Treating a Woman’s Heart Disease

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The paper I’ve been using as a primary source for this week’s Memos is titled “Sex Differences in Ischemic Heart Disease. Advances, Obstacles, and Next Steps”; the purpose of this paper is to provide the current state of the science to clinicians when it comes to preventing and treating heart disease in women. A team of experts combed the medical literature to let their colleagues know where we stand in treatment and where future research should go, and you could look at it as a roadmap for improving prevention and treatment. You could also look at this as an indictment for less-than-quality care for women with heart disease.

There were seven categories of treatment options for various phases of heart disease, from diagnosing heart disease to mortality. I’m going to talk about just two but understand that even though the mortality from heart disease has decreased over the past 30 years, there are still gaps in treatment between men and women.

The first was a 30-minute delay in restoring the flow of blood to the heart in women who were having a heart attack with ST- segment elevation, a distinct change in the EKG. The time from the onset of symptoms and arrival at the hospital as well as time from arrival at the hospital to needle insertion for a percutaneous coronary intervention was 30 minutes or longer compared to men. That means women don’t get to the hospital early enough, so that’s on them. Ladies, you need to make that 911 call a little quicker. But it also means that once they’re there, it takes longer to get the arteries open again. That creates the possibility of more damage.

One of the problems is getting the correct diagnosis. There are 11 other conditions that can cause ST-segment elevation including takotsubo syndrome also known as broken heart syndrome. Still, 30 minutes seems way too long and needs to be improved.

The second is the one that really stunned me: fewer women are given recommendations for cardiac rehabilitation after a heart attack. Not only that but fewer women register to take part in cardiac rehab. They also attend fewer sessions than men do. When I read that, I was almost apoplectic. The heart is a muscle that can be damaged by a heart attack. When it’s time to rehabilitate that muscle, it’s not like restoring range of motion after knee surgery. If this muscle isn’t rehabbed and then trained for the rest of a women’s life, the death rate increases for those women.

That has to change today. If you have any type of coronary event, from atrial fibrillation to a full blown heart attack, the first question you ask is “When can I begin cardiac rehab?” I understand that every insurance plan may be different but you need to understand any limitations, how to exercise after a heart attack, and how to progress. That’s important, not just for the muscle, but also for the nervous system, the lungs, increasing the number of blood vessels, and even to reduce the depression that occurs after a heart attack.

And then you’re going to do it until you get every session you qualify for and get a plan to take home with you to keep improving. When that’s done, you’re going to get a plan from your physician as to how to progress from that point. These are non-negotiable. This has to change and it has to change today. The quality of your life depends on it.

Next Tuesday I’ll finish American Heart Month with a question I get a lot: does taking my calcium supplements increase calcification in my coronary arteries? I’ll let you know on Tuesday.

What are you prepared to do today?

Dr. Chet

 

Reference: Circ Cardiovasc Qual Outcomes. 2018;11:e004437.

 

Emerging CVD Risk Factors for Women

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The paper I referred to in Tuesday’s Memo provided a list of emerging risk factors for heart disease that apply only to women. But first, I wanted to define exactly what a risk factor is and what it means.

As defined by the World Health Organization, a risk factor is any attribute, characteristic, or exposure of an individual that increases the likelihood of developing a disease or injury. The key word is likelihood. It does not mean cause and effect, and that includes genetic tendencies. Lifestyle contributes close to 80% when it comes to raising or lowering risk. You’re not doomed; you just have to be aware and take action.

There were several emerging risk factors for cardiovascular disease (CVD):

  • Gestational diabetes: your risk of getting type 2 diabetes increases four-fold later in life; type 2 diabetes is a risk factor for heart disease.
  • Hypertension during pregnancy: hypertension and preeclampsia increase the risk of heart disease three-fold.
  • Early menopause: women’s hormones are protective against heart disease. When they change during menopause, the risk of heart disease begins to increase; the earlier that happens, the sooner the risk rises.
  • Autoimmune disease: diseases such as rheumatoid arthritis and lupus increase the risk of heart disease. Autoimmune diseases increase inflammation, and that may partially explain this connection.

