Heart Disease: Does Sex Matter?

If a tree falls in a forest and no one is around to hear it, does it make a sound?  Likewise, can someone have a heart attack without suffering from crushing substernal chest pain?  As most physicians know, many (female) patients with acute coronary syndrome (known as a heart attack in laymen's terms) don't present to their physician or emergency department clutching their chest exclaiming Redd Foxx's classic "Elizabeth, it's the big one", as made famous in Sanford & Son.

In a cohort study addressing this question published last week in JAMA, the authors evaluated the outcomes of 1,143,513 patients, of whom 481,581 were female, who participated in an observational registry.  Of note, women were more likely to present without complaining of chest pain (42%) and were more likely to die (14.6%) compared to men in a similar age group (30.7% & 10.3%, respectively).  The good news is that the difference in presentation & mortality was less problematic with advancing age.

A different perspective of Venus vs Mars was published almost 3 years ago in JAMA when authors performed a meta-analysis of 11 independent randomized trails involving 136,247 patients, of whom 38,048 were female.  They initially concluded that women were almost twice as likely to die within the first month post-infarct compared to men (9.6% vs 5.3%).  The findings were not thought to be statistically significant after taking into account the usual confounders.  However, when looking specifically at ST elevation myocardial infarction (STEMI), women were 15% more likely to die within the first month.  A subgroup of women underwent angiography and demonstrated more non-obstructive and less 2- & 3-vessel disease compared to their male cohorts.  After taking into account this difference in angiographic data, there was no difference in 30 day mortality between men & women.  

So what are we to make of these two studies?  The authors stated that despite differences in presentation, no change to the public health message regarding chest pain & discomfort (regardless of sex & age) should be made at this time.  However, as we come to the end of yet another American Heart Month, I would posit that perhaps we should be more suspicious for heart disease in our younger female patients.

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Dark Side of Statins Part 3 FDA Steps In

I'd like to think that the Food & Drug Administration (FDA) values my opinion enough to read this blog but that's a pipedream.  However, last month I did point out a series of studies demonstrating an association between statins and diabetes.  Granted all the studies were observational in nature, thus perfect for developing hypotheses, rather than randomized controlled trials useful for declaring cause & effect.  Still, earlier today, the FDA apparently found the evidence compelling enough to make label changes to warn of the possibility of hyperglycemia.  

One bit of good news:  we don't have to worry about regularly and routinely monitoring liver functions anymore (except as a prior to initiation).  And from the glass is half full/empty department, the FDA is finally admitting to the possibility of cognitive effects (memory impairment, etc) associated with statin use which had been widely reported in the blogosphere but officially denied until now.  So, no, you weren't imagining it but the reality is we don't know what to do.  On the other hand, this does open the doorway to more studies to determine who's at greater risk and why.  And hopefully to determine how to mitigate said risk.  Of course, this is truly ironic since statin use has also been associated with lower risk of dementia.  Hopefully, we'll get to the bottom of this sooner rather than later.

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Will An Orange A Day Keep Strokes Away?

Following yesterday's apple analogy, I'm sure we've all also heard that an apple a day will keep the doctor away.  Well, in a prospective study released early online prior to print publication in April in Stroke, consumption of citrus fruit & juice was associated with a decrease risk of ischemic stroke in women.  Just how did the authors arrive at their conclusion?

Well, they followed 69,622 women for 14 years of the Nurses' Health Study and collected food frequency questionnaires every 4 years.  After taking into account all the usual confounders, they noted that those who consumed the highest quintile of flavanone had a 20% lower risk of ischemic stroke compared to those in the lowest quintile of consumption.  The good news is that citrus fruits & juices are the main dietary source of said flavanones.  On a per gram consumption basis, oranges and grapefruits have more flavanones than their juice counterparts, plus less sugar and more fiber.  However, as a nation, we tend to consume our citrus in juice rather than fruit form.

The findings of this observational study are in concert with most previous studies demonstrating a link between consumption of more fruits & vegetables and lower risk of stroke.  However, in the past, we had not been able to pinpoint one or more specific food items as having greater value than others.  To be safe, we need stronger, more robust evidence prior to making a declarative statement of cause & effect.  On the other hand, it's difficult to imagine any harm from encouraging the consumption of more citrus fruit from a public health perspective (avoiding the excess calories associated with juices).

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Antipsychotics & Dementia: A Few Bad Apples?

Scientifically speaking, one bad apple can spoil the whole barrel.  That phrase applies figuratively, too.  Nationally & internationally, think about the effect performance enhancing drug use has had on professional sporting events.  And locally, a few wayward physicians have branded the rest of us, who do attempt to do our best for our patients, as money-grubbing quacks.  Well, a few years ago, all antipsychotics, both typical & atypical, were given a black box warning by the Food & Drug Administration since multiple observational studies had demonstrated an increase in mortality associated with their use in patients w/dementia.

Previously, all the atypical antipsychotics, while supposedly less likely to cause extrapyramidal symptoms and tardive dyskinesia, had been lumped together as increasing one's risk for weight gain, hyperglycemia, and dyslipidemia (which is why I've always cringed when I see patients taking these drugs to deal w/their insomnia, especially when they tell me that they haven't tried anything else).

Unfortunately, given the increasing numbers of patients w/dementia requiring instituionalization, especially those with aggressive behaviors not ameliorable to non-pharmacologic therapies as well as those with egodystonic hallucinations & delusions, antipsychotic use remains high, if not rampant.  The former is fairly apparent & clear cut to delineate.  However, family members & staff often push for use of antipsychotics even in those patients w/egosyntonic distractions.

In reality, let's say a demented loved one really & truly believes that Edward the vampire and Jacob the werewolf are her friends.  There's no need to medicate this patient who is comforted rather than distressed.  On the other hand, let's say this same demented loved one is deathly scared of the Easter Bunny who is lurking in the shadows.  I think we'd all agree that this patient needs some medication assuming distraction, cognitive behavioral therapy and non-pharmacologic measures aren't enough (after ruling out new onset medical illness, of course).

This is a prelude to a retrospective analysis of a population-based cohort study published in the British Journal of Medicine last week of 75,445 elderly nursing home patients >65yo who were newly prescribed antipsychotics for the past 6 months.  Compared to those given risperidone, those prescribed haloperidol had a 2x greater all-cause mortality while those prescribed quetiapine had a 20% lower all-cause mortality.  The other antipsychotics prescribed in large enough amounts to be assessed, aripiprazole, olanzapine & ziaprasidone, did not show any statistically significant difference in all-cause mortality compared to risperidone.

No, we don't have randomized controlled trials to demonstrate cause & effect.  And no, we don't have head-to-head trials to demonstrate which is the better drug.  But for now, this study suggests that quetiapine might have just jumped to the head of the class.  And we might want to get rid of that bad apple, haloperidol (well, at least have another discussion with family members regarding this new study).

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Is this appendicitis

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Lightheadness sometimes not sure what its from,

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My friend is 54 and fell and hit her head

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I hit the back of my head a week ago tomorrow.

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What can cause continuous lightheadedness and what are the cures?

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For one day i found blood clot in my stool

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