Health Matters - The Blog - with Dr Santora

NIASPAN (or niacin): Should You Stop This Cholesterol Medicine?

2011-05-30T22:39:00.000-07:00

The Study: The AIM-HIGH trial (Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides)

On May 26, 2011, (NHLBI)

The AIM-HIGH trial was the first large-scale outcomes study to evaluate the impact of adding extended-release niacin (NIASPAN) to statin therapy (simvastatin) in patients with established coronary disease. The study was designed to test whether or not increasing HDL cholesterol and lowering triglycerides in patients with low HDL cholesterol and high triglycerides will reduce the risk of recurrent cardiovascular events in patients whose LDL cholesterol was already within a desirable range with statin therapy.

The patients of AIM-HIGH: 3,414 patients that entered the study and were randomized to statin or to statin plus niacin therapy. The age was 64 ± 9 years, 85% were men and all had documented arteriosclerotic vascular disease. Statin therapy had been used in 94% for some period of time before enrollment. The mean LDL-C was 71 mg/dL, HDL-C 34.9 mg/dL and triglycerides 161 mg/dL at randomization to the treatment regimens. will require careful study to determine if there are specific reasons for the failure of niacin to provide incremental risk reduction in this population of patients.

The results: The incidence of cardiac events was almost identical in those taking additional niacin vs those just on a statin (about 5.6%) The observed higher incidence of stroke (28 vs 12) in the niacin arm will need further investigation.

The AIM-HIGH trial was halted 18 months early since the researchers flet that the study goal of reducing cardiac events by 25% in those taking niacin would not be reached.

A number of prior studies used extended-release niacin to treat patients with low HDL-C since niacin has demonstrated benefit in earlier reported studies in conjunction with statins and other drugs, as observed in the HDL-Atherosclerosis Treatment Study (HATS) and the Cholesterol Lowering Atherosclerosis Study (CLAS) and In the Coronary Drug Project niacin alone was shown to reduce myocardial infarction, stroke, and the need for coronary bypass surgery. However, none of these trials compared statin therapy to niacin plus statin therapy. A much larger study with a similar design and measured outcomes is underway (i.e., HPS-2 THRIVE).

Bottom Line:

Patients should not stop niacin unless advised by their doctors. Vast clinical experience and the studies mentioned above (HATS, CLAS,CDP as well as imaging studies) have shown the significant benefit of niacin. In addition, the AIM-HIGH TRIAL was stopped prematurely because it could not statisically attain the 25% reduction in events in the following 18 months. But could it have attained a 5% in 18 more months and 20% in 5 yrs total? We will never know. Furthermore, the findings presented should be interpreted with caution until the full study details are available and additional studies are completed that should provide insight into the effect of niacin in other populations.

Airport body scans- are they safe?

2011-01-03T22:53:00.000-08:00

Airport body scans have created a great deal of anxiety about the safety of such devices due to the potential exposure to radiation. This discussion will only about the safety of such scans, not about the effectiveness of these scanner as an antiterrorist tool.

Background:
After 9/11, airport anti-terrorist measures were in part directed to screening carry-on luggage and checked baggage with xray scanners. Passengers were not exposed to the radiation nor were the airport workers. Passengers were and are asked to walk through metal detectors with the thought that metallic items like guns, knives and explosive devices could be easily identified. Several years ago, especially after the "shoe bomber" was able to smuggle an incendiary device in his shoe, and the availability of plastic explosives and non-metallic weapons, it was felt that the passenger needed to have a full body pat- down or have a body scan to detect such devices.

What are airport body scanners?
There are two types of body scanners:

1. Millimeter wave unit body scanners: One type emits a radiofrequency wave ove the body, reaching just below the clothing and over the surface of the skin to create an image of the surface of the body, just below the clothing, but not through the body itself. There is no radiation at all from this scanner.

2. Xray body scanner backscatter unit: This type of scanner emits a very low amount of radiation that penetrates the clothing, and slightly into the body cavity, like the rectum and vagina. The scanner reconstructs an image of the body beneath the clothing and detects any foreign objects, whether they be metal or non metallic.The ability to penetrate the body cavities is probably limited and variable based on the passengers weight and body shape. This type of scanner does expose the patient to radiation and is the scanner of concern.

What is radiation?
Basically radiation is an energy force that comes in various degrees of strength, from infrared light, ultraviolet light, radio waves and others. Ionizing radiation is the more pwerful type of radiation that can actually interact and change human cells. This is the type of radiation used in medical Xray devices such as chest xrays, CT scans, mammograms etc..The radiation in medical applications can be very powerful such that they penetrate the body and create images of the inside of the body, unlike ariport scanners which only cover the surface of the body. At extremely high and concentrated form of Xray beams are used to actually treat and destroy certain types of cancers.

How much radiation is safe?
It is generally recommended to limit ones Xray exposure to the bare minnum possible. We are constantly exposed to radiation which comes from the enviroment from radioactive decay in rocks and from the atmosphere. People who live at high altitudes such as Denver, Colorado receive more radiation from the atmosphere than those at sea level. Flyng in a plane going cross country at 30,000 ft exposes one to radiation. In truth it is not known for sure what dose can cause cancer and in whom. We do know that certain body parts are more sensitive to radiation, for instance, the breast tissue and thyroid are much more sensitive than the heart to the effects of radiation.

How much radiation dose the airport scanner release to the passanger?
Think of it like this: chest xrays, mammograms and dental Xrays all expose us to much higher doses of radiation than the airport body scan, and none of these medical tests have been shown to cause cancer.

To equal the radiation from:

1. Mammogram: you would have to go through the body scanner 1,300 times
2. Chest Xray: you would have to go throught the body scanner 1,000 times
3. Dental xray: you would need to go through the body scanner 200 times
4. Airline flight: you need to be flying at 35,000 ft for one minute to get the radiation of one body scan

Bottom line:
It is my feeling that the airport body scanners pose no safety risk and I would not hestiate going through it many tens of times. However, it makes common sense that if you are a pilot or stewardess, there are other means to screen to avoid repeated exposure to the scanner, however small the risk.

Chelation Therapy: Hype or Hope?

2010-11-01T22:58:00.000-07:00

THE ISSUE:

October 2010: The FDA today warned eight companies that their over-the-counter chelation products are unapproved drugs and devices and that it is a violation of federal law to make unproven claims about these products.

The companies claim their products treat a range of diseases; including autism spectrum disorder, cardiovascular diseases, Parkinson’s disease, Alzheimer’s disease, macular degeneration, and other serious conditions; by removing toxic metals from the body.

THE BACKGROUND:

The National Heart, Lung, and Blood Institute (NHLBI) and the National Center for Complementary and Alternative Medicine (NCCAM), both components of the National Institutes of Health (NIH), are sponsoring the Trial To Assess Chelation Therapy (TACT). TACT is the first large-scale, multicenter study to determine the safety and efficacy of EDTA chelation therapy for individuals with coronary artery disease.