You can see why these emerging risk factors are primarily associated with women. While depression is also associated with an increased risk in women, it may be that women seek help more than men.

Keep in mind that these conditions don’t make heart disease a given, just a risk. But if that gives you the oomph you need to get to the gym today or skip that sweet roll, I’m okay with that.

What happens after a woman has heart disease or a heart attack? We’ll take a look at that on Saturday including one thing that stunned me and has to change.

What are you prepared to do today?

Dr. Chet

 

Reference: Circ Cardiovasc Qual Outcomes. 2018;11:e004437.

 

It’s American Heart Month

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February was declared American Heart Month by President Lyndon Johnson in December 1963. As I’m searching the recent research in preparing to update the Women’s Heart Health audio, I’ve found new research on women’s hearts. I’m not ignoring men, but the research on women has lagged behind what we know about the risk of heart disease in men, because women’s bodies react differently to heart issues. Now we’re starting to catch up on women’s hearts.

Let’s look at the same risk factors for heart disease and see the differences between men and women. In a paper published this month, researchers looked at the differences in how risk factors for heart disease are managed in women. Here’s what they found:

  • Blood lipids: after menopause, women are less likely to achieve goals in reducing triglycerides and LDL-cholesterol and increasing HDL-cholesterol.
  • Blood pressure: as women get older, those with hypertension are less likely to lower blood pressure; only 29% achieve healthy blood pressures.
  • Exercise: 25% of all women get no regular exercise.
  • Obesity: carrying extra weight impacts the risk of heart disease more in women than men—64% compared to 46%.

There are more risk factors, but what makes these four important is that they can be improved through changes in lifestyle. Eating less. Eating better. Moving more. Even a 10% change can help reduce a women’s risk of getting heart disease.

Some new risk factors are emerging that are unique to women. I’ll cover those on Thursday.

What are you prepared to do today?

Dr. Chet

 

Reference: Circ Cardiovasc Qual Outcomes. 2018;11:e004437.

 

What Happens Inside When You Quit Drinking?

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Beer, wine, hard cider, whiskey, vodka, bourbon—that’s a partial list of alcohol-based drinks we consume. The amount of alcohol that’s recommended is no more than two drinks per day for men and one drink per day for women. Many people exceed that amount on a regular basis. While alcohol, especially wine, has some reported health benefits, even just a little more alcohol has consequences.

Alcohol is a toxin. The liver can handle and detoxify small amounts, but it can take several hours to process one drink. Alcohol is a diuretic, which means it will lead to dehydration when too much is consumed. While alcohol is a central nervous system depressant, it can interfere with sleep patterns. The next day fogginess is a result of the dehydration and nervous system effects. Alcohol is converted to fat and then stored. However, it may not store fat normally and overfill the livers fat storage ability. That results in a fatty liver. And then there’s the weight gain that comes with too much alcohol intake.

What happens if you give up alcohol for 40 days? Researchers in the United Kingdom found out by tracking over 100 people for over a month. Without any change in diet, the subjects lost two to four pounds. Cholesterol levels and blood pressure dropped as well. In addition to that, a marker of prediabetes and insulin resistance dropped as well. Researchers suggested that if those types of results could be put into a pill, it would create a $250 million industry overnight. And all people did was abstain from alcohol.

Is there a substitute? In trying to put a blend together that might have the calming effects of alcohol on the nervous system, I think a decaffeinated chai with its blend of herbs or a chamomile tea might have a similar benefit to the nervous system without the stimulant effects of caffeine.
 

The Bottom Line

Sugar. Salt. Alcohol. If you’re going to give up something during Lent, these deserve a try. There are some real benefits to your body if you do, even if you just reduce your intake. You might just find that you don’t need them at all. It’s worth a try.

What are you prepared to do today?

Dr. Chet

 

Reference: Hepatology. 2015. Volume 62, Issue Supplement S1. Abstract 113.

 

What Happens if You Give Up Salt?

