Monthly Archives: April 2013

Heart attacks: What you should know

Posted on by MaryO
Three coronary artery bypass grafts, a LIMA to...

Three coronary artery bypass grafts, a LIMA to LAD and two saphenous vein grafts – one to the right coronary artery (RCA) system and one to the obtuse marginal (OM) system. (Photo credit: Wikipedia)

Editor’s note: Dr. John P. Reilly is editor-in-chief ofsecondscount.org, the patient education website of the Society of Cardiovascular Angiography and Interventions, which is focused on raising awareness of heart attacks and other cardiovascular diseases. Reilly is the program director for the Cardiology Fellowship Program at Ochsner Medical Center in New Orleans.

(CNN) — If you are one of the nearly 785,000 Americans who suffer a first heart attack this year, what you do in the first few minutes can determine an entire lifetime.

Unfortunately, many people do not know what symptoms to look for or what life-saving steps to take. To help make sense of it all, the following can help you or someone you know survive a heart attack:

Q: What are the top three things I should know about heart attacks?

A: When a heart attack strikes, seconds count.

Seek medical attention immediately. The longer your symptoms persist, the greater the amount of heart muscle damage you may suffer. The start of your symptoms is a signal that blood flow to your heart muscle has been blocked. The emergency department and interventional cardiologist or surgeon will move quickly to restore blood flow to your heart to prevent further damage.

Call 911 for an ambulance. Don’t drive yourself or have someone else drive you. During a heart attack, your heart rhythm can become abnormal or even stop.

Emergency medical providers can perform an electrocardiogram, or EKG, on the way to the hospital and confirm whether you are having a heart attack and treat your heart rhythm abnormalities if needed. They can also call the hospital in advance to prepare a medical team for your arrival so treatment can start immediately.

If available, chew one uncoated aspirin while waiting for the ambulance. This may help slow the formation of blood clots that can cause heart attacks.

Q: What are the common symptoms of heart attacks, and how do they differ between men and women?

A: We’ve all seen the scenario where the actor grabs his or her chest in agonizing pain and falls to the ground. A heart attack seems obvious, but in real life, it’s not always that clear.

Heart attack symptoms can vary and don’t always involve debilitating chest pain. Many patients say their symptoms were not painful but more like an ache or discomfort. Symptoms may start with a dull pain in the chest or disguise themselves as indigestion, nausea, shortness of breath or heartburn. Other common symptoms include arm, neck, jaw, back or upper stomach discomfort, dizziness, change in heart rhythm and sudden cold sweats.

But these symptoms may differ for your wife, mother or sister because women do not always experience the same heart attack symptoms as men. Symptoms may be subtle and difficult to identify and may not even include chest pain.

While this does not mean women cannot have chest pain, other symptoms that may signal a heart attack for women include sudden weakness and fatigue, body aches or flu-like symptoms. Heart disease is the leading cause of death for women, so it’s important that you don’t ignore these symptoms, regardless of how subtle they are.

Q: What are my heart attack treatment options?

A: There are various treatment options available when you’re having a heart attack. The most effective treatment is angioplasty and stenting. In some cases, clot-busting medication is administered intravenously. In rare and severe cases, emergency coronary artery bypass grafting is needed.

Angioplasty is a minimally invasive, nonsurgical procedure that opens the blocked artery. During the procedure, a small mesh tube called a stent may be placed in the artery to restore blood flow and scaffold the vessel open.

Clot-busting medications melt away the blood clot that is blocking the artery. Coronary artery bypass grafting is open-heart surgery where a healthy artery or vein from elsewhere in the body is connected upstream and downstream from the heart artery blockage, bypassing the blockage and creating a new path for blood flow.

Fortunately, medical technology has advanced tremendously in recent years, and many patients can return home and back to their normal — if not better — quality of life within days of treatment.

Q: What should I do following my heart attack?

A: Experiencing a heart attack is a life-changing event and an important time to reflect upon your current lifestyle.

Cardiac rehabilitation benefits many patients by helping them resume a healthy lifestyle following their heart attack. You’ll also be taking medication regularly. Adhering to your medical therapy and scheduling consistent follow-up visits with your cardiologist and primary care doctor are both beneficial habits to adopt.

In addition, it’s important to become your heart’s No. 1 health advocate. Assess your current lifestyle and see where you can make improvements. Can you eat healthier and exercise more, reduce your stress levels or quit smoking? These changes will greatly increase your odds of fighting off future heart attacks.