What is chelation therapy?

Chelation is a process in which a substance is used to bind molecules, so that they can be removed from the body. For example, a person who has lead poisoning may be given chelation therapy in order to bind and remove excess lead, or in other cases, iron, copper, and calcium, from the body before it can cause damage. EDTA chelation therapy, (ethylene diamine tetra-acetic acid), is administered through the veins. Some physicians and alternative medicine practitioners have recommended disodium EDTA chelation as a way to treat coronary artery plaque (hardening of the arteries). The TACT study uses disodium EDTA, as an investigational new drug (IND). Disodium EDTA it is not yet approved by the FDA to treat CAD,

The possible side effects:

A common side effect is a burning sensation at the vein insertion site. Rare side effects can include fever, headache, nausea, vomiting, permanent kidney damage, bone marrow supression, heart failure, blood pressure dropping acutely, and dangerously low levels of calcium in the blood.

How might chelation work?

No one knows how or if chelation works. Some theories are that it removes the calcium that is part of the plaque in the walls of the coronary arteries. Other thoughts are that it reduces inflammation of the artery wall. A less plausible theory is that it causes the lowering of cholesterol or induces hormones that remove the calcium from the plaque.

What is the scientific evidence that chelation works?

No significant scientific studies have been done to verify EDTA chelation therapy's safety and effectiveness for coronary disease, most are just anecdotal reports that a scattered patient or so had a reduction in chest pain episodes. There are only 5 randomized controlled clinical trials regarding the use of EDTA chelation for coronary disease, three trials involved very few people, that only a dramatic improvement could have been detected. The fourth study reported that EDTA chelation was associated with an improvement in ability to exercise in only 10 patients. and the fifth study was never published in completed format. Twelve uncontrolled published descriptive studies reported a reduction in angina. These types of studies are the least scientific type of studies and use clinical observations or review past data.

The Bottom Line:
There is no evidence that chelation works, none at all to date. I believe it should be avoided at this point until the evidence from the TACT study is complete. It is foolish to forgo proven treatments for coronary artery disease. If there is significant chest pain of cardiac origin (angina) there are many options available. Save your money for now and avoid chelation therapy unless there are no other options available:

The Hope:
I hope chelation is proven to work. What doctor would not want to administer it in his/her office? It requires no doctor time, it can be administered by a nurse and it is quite lucrative, certainly more lucrative than the administration of the standard treatments such as cholesterol medications and stents.

As a side:
Thirty years ago when I first started private practice in Orange County, California, I went on a local cable TV show to debate/discuss chelation therapy with a doctor using it to treat heart disease. How some 3 decades later we still do not have a definitive answer and it is not supported by the FDA or any medical society. In fact, The FDA has recently sued manufactures for selling it. I do hope it is proven to work!

The End Of Health Care As We Know It: Obamacare

2010-10-28T19:52:00.000-07:00

The end of medical care as we know it?
The present health care changes being instituted by Obamacare (Patient Protection & Affordable Care Act), when fully implemented, will have disastrous effects on our health care system. The unintended consequences are already being felt. The perfect storm for a healthcare disaster is emerging. We have a rapidly aging and long-living population that depends on extremely complex technologies, medicines and infrastructure. This requires more highly trained primary care and subspecialty physicians. Yet we have a health care bill that is not only poorly funded for theses challenges, but provides disincentives for innovation and hard work. More regulations for physicians, reduced reimbursements and no tort reform, will dramatically limit access to doctors. Physicians are leaving practice, curtailing hours, dropping Medicare patients, retiring early, or refusing to see more patients. Patients will have longer waits to see doctors, they will be sicker when they are seen, there will be more emergency room visits and costs will go up dramatically

Our present health care is the best in the world, and Orange County is a leader in health care quality, technology and innovation. Even so, we all agree that aspects of our health care delivery do need improvement. However, a targeted, evolutionary change is needed to preserve what we do best, not this massive overhaul burdened with new regulations and some 159 new federal programs and bureaucracies. It is simple as this: every new regulation, takes money and time from direct patient care.

To make matters worse, a single payer system and rationing of care is evolving, unless the present health care bill is withdrawn and revised. Today many independent medical practices are financially unsustainable. Hospital reimbursement is many times higher for the same test done in the hospital that can be done cheaper and better in a doctor’s office. Hospitals are buying doctor practices through a Foundation model, which has a non-profit status and tax advantages. Obamacare requires the formation of ACOs (Accountable Care Organizations), which are hospital and physician organizations. If the hospital has acquired a critical mass of doctors, the money goes to the hospital (the ACO), which then has the power to decide how much doctors are paid and the type of services they may provide. The patient’s health care decision will be in the hands of bureaucrats. This is essentially a single payer system. Doctors and patients will be at the bottom of the health care system, in terms of control of health care decisions. Less money for patient care, less doctors to administer the care. Patient care is going to suffer dramatically, and yes, care will be rationed. This is what we must do now:

1. Repeal the present health care plan now by electing the appropriate politicians.

2. Adopt common sense changes: any individual can buy health care, across state lines, carry that insurance from job to job, choose a high deductible, and use your health care expenditures as tax credits through a health savings account.

3. Tort reform is essential. Require two additional medical experts to agree that the malpractice lawsuit has merit. Require that the plaintiff’s attorney pay all attorney fees if they lose. Limit the attorney settlement fees, e.g., the plaintiff’s attorney gets up to 3 times the patient’s award.

4. New medical schools to meet the doctor shortage.

5. Prescription policy revision: Uniform formularies so all brand name drugs are available on all insurance plans at similar prices. At least 90 day supply per prescription. This will save many millions of dollars in lost productivity for patients, pharmacists and doctors.

6. Prevent a single payer system. There has to be a level playing field to encourage doctors to remain independent by providing equal tax advantages and reimbursements for independent doctors, similar to those afforded for foundation model practices.

FISH OIL NOT HELPFUL IN TREATING HEART DISEASE?

2010-09-19T23:19:00.000-07:00

THE STUDY:

Reported on in the LA Times, August 27, 2010 edition mentions a study published in the New England Journal of Medicine concerning the benefits of fish oil.
The study showed that fish consumption (thus fish oils or omega 3 fatty acids) were not very beneficial in patients who already suffered heart attacks. Fish did not significantly reduce their risk of heart attack, stroke, heart failure and other cardiovascular events by eating about 400 mg of fish fatty acids per day. However, the supplement did help those patients who had a past heart attack and were also diabetic. So are all the benefits of fish oil just hype? Is it worth taking fish oil?

