Q&A Session at HealthTap.com

Is this statement true? "A single exposure to lead in adults typically isn't a concern if said exposure isn't of high quantities and doesn't proceed".

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Testosterone: Getting to the Heart of the Matter

In case you missed it, USA Today published an article yesterday about a study published today in JAMA in which the authors linked testosterone use to an increase risk of heart attack, stroke & death.  Now before you peel off your patch, scrub off your gel, or throw away your vial & syringes, read the editorial.  Then ask yourself why you're taking it in the first place.  If it's for antiaging purposes, I would suggest you reconsider.  But if you're taking it because you have clinical hypogonadism, then dig further into this study and its editorial along with the USA Today article which might make it a little easier to understand.

Let's first talk about what a statistical anomaly I found: the confidence interval crossed 0.  The authors pointed out that the risk of adverse outcomes was higher at year 1, 2 & 3 for those who elected to take testosterone.  Yet, when they compared the absolute risk difference, the confidence intervals always crossed 0 for each year.  In other words, the purported risks are not statistically significant!  Check out page 1832 for yourself.  If you agree, then there's no need to tear this study apart any further.

But in case you don't agree, I'll analyze the study in more depth over the next day.  Hint: several issues that I always address w/my patients considering testosterone therapy were not mentioned in the study.

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Quantity of Life vs Quality of Life: That Is The Question!

I made a house call yesterday and met an elderly lady who'd fallen, broken her arm, spent some time in rehab, and then returned home independently.  Obviously, she is a success story in that she has regained a relatively high level of function.  Interestingly, she did not make the connection between an elective hip replacement for chronic ongoing pain vs urgent repair of broken hip.  Granted, both lead to loss of function but she kept referring to having had a hip replacement despite being fully functional, running even, prior to her fall.  When I pressed further, she finally admitted that she'd broken her hip.  So I tried to explain why she hadn't had a hip replacement per se.

In any case, she'd been without a physician for the last several months as her primary care provider had retired.  She insisted that she needed her Temazepam 30mg nightly for sleep, which she'd taken for the last 15-20yrs after failing Dalmane & Ambien.  On the other hand, she had a bottle or two of Norvasc which she wasn't taken despite an elevated blood pressure.  Now, she was a well educated person, who was aware that hypertension is a silent killer.  Yet, when pressed, she couldn't explain why she was taking something that would reduce her risk for stroke while insisting on something that might increase her risk of falls & fracture (she insisted that her 2 falls had nothing to do w/her benzodiazepine).

I bring up this vignette because an analysis of the Global Burden of Disease was published 2 days ago in JAMA looking specifically at the state of our country's health from 1990 to 2010.  What's striking is that while all-cause mortality has decreased over this 2 decade period of time w/concomitant 3yr increase in healthy life expectancy, the number of years lived w/disability actually increased.  In other words, while our quantity of life has increased, our quality of life has decreased.  Even more striking is that while US life expectancy has increased, increase in life expectancy in other countries has outpaced ours such that we're slipping backwards on a global scale.

Which brings me back to my new patient who is well aware of hypertension's reputation as a silent killer.  And despite this knowledge in a well educated patient, she couldn't explain why she wasn't doing more to maintain her current level of function & quality of life.  This is why our national health is circling the proverbial drain.  We know what we need to do but we don't have the collective conscience to act upon our knowledge.

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Statins: Are They Cost Effective?

Yesterday, we discussed a new study demonstrating the safety of statins and the low risk for potential side effects.  On that same day, a re-analysis of data from WOSCOPS was published early online in the European Heart Journal, in which the authors concluded that 5 years of primary prevention w/statins in middle-aged men was cost-effective in reducing healthcare expenditures related to cardiovascular events & healthcare utilization.  Of note, there was no link w/all-cause mortality.

As a quick refresher, WOSCOPS is the West of Scotland Coronary Prevention Study in which 6,595 participants 45-54yo were randomized to 5yrs of pravastatin vs placebo.  The participants were then followed out to 15yrs for this publication.  Even after taking into account cost of medications, use of pravastatin accounted for decrease rate of cardiovascular events, fewer hospital admissions yet short inpatient stays, plus less heart disease, heart failure & stroke plus less need for revascularization.