From CNN.com

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Monday, 12 Weeks Post-Op

Posted on by MaryO

falling-behind

Looks like I’m falling w-a-y behind again.  That’s a pretty good thing since that means normal life is resuming.

When we started rehab, DH was the only student – now there are 5 and they seem to get along pretty well.  Slowly but surely, the challenges are getting greater.  Today (or soon) he will start using weights.

Today’s hav is 14 of 36, just over 1/3 of the way through.

He’s been driving pretty normally for a few weeks but still can’t walk the dog.  Maybe that will come after the weights get started.

We had our class with the dietician and there was only one other woman in the class so it was more of a private session.  At the end, 3 of the guys from Mended Hearts came in to see if we had questions.  One said that he liked having me in the meetings and talking about the role of the caregiver!  This is just not me, talking in any group!

Last week, we had out one-on-one with the dietician.  I’d pretty much already learned most of it from online and books but it was good to check.

This week, on Tuesday, we have a class on how the surgery is performed.  I’ve seen videos but it will be nice to see what they have to offer.  We can also observe a live surgery.  We’ll see!

Last week, on Tuesday, we had the privilege of attending a Congressional Caucus on Rare Diseases.  I took the opportunity (of course!) to say a few words about Cushing’s.  If you’re interested, my write-up is here:  Cushing’s on Capitol Hill.

I have an opportunity for a conference in San Francisco in June.  I happened to have airplane credits so I, without thinking, I got 2 tickets.  Hopefully, DH has the go-ahead to fly by then!

I’m amazed at how well things are going at the 3 month mark.  Hopefully, it’s smooth sailing from here on out!

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Patient Outcomes Significantly Improved By L-Carnitine Following Heart Attack

Posted on by MaryO
myocardial infarction - Myokardinfarkt - scheme

myocardial infarction – scheme (Photo credit: Wikipedia)

L-carnitine significantly improves cardiac health in patients after a heart attack, say a multicenter team of investigators in a study published in Mayo Clinic Proceedings. Their findings, based on analysis of key controlled trials, associate L-carnitine with significant reduction in death from all causes and a highly significant reduction in ventricular arrhythmias and anginal attacks following a heart attack, compared with placebo or control.

Heart disease is the leading cause of death in the United States. Although many of the therapies developed in recent decades have markedly improved life expectancy, adverse cardiovascular events such as ventricular arrhythmias and angina attacks still occur frequently after an acute myocardial infarction (heart attack).

It is known that during ischemic events L-carnitine levels are depleted. Investigators sought to determine the effects of targeting cardiac metabolic pathways using L-carnitine to improve free fatty acid levels and glucose oxidation in these patients. By performing a systematic review and meta-analysis of the available studies published over several decades, they looked at the role of L-carnitine compared with placebo or control in patients experiencing an acute myocardial infarction.

L-carnitine is a trimethylamine which occurs in high amounts in red meat and is found in certain other foods, and is also widely available as an over-the-counter nutritional supplement which is claimed to improve energy, weight loss, and athletic performance. Its potential role in treating heart disease was first reported in the late 1970s.

A comprehensive literature search yielded 153 studies, 13, published from 1989-2007, were deemed eligible. All the trials were comparison trials of L-carnitine compared with placebo or control in the setting of acute myocardial infarction.

This systematic review of the 13 controlled trials in 3,629 patients, involving 250 deaths, 220 cases of new heart failure, and 38 recurrent heart attacks, found that L-carnitine was associated with:

  • Significant 27% reduction in all-cause mortality (number needed to treat 38)
  • Highly significant 65% reduction in ventricular arrhythmias (number needed to treat 4)
  • Significant 40% reduction in the development of angina (number needed to treat 3)
  • Reduction in infarct size

There were numerically fewer myocardial reinfarctions and heart failure cases associated with L-carnitine, but this did not reach statistical significance.

First author James J. DiNicolantonio, PharmD, Wegmans Pharmacy, Ithaca, NY, observes, “Although therapies for acute coronary syndrome (ACS), including percutaneous coronary intervention, dual antiplatelet therapy, b-blockers (BBs), statins, angiotensin-converting enzyme inhibitors (ACEIs), omega-3 fatty acids, and cardiac rehabilitation, have markedly improved clinical outcomes, adverse cardiovascular (CV) events still occur too frequently after ACS. One promising therapy for improving cardiac health involves using L-carnitine to improve free fatty acid levels and glucose oxidation.”