THE BOTTOM LINE:
Fish oil (omega 3 oil or flaxseed oil) is the one supplement you should take, and these supplements will benefit just about anyone and should be taken by most people. The problem with the reults of the study is more the design of the study. These patients already had coronary heart disease and prior heart attacks. Most patients after a heart attack are placed on multple risk altering drugs like statins, niacin, aspirin, beta blockers, aspirin and perhaps Plavix. With this vigorous regimen, the additional benefits from fish oil may be hard to see but are definitelty there.

Substantial research prove fish oil may prevent cardiovascular disease through various mechanisms:

Clinical studies have shown that omega-3 fatty acids:
  Reduce the rate at which atherosclerotic plaque developes

Helps to prevent thrombosis (blood clotting in blood vessels).

  Lower triglyceride levels. Raise HDL cholesterol slightly.


  Lower blood pressure

  Reduce the risk of arrhythmias which increase the risk of cardiac arrest.

  Improves endothelial function which supports the growth of new blood cells.

Although omega-3 fatty acids can be obtained from sources other than fish oil, the most beneficial forms are only available in fish oil. Docosehexaenoic (DHA) and eicosapentaenoic (EPA) are long chained fatty acids which cannot be found in any other source.
Omega-3 can be included in the diet by eating fatty fish (such as salmon) three times a week.
Fish oil supplements, starting 2,000mg day would be benficial for most people if no contraindications.

HEART BYPASS SURGERY BETTER THAN STENTS?

2010-09-19T22:30:00.000-07:00

THE STUDY:
THE SYNTAX STUDY reported in the LA Times, Sept 12, 2010, suggested that patients who got coronary stents were 28% more likely to suffer a heart attack, 46% more likely to need a repeat procedure, and 22% more likey to die than patients who had coronary bypass surgery (CABG). The study followed 1.800 patients in Europe or the United States who had a Taxus drug coated stent or underwent CABG.
The results were for those with severe diesase. What is severe disease? The heart has four major coronary arteries: the Left Main, the Left Anterior Descending, the Circumflex, and the Right Coronary Artery. The latter three can also have large branch arteries that may be big enough to require repair. These arteries can be repaired by bypass surgery, hence the possibility of double, triple, quadruple or even quintuple (five way) bypass grafts, or stents in as many arteries as needed. This study shows, and it has generally been known that usually the need for 3 arteries requiring fixing, tends to favor bypass surgery rather than stenting in 3 or 4 arteries.

THE BOTTOM LINE:
If you need one or two arteries fixed, and the arteries are of good size, meaning 2.5mm to 3mm or more in diameter, and the narrowed segment in the artery is short, stents are preferable in most cases to coronary bypass surgery, in my opinion. Drug coated or so called drug eluting stents (DES) have been the most significant advance in treating advanced coronary artery disease (blockages). When I first starting performing coronary balloon angioplasty (PTCA) in 1984, there was a 30% chance or more that the artery would renarrow in 6 months. Now with drug eluting stents (DES), less than 5% will narrow, and if so it is in one year. After one year then stent has <1% chance of narrowing. With bypass surgery, each graft deteriorates over time at about 4% per year risk of closing, so by 10 years about 60% of grafts are closed or closing and probably a repeat bypass surgery is needed.

Diet Pill Causes Increased Heart Attack Risk

2010-09-19T21:31:00.000-07:00

The Study:

An FDA advisory panel has voted to recommend that the FDA either severely restrict access to the weight-loss drug sibutramine (Meridia, Abbott Laboratories) and add tougher warnings or pull the plug on it altogether, due to its increased CV risk profile. Only two of the agency's Endocrinologic and Metabolic Drugs Advisory Committee, which spent Wednesday reviewing the results of the Sibutramine Cardiovascular Outcomes Trial (SCOUT), concluded that the drug should remain on the market with a boxed warning only, and no members thought the drug could stay on the market with no labeling changes.

The Bottom Line:

Meridia is one of only three drugs available for weight loss, the other two are: Alli which prevents fat absorption and has the unpleasant side effect of bloating, gas and diarrhea, and Phentermine which can cause an increase in heart rate, jitters and insomnia. All three cause only mild to modest weight reductions. Meridia in a recent study posed an increase in heart attack risk compared to placebo, in a range, that when considering it is only modestly effective in causing weight loss, makes it an unacceptable drug.

What to do:

If you have serious obesity issues, with a body mass index (BMI) more than 30, or if you have more than 25lbs to lose, any of the popular diet programs are acceptable: Jenny Craig, Weight Watchers, NutriSystem or Optifast.

My Recommendation:

Optifast has a 35 year track record of rapid, safe and effective weight loss that has a high probablity of being sustained over five years. In the late 1979 and 1980 i studied the effect of Optifast on heart function and rhythm in masively obese patients on an Optifast diet. The heart responded by returning to normal size and function and a normalization of heart beats. My present experience as a cardilogist dealing with morbidly obese patients has shown that Optifast has had been amazingly effective in causing signifcant, safe weight loss. Please see OC-OPTIFAST.COM if you are in need of fast, safe and effective weight loss

CALCIUM SUPPLEMENTS AND HEART ATTACKS

2010-08-01T21:27:00.000-07:00

THE STUDY:

"Effect of calcium supplements on risk of myocardial infarction and cardiovascular events: meta-analysis."
Mark J Bolland, Alison Avenell, John A Baron, Andrew Grey, Graeme S MacLennan, Greg D Gamble, Ian R Reid.
BMJ, 2010;341:c3691; Published online 29 July 2010

DR Reid and colleagues decided to investigate further by conducting a meta-analysis (a study that pools and re-analyzes results from lots of other studies and as if they belonged to one giant study).

They searched established sources for published reports of trials that met their criteria. The trials had to be randomized, placebo-controlled trials that ran for at least one year and examined the effect of calcium supplements (dose of 500 mg per day or higher) on at least 100 participants of average age of 40 years.

They found 15 trials that matched their criteria: 5 had patient-level data covering over 8,000 participants over a median follow-up of 3.6 years, and 11 had trial-level data covering nearly 12,000 participants and a mean duration of 4 years.
Five studies showed:

A 31 per cent higher risk of heart attack in the people who took calcium supplements compared to those who took placebo (143 on calcium versus 111 on placebo; hazard ratio HR 1.31, 95 per cent confidence interval CI ranged from 1.02 to 1.67, statistical significance P=0.035).
An increase in stroke risk, but this was not significant (HR 1.20, 95% CI 0.96 to 1.50, P=0.11).
Non-significant increases in risk of death and a composite end-point comprising sudden death, heart attack or stroke.

Eleven studies showed:

27 per cent higher risk of heart attack in the people who took calcium supplements compared to those who took placebo (166 vs 130, pooled relative risk 1.27, 95% CI 1.01 to 1.59, P=0.038).