So bottom line, statins are safe to use and even cost effective in lowering risk for cardiovascular & cerebrovascular events, even in those who've yet to suffer such an incident.  However, as I noted yesterday, despite this study, statins, like all other medications, are not w/o risk.  Thus, we should not reach out to make use of them unless the patient has failed maximal non-pharmacologic therapy, eg nutrition & physical activity.

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Fluke or Trend? Vitamin D vs Heart Disease

The latest supplement being lobbed back & forth these days is vitamin D.  At the very least, we have plenty of cause & effects studies demonstrating that vitamin D is necessary for bone health.  Without enough vitamin D, we end up with rickets.  But what about health matters unrelated to bone?  Heart disease?  Diabetes?  Cancer?

It turns out that there are plenty of studies linking low vitamin D to greater risk of death from all-causes & from heart disease.  However, these observation studies don't demonstrate cause & effect.  But as the Rolling Stones say, you can't always get what you want.  So in this case, I'll settle for an observational study published this month in the American Journal of Medicine in which the authors concluded that 25OH vitamin D less than 21ng/mL was linked to an increase risk of all-cause & cardiovascular mortality.

In a fashion not unlike that of the National Security Administration, except with permission & proper supervision, the authors gathered data from 10,170 men & women avg 47yo participating in the National Health & Nutrition Examination Study and correlated this with the National Death Index for an average of just under 4yrs.  They noted that low levels of 25OH vitamin D, up to what's currently considered insufficiency at 21ng/mL, were associated with increase risk of death from both all-causes & heart disease.  This is consistent w/recent reviews concluding that "normal" values in 30-100ng/mL range do not improve upon outcomes.

Yet despite the fact that this study supports the trend of studies linking vitamin D to our health, there's still no conclusive proof of cause & effect.  So what are we to do in the meantime?  Well, the good news is that unless you exceed 100ng/mL, it's unlikely that you'll suffer from hypercalcemia & other maladies.  In other words, vitamin D supplementation appears to be safe, as far as we currently know.  Which then makes it easier to consider supplementation if we don't have time to wait around for a cause & effect trial.  Of course, this is something that should be discussed w/your family physician.  And don't forget to think like Goldilocks. You want your 25OH vitamin D level just right, not too high & clearly, not too low.

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James Gandolfini's Demise: Heart Attack or Cardiac Arrest

My wife had the pleasure of meeting James Gandolfini earlier this year at a fundraising function and told me that he was just delightful in person, nothing at all like his most famous role as Tony Soprano.  As I'm sure you're all aware by now, the 51yo actor passed away 2 days ago while in Italy.  What's not clear is exactly how/why this happened.  Initial reports stated that he died from a heart attack.  Now some are calling this cardiac arrest.  What's the difference?  And does it really matter?

USA Today put together a nice review of the differences between two conditions.  Most notably, a heart attack (also known as myocardial infarction) is due to blockage of blood flow to the heart, leading to death of cardiac tissue, thus causing chest pain.  Death of heart muscle can also impact the electrical conduction system of the heart, leading to a short circuit, thus stopping the normal beating of the heart, ergo cardiac arrest.  While one can survive a heart attack, if the heart's normal rhythm isn't restarted in time, cardiac arrest most often leads to death.

So what's your chances of a heart attack or cardiac arrest?  Work w/your family doc & review your risk after plugging in a few numbers & facts into the Framingham calculator that gives a 10 year estimate of heart attack risk.  Remember that a 10 year risk >20% is considered the equivalent of already having had a heart attack.  Also, know that this calculator isn't 100% accurate but just the basis for starting a conversation & discussing options for optimizing your health.  Depending upon your age, ethnicity and especially your family history, your risk score may come out higher or lower than it should.  Still, that doesn't mean that you can ignore your blood pressure, cholesterol, sugar & tobacco use.

Take care of yourself, if not for you, then for your family.  51 is an awfully young age at which to pass away. The only consolation I have is that we're a better world for having enjoyed his skills.