“The potential mechanisms responsible for the observed beneficial impact of L-carnitine in acute myocardial infarction are likely multifactorial and may, in part, be conferred through the ability of L-carnitine to improve mitochondrial energy metabolism in the heart by facilitating the transport of long-chain fatty acids from the cytosol to the mitochondrial matrix, where b-oxidation occurs, removing toxic fatty acid intermediates, reducing ischemia induced by long-chain fatty acid concentrations, and replenishing depleted carnitine concentrations seen in ischemic, infarcted, and failing myocardium,” says DiNicolantonio.

L-carnitine is proven to be safe and is readily available over the counter. The investigators agree that the overall results of this meta-analysis support the potential use of L-carnitine in acute myocardial infarction and possibly in secondary coronary prevention and treatment, including angina. They advocate for a larger randomized, multicenter trial to be performed to confirm these results in the modern era of routine revascularization and other intensive medical therapies following acute myocardial infarction. But, says DiNicolantonio, “L-carnitine therapy can already be considered in selected patients with high-risk or persistent angina after acute myocardial infarction who cannot tolerate treatment with ACE inhibitors or beta blockers, considering its low cost and excellent safety profile.”

These findings may seem to contradict those reported in a study published earlier this month in Nature Medicine by Robert A. Koeth and others (Koeth, R. A. et al. Nature Med.*), which demonstrated that metabolism by intestinal microbiota of dietary L-carnitine produced trimethylamine N-oxide (TMAO) and accelerated atherosclerosis in mice. They also noted that omnivorous human subjects produced more TMAO than did vegans or vegetarians following ingestion of L-carnitine, and suggested a possible direct link between L-carnitine, gut bacteria, TMAO, and atherosclerosis and risk of ischemic heart disease.

“The Nature Medicine paper is of interest,” agrees senior investigator Carl J. Lavie, M.D.,FACC,FACP,FCCP, Medical Director of the Cardiac Rehabilitation and Prevention Center at the John Ochsner Heart and Vascular Institute at the University of Queensland School of Medicine in New Orleans, “but the main study reported there was in animals, and unlike our study, lacks hard outcomes.” He also notes that “there are various forms of ‘carnitine’ and our relatively large meta-analysis specifically tested L-carnitine on hard outcomes in humans who had already experienced acute myocardial infarction.”

from Sciences, E. (2013, April 16). “Patient Outcomes Significantly Improved By L-Carnitine Following Heart Attack.” Medical News Today. Retrieved from
http://www.medicalnewstoday.com/releases/259096.php.

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Cushing’s syndrome increased risk for coronary arterial atherosclerosis

Posted on by MaryO

cushings-ladyNeary NM. J Clin Endocrinol Metab. 2013;doi:10.1210/jc.2012-3754.

In a recent study supported by the NIH, researchers determined that patients with Cushing’s syndrome have a greater risk for developing coronary arterial atherosclerosis, increasing their rate of cardiovascular morbidity. These findings were published in the Journal of Clinical Endocrinology & Metabolism.

The researchers conducted a prospective case-control study of 15 consecutive patients with adrenocorticotropic hormone (ACTH)-dependent Cushing’s syndrome who were matched with 15 controls (aged 32 to 66 years) with at least one risk factor for cardiac disease (ie, diabetes, hypertension, hyperlipidemia, family history of early-onset coronary artery disease and previous or current smoking).

Researchers used a multidetector CT (MDCT) coronary angiogram scan to measure calcified and noncalcified coronary plaque volume and Agatston scores. Additional variables included fasting lipids, BP, history of hypertension or diabetes and 24-hour urine free cortisol excretion.

According to data, patients with Cushing’s syndrome had significantly greater noncalcified plaque volume and Agatston scores compared with controls (noncalcified plaque volume median [interquartile ranges]: 49.5 vs. 17.9,P<.001; Agatston score: 70.6 vs. 0, P<.05).

Patients with Cushing’s syndrome also demonstrated higher systolic (143 mm Hg) and diastolic (86 mm Hg) BP compared with controls (systolic: 134 mm Hg, diastolic: 76 mm Hg).

The limitations of the study include the small cohort of patients and potential selection bias due to ectopic ACTH secretion. However, the researchers wrote that these findings demonstrate a significant difference between the two groups included in the study.

“Overall, the findings point to the possible causes of cardiovascular morbidity in patients treated with exogenous steroids and indicate the need for further studies of that population,” they wrote.