Reid and colleagues concluded that:

"Calcium supplements (without coadministered vitamin D) are associated with an increased risk of myocardial infarction."

They found the results were independent of age, sex, and type of supplement and consistent across trials.

Although the risk they found was not large, because so many people take supplements it could mean a large burden of disease in the population as a whole, warned the authors.

Other studies have shown that people with high calcium intake that comes from their diet as opposed to supplements do not have a higher risk of heart attack or stroke, suggesting that perhaps the risk is limited to supplements.

THE BOTTOM LINE:

To make it simple, out of the 20,000 patients, 309 had heart attacks on supplements vs 241 on placebo, the real difference is about 68 more heart attacks for 10,000 patients, a very small amount, or about 0.7%, and only those not taking vitamin D.

It is more likely that the heart attack rate was higher (and as mentioned the absolute increased rate is very small), may be due to vitamin deficiency, rather than the calcium supplements.

WHAT TO DO?

Take calcium supplements only if you need them because you are developing osteoporosis. If you do take them, make sure you take Vitamin D. Even if you do not have osteoporosis, taking Vitamin D 3, about 2000iu gel caps per day are reasonable to protect your heart.

TESTOSTERONE SAFE FOR YOUR HEART ?

2010-07-05T22:03:00.000-07:00

THE ISSUE:
Two recent studies showed a link between high testosterone and heart disease. Both were very small studies and the results and conclusions are debatable:
Study 1.

Testosterone therapy associated with cardiovascular risks, other adverse effects

Older men with limitations in mobility and a high prevalence of chronic diseases who used a testosterone gel had a significantly increased risk for cardiac, dermatologic and respiratory adverse events, according to results of a recent study that investigated the safety and efficacy of testosterone in this population.

Researchers randomly assigned 209 men aged 65 years and older (mean age, 74 years) with limited mobility and a total serum testosterone level of 100 ng/dL to 350 ng/dL or a free serum testosterone level of less than 50 pg/mL to two treatment arms. For 6 months, one group received testosterone gel while the second received a placebo gel.

The trial was halted early by the data and safety monitoring board because of a significantly higher rate of adverse cardiovascular events in men assigned to testosterone gel.

At baseline, the researchers reported a high prevalence of hypertension, diabetes, hyperlipidemia and obesity.

During the study, men assigned to testosterone gel experienced significantly greater improvements in strength tests (leg press and chest press) and stair climbing while carrying weight.

However, men in the testosterone gel group were found to be twice as likely to experience adverse events, specifically, cardiac respiratory and dermatologic, compared with men in the placebo group. CV-related events were significantly higher in the testosterone group vs. the placebo group (23 vs. 5). The relative risk of these events persisted in the testosterone group during the 6-month study.

“Caution is warranted in interpreting this finding because of the small number of events and because of limitations with the respect to the ascertainment of adverse events,” the researchers wrote. “Caution is also warranted in extrapolating these findings to other doses and formulations of testosterone or to other populations, particularly young men who have hypogonadism without CV disease or limitations in mobility.”

STUDY 2:
Higher Testosterone Levels Are Associated With Higher Cardiac Risks

Study participants were age 65 or older and included 697 community-dwelling men who were participating in the National Institutes of Health-funded study, Osteoporotic Fractures in Men (MrOS). None of these men were receiving testosterone therapy, according to the study abstract.

All subjects had blood tests to determine their testosterone levels. The investigators then divided the men into quartiles, or four groups, of testosterone range to observe trends in rates of coronary heart disease events. This type of heart disease results from plaque-clogged or narrowed coronary arteries, also called atherosclerosis. A coronary heart disease event included a heart attack; unstable angina, which is chest pain usually due to atherosclerosis and which doctors consider a prelude to a heart attack; or an angioplasty or bypass surgery to clear blocked arteries.

During an average follow-up of nearly 4 years, 100 men, or about 14 percent, had a coronary disease event, in particular, heart attacks, Sueoka said. After the researchers adjusted for other potential contributing risk factors for heart disease, such as elevated cholesterol, they found that higher total testosterone level relates to an increased risk of coronary disease. Men whose total testosterone was in the highest quartile (greater than or equal to 495 nanograms per deciliter, or ng/dL) had more than twofold the risk of coronary disease compared with men in the lowest quartile (below 308 ng/dL).

Other important measures of testosterone in the body and of a protein that tightly binds with testosterone (sex hormone-binding globulin) also showed a close relationship between testosterone and coronary heart disease, Sueoka said.

The investigators did not divide the men by normal or abnormal testosterone levels because the definition of abnormal levels depends on many factors, including increasing age. In fact, says Sueoka, "Men with the highest testosterone could potentially be at risk for heart disease regardless of the definition of "normal" levels."

BOTTOM LINE:

Almost all studies to date show that low levels of testosterone are associated with increased cardiovascular risk. Replacing testosterone to high normal range in older men who are testosterone deficient is beneficial, not only for cardiovascular health, improved mood and physical well being. Until proven otherwise, it is probably wise to maintain normal testosterone levels in men who have no other contraindication. Study 1 was a very small, short study and used higher than recommeded doses of testosterone. Study 2 observed the heart attack rate in those with higher natural levels of testosterone, no causal relationship can be determined from this. Remember, replacing testosterone in men who are deficient is not the same as anabolic steroid abuse that athletes undertake. Anabolic steroids do cause heart disease.

Statins May Not Lower Death Rates Among Patients Without Heart Disease.

2010-06-29T22:57:00.000-07:00

The Issue: Three studies recently published and referenced in The Los Angeles Times, question the benefit of statins in preventing cardiac deaths when used in patients without known heart disease.

The Los Angeles Times (6/29, Healy) reports that "a simmering scientific dispute over statins, the cholesterol-lowering prescription drugs that rake in some $26 billion a year for their makers, heated up Monday with an exchange of published volleys that drove back the reputation of the widely prescribed medications in one area even as it advanced their stature in another." One meta-analysis "published in the Archives of Internal Medicine found that statins do not lower death rates among patients with risk factors but no evidence of established cardiovascular disease who take them as a preventive measure." Meanwhile, "a study released Monday characterized as 'flawed' a widely hailed 2008 study that appeared to establish the benefit of the statin rosuvastatin (commercially marketed as Crestor) in the prevention of heart attack and stroke."

AFP (6/29) reports that the meta-analysis "involving 65,229 people questioned the wider use of statins...in patients who do not have but could develop heart disease." Researchers found that altogether, nearly 2,800 participants "died, including 1,447 in the placebo group and 1,346 in the statin group. It is not a statistically meaningful enough difference to recommend preventative treatment with statins, the authors concluded."

HealthDay (6/28, Reinberg) reported that "even though the statins were doing their job and the levels of LDL...cholesterol were higher among people taking the placebo than those taking statins, there was no association between risk of dying and LDL level," the researchers found.

