes down, bad cholesterol LDL goes up and becomes more dense, and triglycerides worsen. Lpa and B-100, lipoproteins which are kind of like subcholesterol particles, both increase as well with trans fats. Inflammatory chemicals in the body increase with trans fats, such as TNF, C-RP, IL-6, which are associated with atherosclerosis, cardiac sudden death, diabetes, and congestive heart failure.
One meta-analysis showed with only a 2% increase in trans fat to the diet was associated with a 23% increased risk of CHD. 23% isn’t that much, but considering only a 2% increase in consumption of trans fat, it spells “unhealthy”. Dieticians note there is no benefit to trans fat, so without any benefits, the risks are not worth it.
Denmark showed in 2004 that making the food industry lower the trans fatty acids did not significantly change the quality, cost, or availability of food. Also saturated fats were not used more to replace the trans fatty acids.
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4
July
2007
Heat exhaustion is when the body becomes dehydrated, mostly from sweat due to the dog-gone heat! Heat stroke is when the body’s core temperature rises to above 105 degrees Fahrenheit. After about 30minutes basically the brain and other internal organs get fried from this elevation in temperature.
Sweating is the #1 way to cool the body down. However, when the relative humidity outside is great than 75%, sweating doesn’t work well. And when the temperature outside is greater than 90 degrees Fahrenheit, the body doesn’t cool off well. So these factors can lead to overheating of the body.
Heat exhaustion symptoms include: lowered blood pressure, lightheadedness, irritability, headache, nausea, fatigue, muscle aches, and hyperventilation.
Heat stroke symptoms include: delirium, losing consciousness, shortness of breath, and excessive bleeding. Heat stroke tends to occur in young healthy people who don’t sweat during exercise on a hot, humid day.
Treatment of heat exhaustion and heat stroke include: get out of the sun, get out of the heat, drink cool fluids, and even ice but don’t induce shivering will increase body temperature. CPR might be needed. Call 911.
Sweaty, sweaty, sweaty. Ooh, it is summertime and it is hot. But all this sweating and heat can cause heat exhaustion, or worse yet heat stroke. So this morning I got up to do the news, not realizing it was the 4th of July — I could have slept in. Such is life. So I hope you watch the video to see ALL MY HARD EFFORTS this holiday morning. Now it is time to baste the ribs on the grill. We are grilling for 8 hours to get it smoky and just right.
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23
May
2007
Effect of Rosiglitazone on the Risk of Myocardial Infarction and Death from Cardiovascular Causes. NEJM 5/21/07; 356
Avandia (generic name rosiglitazone) is a thiazolidinedione medication for type II diabetes. It is an agonist for peroxisome-proliferator-activated receptor gamma (PPAR-gamma) and has been around since 1999.
In diabetics, 65% of deaths are cardiovascular related. The meta-analysis of this study was done to increase the power to see what are the cardiovascular outcomes.
116 studies were investigated and 42 studies were analyzed for this meta-analysis. Criteria for entry included more than 24 weeks of drug exposure, randomized studies, MI (heart attack) or cardiovascular deaths had to be reported. Outcomes: MI. Cardiovascular Deaths.
15,560 people were in the Avandia treatment group and 12,283 in the control group (control group were divided into those taking insulin, sulfonylurea, metformin, and placebo). Most of the subjects were men around 57 years old, and diabetes control was relatively poor in both groups (HbA1C average 8.2%)
The trials had very few MIs or cardiovascular deaths, so they used some statistical method I have never heard of, the Peto Method. I’m not sure how they determined what would be clinically significant and statistically significant between Avandia group and control group.
Results are pretty similar. In the Avandia group, there were 86 MIs (0.55%) and in the Control group 72 MIs (0.58%). For cardiovascular deaths, the Avandia group had 39 deaths (0.25%) and the Control group had 22 deaths (0.18%).
So for MIs, Avandia had a 1.43 times increased risk of MI compared to control (43%) that is statistically significant. But in epidemiology, 43% increase risk is a weak to mild association. You need more of a 200-300% increase risk to be a strong association. Also if you just look at the numbers, 86 heart attacks out of 15,560 isn’t a whole lot in particular vs. 72 heart attacks out of 12,283 controls.
For cardiovascular, there is no increased risk of cardiovascular death that is statistically proven.
I think the findings are interesting but it is too soon to “jump the gun” like the media is doing. A study needs to be done and powered correctly to see if Avandia does indeed cause heart attacks and/or cardiovascular deaths. But I don’t think anyone can say for sure at this point that Avandia does cause heart attacks. We do know Avandia can’t be used in Stage III or IV congestive heart failure and I wonder if the heart attacks were due to this. Many questions have been raised from this meta-analysis.
© John S. Hong, MD, MS May 22, 2007
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