Disclosure: The researchers report no relevant financial disclosures.

~~~~~~~~~~~~~~

PERSPECTIVE

Alice C. Levine, MD Alice C. Levine

  • It has long been recognized that endogenous hypercortisolism (Cushing’s syndrome) and administration of supraphysiologic doses of glucocorticoids are associated with increased mortality, primarily due to cardiovascular disease. Excess glucocorticoids induce all of the features of the metabolic syndrome including obesity with central weight gain, hypertension, impaired glucose tolerance/diabetes mellitus and dyslipidemia, all of which increase cardiovascular risk. In this small but well-designed study, the authors attempt to determine whether excess glucocorticoids have a direct adverse effect on the coronary vasculature. Utilizing multidetector computerized tomographic (MDCT) coronary angiography, a validated noninvasive method of assessing calcified and noncalcified coronary plaques, they compared measurements of coronary plaques (Agatston score) in 15 patients with ACTH-dependent Cushing’s syndrome (CS) vs. 15 age-, sex- and body weight-matched controls with at least one risk factor for cardiac disease. They found significantly greater coronary calcifications and noncalcified coronary plaque volumes in patients with active or previous hypercortisolism.There are obvious limitations to the study; most notably the small sample size, the predominance of patients with CS due to ectopic ACTH (14/15) and significantly more hypertension in the CS vs. the control group. However, other than the HTN, the groups were well-matched and there was no statistical difference in the Framingham risk scores between groups. This is the first study to demonstrate direct effects of CS on coronary plaque burden.The findings, while unsurprising, underscore several important features of CS which endocrinologists need to consider. Firstly, as there were no statistical differences in plaque burden in patients with CS who were eucortisolemic (4/15) vs. those who were hypercortisolemic (11/15) at the time of study, the effects of CS on the coronary vasculature may persist even after biochemical cure. Many previous studies in larger cohorts have similarly demonstrated that the adverse effects of high glucocorticoids on cardiovascular, metabolic, psychiatric and neurocognitive function may be only partially reversible with disease remission. Secondly, even adjusting for all the confounding variables, hypercortisolism seems to be an independent risk factor for the development of coronary artery disease. The possible mechanisms underlying this observation are discussed and include increases in prothrombotic factors, circulating levels of vascular endothelial growth factor (VEGF) and angiogenesis. It is also plausible that cortisol increases atherosclerosis through the mineralocorticoid rather than the glucocorticoid receptor, suggesting the possibility of treating this particular deleterious effect of hypercortisolism with a mineralocorticoid-receptor blocker such as spironolactone.

    Within the CS group, no significant correlations were observed between the coronary plaque volumes and the duration of CS or urinary free cortisol (UFC) either at presentation or at the time of MDCT. Although this lack of correlation may also be attributable to the small sample size, it is well known that the onset of Cushing’s syndrome is often insidious and it is impossible to pinpoint the exact duration of the abnormality in most patients. This study’s finding of direct, adverse and possibly irreversible effects of hypercortisolism on the coronary vasculature should make endocrinologists even more vigilant in diagnosing and treating the disease as early as possible in its course.

    • Alice C. Levine, MD
    • Professor of medicine, division of endocrinology, diabetes and bone diseases
      Co-Director of The Adrenal Center
      Icahn School of Medicine
      Mount Sinai, New York, NY
  • Disclosures: Levine reports no relevant financial disclosures.

From Healio.com

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Wednesday, Nine Weeks Post-Op

Posted on by MaryO

day-late

Running Late!  The Nine Week Anniversary was 2 days ago.  I got so tired singing  Holy Thursday, Good Friday and three Easter Services that I’ve just been resting up for a few days.

It also turned out that our son came home Thursday night, after rehab, after that service so my energy has been really sapped.

DH is still doing well, the rehab continues and he’s done 5 as of today.  We also signed up for our first patient meeting next Tuesday and a class on Cardiac Valve Surgery later this month.

So…we have rehab Wednesday and Thursday this week, Mended Hearts on Saturday, Monday rehab, Tuesday patient meeting, Wednesday and Thursday rehab…

Soon we’ll be experts!

Because DS was here, we ate some foods that I doubt are on the new diet.  I hope that there are no setbacks because of this.

Yesterday was one of those busy days.  A friend happened to call on Monday while we were driving back from rehab and DH took the call since I was driving.  As a result, DH, DS, my mom and I all went out with the friend in the afternoon.  In the morning, I had a staff meeting for work.  Our son decided that it was closer for him to take the train back to NYC from our friend’s, so we swung by the train station on the way home.

A tiring, but fun, day.  Our friend also has stairs up to her house, so it was one of the first times DH climbed a lot of them.

In church on Sunday, someone prayed for another who had had surgery before DH’s and wasn’t doing well yet.  It makes me very thankful for how well things are working out here.

 

 

 

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