Bloomberg News (6/29, Kelley) reports that the authors of the second article indicate that "nine of the 14 researchers who conducted the study, dubbed Jupiter, had financial ties to London-based AstraZeneca that may have influenced the way they did their job." Bloomberg points out that "AstraZeneca in March 2008 stopped the study early because of 'unequivocal' evidence that the pill cut deaths better than a placebo in people who had no evidence of existing heart disease." The AP (6/29, Johnson), Reuters (6/29, Kelland), and MedPage Today (6/28, Bankhead) also covered the story.

The Bottom Line:

We know that statins do reduce the chance of another heart attack in those with a previous heart attack (this is called secondary prevention). There is little dispute in this regard.

The problem occurs in primary prevention, that is, do they prevent first heart attacks. There has been a trend to use more and more statins to get the cholesterol levels lower and lower. Some have suggested that statins be put in the drinking water! There has been a trend to treat those with any elevation of cholesterol and a recent study, The Jupiter Study, suggested a benefit in those with normal cholesterol. That study caused a tremendous amount of controversy, and now review of that study brings more skepticism of such use of statins.

Statins do save lives and if used in the proper group of patients will save money by preventing heart attacks and need for stents or coronary bypass surgery. However, in my experience, 20% or more of the patients have significant side effects, like muscle aches, confusion, etc.. If the cholesterol is normal, the statins should be used only if there is coronary calcium on an EBCT heart scan, or signs of plaque in the carotid arteries dectected by ultrasound, of blockages in the arteries of the legs, detected by ultrasound. See ocvitalimaging.com or The OC Cure for Heart Disease (available on Amazon), for further discussion.

DO NSAIDS (ANTI-INLAMMATORY DRUGS) INCREASE BLOOD PRESSURE?

2010-06-27T22:57:00.000-07:00

If you have well controlled blood pressure with certain medications like diuretics, ACE inhibitors or beta blockers, or are newly diagnosed with high blood pressure - exam the pain medications you are taking. It is noT uncommon for anti-inflammatory drugs, prescription or over the counter, such as ibuprofen, naproxen, aspirin, or cox inhibitor drugs like Celobrex, to cause an increase in blood pressure in certain groups of patients.

BOTTOM LINE:
YES, CERTAIN DRUGS USED FOR PAIN AND INFLAMMATION TO TREAT ARTHRITIS PAIN CAN INCREASE BLOOD PRESSURE. MAKE SURE YOU REMEMBER TO TELL YOU DOCTOR THAT YOU ARE TAKING THESE DRUGS IF YOU ARE BEING TEATED FOR HIGH BLOOD PRESSURE

Do Blood Pressure Medications Cause Cancer?

2010-06-27T22:20:00.000-07:00

Sipahi I, Debanne SM, Rowland DY, et al. Angiotensin-receptor blockade and risk of cancer: Meta-analysis of randomised controlled trials. Lancet Oncol 2010; DOI:10.1016/S1470-2045(10)70106-6. Available athttp://www.thelancet.com.

The above study recently did a meta analysis from five trials that used a certain type of blood pressure medications called ARBs, they concluded the following:

New cancer data were available for 61 950 patients from five trials, including only three of the seven FDA-approved ARBs; most patients in this meta-analysis (85.7%) received telmisartan (Micardis, Boehringer Ingelheim) as the study drug; the other patients received losartan or candesartan. The five trials with new cancer data were ONTARGET, PROFESS, LIFE, TRANSCEND, and CHARM-Overall. In addition, data were available for cancer deaths in LIFE, TRANSCEND, VALIANT, and Val-HeFT.
It remains unknown whether other ARBs—irbesartan (Avapro, Bristol-Myers Squibb/Sanofi-Aventis),valsartan (Diovan, Novartis), olmesartan (Benicar, Daiichi Sankyo), and eprosartan (Teveten, Abbott)—are linked to a higher risk of new cancer incidence, the investigators say. "Given the limited data, it is not possible to draw conclusions about the exact risk of cancer associated with each ARB," they observe.
In the meta-analysis, patients randomly assigned to receive ARBs had a significantly increased risk of new cancer occurrence, compared with those in the control groups (7.2% vs 6.0%; risk ratio [RR] 1.08; p=0.016). When analysis was limited to trials where cancer was a prespecified end point, the RR was 1.11 (p=0.001).
Among the malignancies examined—lung, breast, and prostate—only new lung-cancer occurrence was significantly higher in those randomly assigned to ARBs than in control subjects (0.9% vs 0.7%; RR 1.25; p=0.01). There was also a "weak trend" for an increased risk of prostate cancer with ARB use, Sipahi said.

BOTTOM LINE:

I do not think there is enough evidence to stop these drugs. They are important in our blood pressure armamentarium and are very well tolerated. If you look at the data, the difference was 7.2% on the drugs developed cancer and 6.0% without the drug developed cancer (mainly lung cancer), a difference of 1.2%, and this was mainly in the group who were taking both Micardis and another blood pressure drug, Ramipril.The question in my mind is why did so many patients not taking the drug (6%) get lung cancer!

Can You 'Bypass Coronary Bypass Surgery"?

2010-03-03T22:55:00.000-08:00

Coronary bypass surgery (CABG) and the newer coated medicated stents represent amazing technology that often prolongs life, improves the quality of life and relieves angina. We recently have seen, with President Clinton's recent experience, that CABG (and coronary stents) may close and require another bypass surgery or a stent. There are times, however, that a repeat surgery is extremely risky or technically not possible or a stent is technically not possible due the shape or size or bends in the coronary arteries. For such patients who continue to have chest pain and can not undergo these procedures, there is a very effective non surgical treatment called external counterpulsation (ECP).

ECP has been aound for decades but is not widely know. We have been using ECP for over a decade at the Orange County Heart Institute and Research Center. The treatment is 90% effective in relieving angina (chest pain), improving exercise tolerance, and overall quality of life.

Bottom Line: Yes, carefully selected can "Bypass Bypass Surgery" See our web site:ocheart.org for more information on this amazing treatment

President Clinton and Heart Disease

2010-03-03T22:41:00.000-08:00

President Clinton recently had two stents placed in the coronary arteries after developing chest pain (angina). He coronary bypass surgery (CABG) about five years ago to correct blocked coronary arteries. What happened? Is this unusual? Actually, the need for a repeat coroanry bypass surgery or placing stents in a person who had prior bypass surgery is not at all uncommon. The bypass grafts come from two sources: veins from the legs whcih have about a 4 to 5% chance of closing each year ( so about 60 to 70% close at ten years after bypass surgery), or grafts made from arteries, either the internal mammary artery which comes from the artery along the chest wall or from an artery from the arm, called the radial artery. These grafts have a much higher probability of staying open, about 90% are still open at 10 years after bypass surgery.
The best way to prevent graft closer is to strictly modify all risk factors, like cholesterol, blood pressure, smoking, diet etc. Many people think that since they had bypass surgery at age 55 or 60 yrs of age, that it will take another 55 to 60 years for the bypass grafts to fail. Fortunately the newer drug coated stents are fantastic and probaly will give President Clinton a number of years free of symptoms. He will need yearly stress tests to assess the function of his grafts and stents.