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Just How Fast Is Your Heart Beating? Part 2

Back in March, I looked at a study using resting heart rate (RHR) to predict cardiovascular fitness w/o exercise.  Then last month, I looked at another study using RHR to predict mortality.  So I thought I'd point out a prospective observational study published in this month's European Heart Journal in which the authors linked increased night-time heart rate to greater all-cause & cardiovascular mortality.

The authors arrived at their conclusion by following 653 men & women (avg 64yo) who had completed a 48 hour Holter recording of their heart's electrocardiographic activity.  RHR (avg 73bpm), 24hr heart rate (76bpm), and night-time heart rate (66bpm) were all calculated from the recordings but after taking into account the usual confounders, only night-time heart rate was statistically significant at just over 6yrs (avg 76mo).  Of note RHR & 24hr heart rate were also linked to all-cause mortality but not as well as night-time heart rate in predicting cardiac events.

Ok, so you can't set your alarm to wake you up at 1AM, 2AM & 3AM in order to measure your heart rate for 15 minutes, on two separate nights.  That's where this monitoring comes in handy.  But regardless of whether you can measure or not, you can certainly make a difference by improving your cardiorespiratory fitness via exercise.  And as we learned last week, high intensity interval training is an excellent way to improve fitness as measured by oxygen consumption (VO2 max).

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Spaghetti on the Wall: Alzheimer's Disease, Heart Attacks & Death

Throw spaghetti on the wall and see if it sticks.  The idea is to try some (random) ideas and see which one works.  In one sense, you can look at observational studies as just that, throwing spaghetti on the wall, especially when a trial is published with a new association, heretofore unknown.  Of course, you follow up that first strand of spaghetti with another, and perhaps even a few more for good measure, just to make sure you're looking at a trend and not a fluke.  But when it comes to research, we need randomized controlled trials to offer proof of cause & effect, no matter how many observational studies are published.

But with all that in mind, I must admit that my curiosity was piqued when I stumbled upon a study published early online last week in the European Heart Journal in which the authors concluded that use of cholinesterase inhibitors (ChEI) in those with Alzheimer's disease (AD) was associated w/lower risk of heart attack & death.  I don't know about you, but for me, that came out of left field.  The authors followed 7,073 Swedes (avg 79yo) w/AD for an average of 503 days (just over a year & 4mo for those of you who think like I do in those terms).  

After taking into account the usual suspects (confounders), the authors noted that those participants w/AD who took a ChEI had a one-third lower risk for heart attack or death compared to those who did not take a ChEI.  Similar statistics were noted when ChEI use was compared to heart attacks & deaths in isolation in non-users.  More importantly, use of the highest ChEI doses was associated w/lowest risk of heart attack (65% lower) and death (46% lower), again compared to non-users.

So what's this mean for you & me?  I dunno!  But it's certainly intriguing!  And I'm definitely looking forward to that next strand of spaghetti being flung against the wall . . .

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Is a Vegetarian Diet Really That Good for You?

The Truth Is Out There.
X-Files 1993-2002

Now, I'm game for just about anything that might make/keep me healthier and prolong (quality of) life, but I have to give you the following disclaimer:  I'm an omnivore, so you'll need to pry that well marbled USDA Prime rib eye from my cold dead hands.  But just yesterday, I stumbled upon a headline that read "Veggies Are Key to Long Life" and feared that my eating habits as I've known them for the past 5 decades were about to come to an abrupt 180o turn.  The referenced article was a prospective cohort study published early online in JAMA Internal Medicine (aka Archives of Internal Medicine) in which the authors concluded that vegetarian diets are linked to lower all-cause mortality & some cause-specific mortality.  But just like Michael Douglas' proclamation earlier this week that oral sex begat (his) oral cancer, the science isn't always so clear cut.

To arrive at their conclusions, the authors followed 73,308 Seventh Day Adventists  for close to 6yrs.  While their average age was 56-59yo, their average body mass index was only 24-28kg/m2, much less than the average American these days, which might bring into question the generalizability of the results.  Nonetheless, they were able to conclude that any vegetarian diet was associated w/12% lower all-cause mortality compared to non-vegetarian adherents (like myself).  Interestingly, the results for ischemic heart disease mortality, cardiovascular disease mortality, and cancer mortality did not reach statistical significance, while "other mortality" barely did at 15% lower risk.