NFL considering echocardiograms

2010-01-25T21:15:00.000-08:00

The article:

By Chris Mortensen ESPN Archive

Between the time of Bears defensive end Gaines Adams' death last Sunday to his funeral Friday, the NFL's Cardiovascular Committee began discussing the possibility of subjecting all players to a heart scan called an echocardiogram, starting with potential draft picks invited to the NFL scouting combine next month.

NFLPA medical director Thomas Mayer told ESPN that the medical examiner who performed an autopsy on Adams stated the enlarged heart that led to his death could have been detected by an echocardiogram.

But, as Mayer pointed out, the process is complicated. Is the fear of legal liability going to influence a doctor? Are cardiologists going to agree on whether a player has an enlarged heart or an athlete's heart? Does that mean he's systematically finished as a football player?

More likely, a questionable echocardiogram could lead to more sensitive tests, such as a cardio catheter procedure. Currently, echocardiograms are ordered only when a player has an abnormal EKG or has a family history of heart problems.

The NFLPA has reviewed Adams' medical files dating back to his entry into the league and his EKG and family history were normal. Adams, who had just completed his third season in the NFL, went into cardiac arrest at his family's home in the early morning last Sunday in South Carolina. The autopsy showed Adams had an enlarged heart, which can indicate hypertrophic cardiomyopathy, a condition that often leads to cardiac arrest.

Chris Mortensen is the senior NFL analyst for ESPN.
Updated: January 24, 2010, 1:31 PM ET

Does it make sense?

The most common cause of sudden death in young athletes, 14yrs old to late 20's, is a cardiomyopathy. A cardiomypathy is disease of the heart muscle (as opposed to disease of the coronary arteries that we see in older adults, or of the heart valves or of the electrical system of the heart.). The best test is a simple ultrasound test called an echocardiogram. It is relatively inexpensive and easy to do. It is true that a young person can die suddenly, even if the echocardiogram is normal, but that would be rare. At the Dick Butkus Center for Cardiovascular Wellness (Butkuscenter.org) we believe althletes starting in high school should be screening with an EKG (electrocardiogram) and an Echocardiogram. At this age group, cost is a problem, though we try to do them for free and hope to get a donation of $50 for the screening. For professional athlete, cost is not a problem. It makes sense from a business and medical point of view. It is true that cardilogists may not agree at times on borderline abnormal echocardiograms, but that is whatt second opinions are for. A very abnormal test may end the players career, but it may also save his or her life.

For the older player, more than 35 years of age or older, they will more likely die from coronary artery blockages, they should be screened with Ultrafast CT scans called EBCT heart scans that detect plaque in the arteries. A simple 5 minute test. (ocvitalimaging.com)

Bottom line:

Screening althletse with echocardiograms makes sense and should be done by all sports organizations, not just the NFL.

Anabolic Steroids Can Cause Heart Disease

2010-01-16T21:30:00.000-08:00

The Question: Are anabolic steroids dangerous? Can they cause heart disease?

The Answer: Anabolic steroids are a significant risk factor for cardiac disease and heart attacks.

The Facts:

Anabolic steroids are actually "designer drugs". They are synthetic substances that have varying properties and effects similar to testosterone. However, they are not testosterone. They improve recovery time from exercise, increase muscle mass and strength, and have a host of other testosterone like effects on the body, some not very good. It is impossible to do a "double blind" study (the most accurate type of study) to see if steroids shorten the life expectancy of a person. It would be unethical and never will be done. We published the only scientific evidence, in Preventive Cardiology, Fall 2006, that there is an association between steroid abuse and heart disease.

The Study:
We did the next best thing. We did a real life, observational study. At the Orange County Heart Institute, we studied 14 bodybuilders who used anabolic steroids for at least 10 years. They had no other known risk factors for heart disease. We did EBCT heart scans to detect plaque in the coronary arteries. This is the most accurate non invasive way to detect hardening of the arteries, the leading cause of heart attacks and death in men and women. A majority of the study subjects had premature and severe coronary artery disease. Several of the subjects in their early 30's had hardening of the arteries similar to a 75 year old man. The earlier in life you develop coronary artery plaque, the more likely you will die of a heart attack at an early age. Please see the article published in Preventive Cardiology, Fall 2006., go to Research Article tab on our web site: ocheart.org

The Reason:
We do not know the reason why anabolic steroids cause heart disease. Is is a direct toxic effect or irritant to the lining of the arteries, or is it an indirect means such as causing the good cholesterol, HDL cholesterol, to be very low and therefore promote plaque buildup. Everyone participant had HDL cholesterol in the 15 to 20 range (higher HDL is better, a level greater than 50 is protective). Certainly not everyone who takes anabolic steroids will get early heart disease, just like not everyone who smokes will get early heart disease, but the risk to your heart from abuse of steroids or cigarettes is very high and very real.

The use of steroids in high school athletes and college athletes is very high. In high school athletes the steroids cause a significant physical change and emotional change that can destroy lives and also lead to high rate of suicide. Dick Butkus, NFL Hall of Fame, has lead the way through his I Play Clean program, to get steroids out of high school sports. see the Iplayclean.org .

The Bottom Line:
Anabolic steroids cause heart disease, no question about it. Not everyone who abuses them will have a heart attack, but the risk is real. If you have been using steroids for 8 to 10 years, you should get an EBCT heart scan to see if you have developed hardening of the coronary arteries (see ocvitalimaging.com).
Lastly, don't confuse anabolic steroids with testosterone supplements in middle aged men. studies show that if you have a low level of testosterone, having testosterone supplementation to maintain your testosterone levels in the high normal range can actually protect your heart.

Prostate Disease and Erectile dysfunction and Heart Disease

2010-01-04T22:49:00.000-08:00

Prostate cancer and sexual dysfunction are associated with increased risk of heart attacks.

Prostate Cancer:

Wall Street Journal

Tuesday, December 29, 2009

Immediate Risk for Cardiovascular Events and Suicide Following a Prostate Cancer Diagnosis: Prospective Cohort Study

Published in the December 2009 Issue of PLoS Medicine

The researchers identified nearly 170, 000 men diagnosed with prostate cancer between 1961 and 2004 among Swedish men aged 30 years or older by searching the Swedish Cancer Register. There was a significant increase in heart attacks in the men recently diagnosed with prostate cancer compared to similar age men without prostate cancer. The theory is that the emotional stress associated with the new diagnosis of prostate cancer leads to heart attacks.

Erectile Dysfunction:

Mayo Clinic Proceedings,

Men with erectile dysfunction (ED) are 80 percent more likely to develop heart disease compared to men who do not have ED, a new Mayo Clinic study finds. Men ages 40 to 49 with ED are twice as likely to get heart disease.

Bottom Line:

If you have been diagnosed with prostate cancer or erectile dysfunction, you should be tested for coronary artery disease, the leading cause of death in men and woman. If you have no symptoms, you should have a screening CT scan for calcium in the coronary arteries using an EBCT heart scan to see if you have plaque build up (coronary calcium and plaque are the same thing). If you have no coronary calcium, you do not have coronary artery disease. If you have coronary calcium, you should be placed on aspirin and a statin cholesterol medicine. Then get a stress test to see if the plaque is obstructing blood flow. If the stress test is abnormal, usually an invasive coronary angiogram is performed to see how severe the obstruction is and to determine if a coronary stent is needed.

CT Scans May Cause Cancer: The Truth?

2009-12-16T22:07:00.000-08:00

The Study:

The Archives of Internal Medicine released the the study this week, stating the use of CT scans in the USA has increased significantly over the years, to 70 million scans a year. It estimates about 29,000 future cancer cases could be related to CT scans from 2007, with nearly 15,000 resulting in death.

The Truth?

Everyone agrees that we should limit our exposure to radiation because of the potential risk that it may cause cancer. The present study did not prove that cancer will occur, it was a guess that it may lead to cancer. The study was not a study comparing the number of patients who got cancer after receiving a CT scan to the number who got cancer and never received a CT scan. It was simply a mathmatical assumption.

I believe the risk assumption is overblown based on the fact that cardiologists have done tens of millions of invasive coronary angiograms and coronary angioplasties and stents for many decades. The radiation exposure during the procedure to implant a stent or perform balloon angioplasty is considerable and we have not reported higher cancers in these patients. We have also done many millions of nuclear stress tests (Thallium and Cardiolyte), these have high radiation exposure, and again no reported increase in cancers.

The Common Sense Approach:

I have been involved in invasive coronary angiography and PTCA and stents and other interventions for 30 years, and involved with cardiac CT scanning for a decade. These are potentially life saving modalities and when applied in a common sense manner, the benefits way exceed the potential harm.

1. Screening CT: A screening CT scan is done to try and detect early disease of the heart, lungs or other organs, in a patient without symptoms. Common screening CT scans are Full Body Scans, CT lung screening , or CT scan of the heart to detect coronary calcium (plaque), try to have it done on a special type of CT scanner called an EBCT Scanner. This is a very fast, very low radiation CT scanner that produces 1/10 to 1/20 of the radiation of conventional CT scan. In addition, the radiation output is fixed and can not be mistakenly increased.

2. Diagnostic CT: These are done to detect a cause of a symptom from the pelvis, abdomen, chest or heart. When dye is injected these are called CT angiograms. The newer conventional scanners are mechanical scanners where the lens rotates or spirals around the body. The number of lenses, like 16, or 64 lenses are called "64 slice or 16 slice CT scanners", have lower radiation than the older 4 slice and 2 slice CT scanners.

Bottom Line:

CT scans save many more lives than the potential harm they are guessed to cause. The risk is overblown but it is wise to choose the right type of CT scanner (EBCT for screening, multislice for diagnostic). If your doctor thinks you should have one, it is reasonable to ask why, but if trust his or her opinion, the radiation risk should not dissuade you.

For information on various CT scanners see: ocvitalimaging.com

PLAVIX and drug interactions: the confusing truth

2009-12-01T22:07:00.000-08:00

The controversy is this :do these acid inhibiting drugs reduce the effect of Plavix and therefore make Plavix less effective, thereby making a clot more likely to form in the coronary artery. The most important use of Plavix is to prevent clots in stents (small meshed tubes to keep arteries expanded) that are placed in the coronary artery.

PLAVIX is a widely used drug that prevents clotting by inhibiting platelets from binding together and forming a larger clot in an artery. These clots can lead to a heart attack or stroke. Aspirin also has a similar effect on platelets, but through a separate mechanism, so often Plavix and aspirin are used together to enhance the anti-clotting effect of each other. One side effect of Plavix is that it may irritate the stomach lining, so, often antacids or acid inhibiting drugs are given with Plavix.

The following are proton pump inhibitors that are thought to possibly interfere with Plavix:

Omeprazole (brand names: Losec, Prilosec, Zegerid, ocid, Lomac, Omepral, Omez)

Lansoprazole (brand names: Prevacid, Zoton, Inhibitol, Levant, Lupizole)

Dexlansoprazole (brand name: Kapidex)

Esomeprazole (brand names: Nexium, Esotrex)

Pantoprazole (brand names: Protonix, Somac, Pantoloc, Pantozol, Zurcal, Pan)

Rabeprazole (brand names: Rabecid, Aciphex, Pariet, Rabeloc. Dorafem: combination with domperidone

The following are H-2 blockers which are thought to be safe, except for Tagamet:

cimetidine ( brand name)  Tagamet

famotidine ( brand name) Pepcid

nizatidine ( brand name)  Axid

ranitidine (brand name) Zantac 

The Bottom Line:

The studies are conflicting and most likely the effect on Plavix is very minimal.That being said, it probably isn't worth taking the risk of having a stent clot off. So if you need something for an ulcer or gastric reflux, the H-2 blockers, except Tagamet are the safest. If you must use a proton pump inhibitor, probably Protonix is best.

Teen Study Backs Heart Screens for Athletes

2009-11-24T21:39:00.000-08:00

Los Angeles Times, Health insert for November 23, 2009, references an article on screening athletes for heart disease. The study was presented at the American Heart Association's annual scientific session. The study recommends screening athletes for silent heart disease using both EKG (electrocardiograms) and echocardiograms (ultrasound of the heart). They found abnormalities in 36 of the of the 134 athletes screening. About 3,000 deaths occur each year in young athletes due to a heart ailment, states the article.

It is my believe that this is a sound an necessary approach to screening our kids. I believe the actual number of deaths is actually under reported. In one year, in Orange County, Calif. 14 such deaths were reported. The death of an apparently healthy child shakes the community to its core. The the total number of deaths is not huge, the death of even one young person is a tragedy. The loss of years of life is gigantic since many of these deaths occur in a teenager who normal is expected to live another 60 years.

The question really is of resources and money to screen.

The Dick Butkus Center for Cardiovascular Wellness, a non-profit organization in which I participate) is dedicated to screening for sudden death. View the web site on this blog.

Bottom Line: Screening Teen Athletes with EKGs and echocardiograms is a very worthwhile approach to save lives!