However, if you looked at female vegetarians (which I'm definitely not either), there was no statistically significant reduction in either all-cause or disease specific mortality.  Male vegetarians did demonstrate 18% lower all-cause mortality and 29% lower cardiovascular disease mortality.  In case you're wondering, ischemic heart disease refers exactly & only to heart disease while cardiovascular disease includes carotid artery disease & stroke, too.

Now, little did I know, but among vegetarians, you can further sub-classify yourself as vegan, lacto-ovo-vegetarian, pescovegetarian, and even semi-vegetarian.  Well, the authors did, any way, lumping those who ate non-vegetables less than once per month as vegans; lacto-ovo as those who consume eggs & dairy more than once a month but no other non-vegetables; pesco- as those who consumed fish at least once a month but any other meat less than once a month; semi- as those who consumed fish & non-fish meats more than once a month but no more than once a week.  Got it?  Sound a bit like a slippery slope, right?  

Well, if you're only as strong as your weakest link, it turns out that sub-classifying vegetarians reduced statistical significance such that only pesco-vegetarians achieved 19% lower all-cause mortality & 35% lower ischemic heart disease mortality.  All others were unable to reach statistical significance.  And remember that slippery slope, while vegan, lacto-ovo & pesco tended to liver longer (albeit w/o statistical significance), semi-vegetarians showed worst statistics.

Yes, I remember that quote about "Lies, damned lies & statistics" popularized by Mark Twain.  But in this instance, that "faulty" headline doesn't nearly capture the complexity of the data.  It's unfortunate that we can't summarize new findings in 15 second sound bites or 140 characters.  I guess that means I can go back to gnawing on some gristle for a while longer.

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Breast Cancer Genetics: The Role of Your Family Physician Part 2

So now that the furor over Angelina Jolie's disclosure has died down, I thought I'd take a closer look at the US Preventive Services Task Force evidence review published last month in Annals of Internal Medicine in which they concluded that selective estrogen receptor modulators can reduce the risk of breast cancer.  However, if you'll recall that there's no such thing as a free lunch, then it shouldn't come as a surprise that use of tamoxifen was associated w/greater risk of thromboembolism & endometrial cancer than raloxifene, albeit tamoxifen reduced breast cancer risk better than raloxifene.

The authors arrived at their conclusions after finding 89 fair-to-good quality trials in which both SERMs reduced risk of invasive breast cancer w/tamoxifen getting the edge over raloxifene but at the cost of the above noted complications.  Of note, taking one of two SERMs did not reduce either cancer-specific nor all-cause mortality.  On the other hand, both medications lowered the rate of fractures.

So what should you do?  Start w/your family doc who should know your medical history & family history.  Then use one of several online calculators to determine your risk for breast cancer.  Consider genetic testing if your risk is high eneough.  And finally ask your doc about chemoprophylaxis vs prophylactic mastectomy if your genes demonstrate high enough risk.

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Crystal Ball: Diabetes vs All-Cause Mortality

Get out your crystal ball.  An analysis of the 679 patient Gargano Mortality Study and the 936 patient Foggia Mortality Study was published earlier online this month in Diabetes Care in which the authors noted that all-cause mortality can be predicted based upon a model that includes age, body mass index, diastolic blood pressure, LDL cholesterol, triglycerides, HDL cholesterol, urine albumin:creatinine ratio, and blood pressure & insulin therapies, with validated accuracy.  A web-based online version of this calculator is available.  While it may be intuitive, use of this model might assist a patient or family about the appropriateness of any given procedure.  Or it might provoke a patient into improving some aspect of his/her life in order to reduce all-cause mortality.  Just something to ponder . . .

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Just How Fast Is Your Heart Beating?

Just under 2 months ago, I looked at a study attempting to predict cardiorespiratory fitness via non-exercise means.  Of note, the authors linked body mass index and resting heart rate to CRF.  But do we really care as much about CRF as we do our mortality?  In fact, in a prospective cohort study published last month in Heart, the authors concluded that resting heart rate was an independent predictor of mortality, regardless of physical fitness, physical activity and the usual slew of cardiovascular risk factors.

The authors measured resting heart rate prior to testing physical fitness as measured by VO2max (oxygen consumption) in 2,798 Danish men who were then followed for 16 years.  As demonstrated in a figure in the paper, there was an inverse correlation between physical fitness and RHR.  In other words, those who were more fit as determined by a greater VO2max also had a lower RHR.  

To my amazement, the 222 fittest men w/avg VO2max 38L/kg/min also had an average resting heart rate of just 48 beats per minute while the least fit 54 had an RHR greater than 90bpm.  Typically, we declare anyone with heart rate less than 60bpm as being bradycardic, and very rarely, aside from exceptionally fit young athletes, do I see resting heart rates less than 56bpm.

Yet, after taking into account all the usual confounders, the authors noted that compared to those w/RHR less than 50bpm, mortality increased by 16% for every 10bpm increase in RHR.  Those with what I previously considered an excellent RHR of just 51-60bpm had a 20% greater mortality compared to those w/RHR less than 50bpm.  Those with a normal or average RHR of 71-80bpm had 33% greater mortality while those with RHR greater than 90bpm had more than twice the mortality of those w/RHR less than 50bpm.  So just how fast is your heart beating now?

By the way, if you're worried and wondering about what you can do to lower your RHR and thus your mortality, aerobic exercise is the key, that is, after you've been cleared by your family physician to engage in exercise.  So don't just sit there, do something!

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Red Meat vs Death Part 2

My, how quickly time passes by when we're having fun!  I can't believe a whole year has gone by since last March when I first wrote about a link between red meat consumption and risk of death in the NIH-AARP Diet & Health Study.  In the meantime, red meat has taken a beating and needs to find a new public relations firm to improve its reputation, as it's now been linked to stroke, colon cancer & diabetes, among other conditions.

Well, red meat, especially processed meat, was linked to all-cause mortality, cardiovascular mortality and cancer mortality yet again, this time in the observational study, European Prospective Investigation into Cancer and Nutrition (EPIC), published early online last week in BMC Medicine.  To arrive at their conclusions, the authors followed for an average of a dozen years 448,568 participants 35-69yo free of cancer, stroke or heart disease at baseline.  

Similar findings have also been noted in the Nurses' Health Study and the Health Professionals Follow-up Study, too, most recently last April.  The authors concluded that lowest risk of death was calculated to be associated with consumption of less than 20g/d of processed meat, which could potentially prevent 3% of all deaths.

Bottom line: we should reconsider what we're eating.  After all, we're what we eat.

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Mirror, Mirror, On the Wall . . . Part 2

Yesterday, we looked at a risk calculator developed to help quantify one's risk of dying over the next 10 years as a means to start discussing risk versus benefit regarding any appropriate treatment.  After all, age shouldn't be the only factor in deciding upon whether to perform a procedure or not.  In fact, I'd wager better odds in a healthy 75yo compared to a sickly 65yo.  Another way to predict all-cause mortality & cardiovascular mortality is cardiorespiratory fitness but this requires specialized equipment and training, which isn't always available in rural and low income urban areas.

Therefore I read w/great interest a study published earlier this week in the European Heart Journal in which the authors developed a non-exercise measure of cardiorespiratory fitness (NET-F) using several readily available risk factors determined by following 32,319 participants 35-70yo for 9yrs.  Ironically, it turns out that the sum of these risk factors was better than use of the risk factors in isolation.  Specifically, the calculator made use of gender, age, body mass index, resting heart rate & self-reported physical activity.

OK, so maybe you can't control your resting heart rate & body mass index as much you can just about every other risk factor.  But with continued aerobic exercise, RHR & BMI does tend to decrease as one becomes more fit.  That leaves gender & age as factors out of your control but self-reported physical activity is still under your control.  In other words, you're still the master of your fate.  So don't just sit there, do something!

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