Do We All Need Statins?

2009-11-23T21:57:00.000-08:00

Parade (insert to the Sunday edition of the Orange County Register, and the LA Times, November 22, 2009), asks this question in response to a study, The Jupiter Study, published in the New England Journal of Medicine.

Simple Answer: Absolutely Not!

The study placed 9,000 patients on a statin medication (Crestor) if they had a so called "normal" LDL (bad) cholesterol plus an elevated CRP (C-reactive protein: a measure of inflammation). The other half (9,000) took a placebo. They were men over 50 years and women over 60 years of age. The study showed that in 9,000 people who took the statin, there were 50 fewer deaths from all causes compared to the placebo group, suggesting that the CRP predicts who, with normal cholesterol should be treated based on a high CRP.

Once again, if you look at the numbers, the benefits were small, but the study was stopped prematurely after 18 months or so. Why? Would it show less or no benefit if it was say 5 years? Why stop a study when you are talking about a drug that you will be using for the rest of your life? Why out of almost 18,000 people, did only about 10 in each group need to stop medications because of muscle aches? Why did more (about 50) of the people in the placebo group have a family history of early heart disease and more (about 50) have metabolic syndrome (a precursor to diabetes and a risk factor for heart disease). What happened to the 25% of the people who stopped taking the medications in both groups?

The results: 50 fewer deaths in the group that took the statin out of 9,000 patients.

So what's wrong? Another flawed study for the reasons mentioned above with results that are questionable, being touted as a revolutionary new direction for the treatment of heart disease.

I use a great a large amount of statins in my patients, and they do save lives when used in the correct group of people. The group outlined in this study is not that group.

Bottom Line:
This study in my view point, and that of many physicians, does not present convincing evidence to give more statins based on the CRP level in people with LDL levels in normal range (<130). Perhaps if the study was carried out for five years and those who dropped out were removed from the statistics, we would have a better basis to make recommendations.

The Mammogram Controversy

2009-11-19T21:24:00.000-08:00

New scientific advisory board no longer recommends yearly mammograms at age 40, but continues to endorse mammograms every two years after the age of 50. But does it make sense?

Their thinking is that since women age 40 to 50 have a lower incidence of breast cancer and the fact that they have denser breast tissue, the mammograms pick up more abnormalities that lead to more testing that often does not lead to breast cancer, and often causes more unnecessary biopsies and undue anxiety on the patient. It also, they claim, causes unnecessary radiation exposure. Is this a reason not to screen woman at age 40?

All tests have a certain degree of accuracy. The ideal test would be 100% sensitive, which means it will pick up every cancer in every patient. It would also be 100% specific, which means every time it detects an abnormality, that abnormality is truly a cancer and not something else, like scar tissue. No such test exists for any disease, not with PSA tests for prostate cancer, nor PAP smears for cervical cancer, or colonoscopies for colon cancer. All of them will miss a certain number of cancers, all of them will find an abnormality that really is not a cancer and requires further testing to determine so.

So what would make sense?

Leaving the screening recommendations as it is makes the most sense, because picking up disease in younger patients leads to more years of life saved. The radiation dose is minimal. If a mammogram is abnormal, the best way to minimize anxiety is to do the next phase of testing very quickly, see a breast surgeon for an opinion within say 48hrs. That will minimize anxiety. To stop doing the screenings to avoid anxiety if a mammogram is abnormal makes no sense at all. If any change was to be made, it would make more sense to screen woman every year after age 50, since the disease is more common at that age, and screen woman in their 40's every other year since it is less common in that decade of life. That makes more sense if you were looking to make a change of some sort.

Bottom Line: Leave the screening mammogram schedule as it is. If an abnormality is found, have the patient see the appropriate doctor within days.

Zetia: (ezetimibe) the common sense story

2009-11-18T21:01:00.000-08:00

Nov. 17, 2009 Inaugural Blog:

It could not be a better time for a cardiologist to start a blog. A just released study, ARBITER 6-HALTS study, about a cholesterol lowering drug, called Zetia (ezetimibe) (it is also a component of the drug Vytorin), has brought forth numerous calls from patients asking if they should stop Vytorin or Zetia. I will keep it simple:

The study in question: ARBITER 6-HALTS study

In patients with high cardiovascular risk, extended-release niacin is associated with better outcomes than ezetimibe, according to a New England Journal of Medicine study released online.

Researchers randomized over 350 patients on long-term statins to added therapy with either niacin or ezetimibe. The primary endpoint was the difference in change of carotid artery intima–media thickness from baseline to 14 months between groups. After 208 patients had completed the trial, it was stopped when results significantly favored niacin.

The problem with the study:

The study had a small number of patients and was stopped after only 14 months. Why would you stop a study after 14 months, when most people will have to be on these medications for many years if not for the rest of their lives? Maybe at 4 or 5 years, an advantage would be seen with Zetia. Also the method used to measure the drug's effectiveness, called carotid IMT, was used to see if the lining of the carotid artery thickened more with Zetia, than with niacin. The idea is if the lining thickens more while on Zetia, than on niacin, then Zetia is less effective. carotid IMT is a questionable marker to follow atherosclerosis (hardening of the arteries). Also, these patients had relatively low HDL cholesterol, which niacin is more effective for this problem than Zetia, which usually does not change HDL.

The bottom line:

The study was a somewhat weak study. Zetia is a worthwhile medication and I tell my patients to continue the drug, until there is convincing evidence otherwise.

I believe that Zetia (and Vytorin) is an effective drug, but it is a third line drug. I use the drug frequently, but I approach cholesterol this way:

If a patient has no known heart disease (that is, they have never had a heart attack, or a stent or PTCA or coronary bypass surgery), I try not to put them on cholesterol medications if at all possible:

1. I obtain an EBCT heart scan. This is a high speed, low radiation CT scan to detect plaque, to see if they have coronary calcium (which is plaque in the coronary arteries).

a. If they have no coronary calcium, I feel comfortable treating them with diet and exercise and not with medications

b. If they have coronary calcium (plaque), then They need medications as follows:

1. If LDL cholesterol is high;: start with a statin, and only add Zetia if the statin alone will not get their LDL to goal, or if they have side effects from statins and can't tolerate them, then I use Zetia alone.

2. If they have a low HDL cholesterol, this is a serious risk factor, and I use extended release niacin which is the most effective way to raise HDL. niacin and a statin is the most effective way to slow plaque progression.

3. If the triglycerides are very high, I use a fenofibrate (like Trilipix or Tricor), plus fish oil and possibly niacin.

For more information on this approach to treating cholesterol:

Read:

The OC Cure for Heart Disease, by Dr Larry Santora, MD, Dick Butkus, Steve Armentrout, MD available on line at Amazon.com and Barnes and Noble.com

View our website :

ocvitalimaging.com