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The next category of foods that you could give up for Lent is salt and sodium. Why do I mention both? Because they’re not exactly the same thing. Salt is sodium-chloride, a one to one proportion of sodium and chloride; sodium is just sodium. The typical American takes in over three grams or 3,000 mg of sodium per day. The upper limit is 2,300 mg and the goal is 1,500 mg. In past centuries, packing a food in salt was one way to preserve it, but with today’s refrigeration systems, we don’t need salt as a preservative. We just like it.

Where do we find sodium? Salt is added to all types of chips, nuts, processed meats, and deep-fried foods. But sodium is also added to many types of prepared foods. With the emphasis on reducing fat and carbohydrates, the flavor is often enhanced with sodium.

What could you expect to happen if you reduced your salt and sodium intake? You would probably lose some fluids. You body must keep sodium in a specific ionic balance, and reducing sodium would reduce the need for additional fluid. That could result in the reduction of blood pressure, something almost everyone could benefit from. That eases the strain on the heart, which won’t have to pump as hard because the resistance would not be as great.

As I’ve confessed before, I’m a salt-aholic so I’m going to work on reducing my sodium intake—no salty crunchy chips or roasted nuts, and no added salt to anything. I’ll also limit my intake of processed meats such as ham and bacon. We’ve become used to salt and sodium and it’s jaded our taste buds. No substitutions for this one. Time to retrain our taste.

What are you prepared to do today?

Dr. Chet

 

Happy Fat Tuesday!

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Today is Mardi Gras—in case anyone doesn’t know, Fat Tuesday is the literal meaning of the French term. It’s the final celebration before the period of Lent that culminates in Easter Sunday. Many Christians use this time to give up something they enjoy as a sacrifice. The idea is to reflect and focus on our spiritual self; no matter your beliefs, giving up something you enjoy to focus on your inner self is a good idea. This week, I’m going to talk about giving up three typical categories of food and drink: sugar, salt, and alcohol. What benefits could you gain in the 40 or so days of abstinence from these foods? What may be a healthier substitute?

Let’s start with sugar, and by that I mean cake, cookies, donuts, sweet rolls, pies, ice cream, and candy. These are the ultimate in refined carbohydrates. If you were to abstain from these foods for 40 days, several things could happen. First, your insulin levels would probably drop because you wouldn’t have high levels of sugar hitting your bloodstream. If you’re prediabetic, you might see your triglyceride and HbA1c levels decline. If you had a fatty liver, it would most likely begin to clear up.

What could you substitute that would be healthier? Berries, fresh or frozen, any type, and you could even put a tablespoon of whipped cream on them. The antioxidants and phytonutrients would be better than the refined sugar; fruit sugar is processed differently, so it would not affect your blood sugar. Second choice would be citrus, and third would be apples.

If you’re considering giving up something for the next 40 days or so, make sure it’s something you really enjoy and eat regularly. Paula has a friend from Montana whose father, years ago before every food was available year round, gave up watermelon every Lent. It has to be meaningful.

What are you prepared to do today?

 

Dr. Chet

 

How New and Expectant Mothers Can Be Healthier

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Complicated issues require complex solutions and the rise in maternal mortality rate (MMR) is complicated. Public healthcare policy and access to quality pre- and post-natal care is not directly in our hands; legislative public heath policies take time and not everyone agrees on what should be done. But a mother’s health is in her hands to some degree. What can she do to put the odds in her favor to have a healthy baby and protect her body for the long term?

Lose weight if necessary. Obesity carries with it an increased risk of high blood pressure and prediabetes. Even a 10% loss in weight may help her body withstand the stresses that pregnancy and childbirth bring. Obviously losing weight while pregnant is a delicate dance; it’s crucial to emphasize complete nutrition while minimizing calories.

Improve her fitness level. When you look at the physiological causes of MMR, close to 50% could be attributed to cardiovascular or metabolic issues such as prediabetes and hypertension. The more fit a woman is before she becomes pregnant, the lower the risk of those conditions.

Address issues during pregnancy such as gestational diabetes and preeclampsia seriously. They can impact a woman after she gives birth and contribute to increased bleeding, dangerously high blood pressure, and other cardiovascular issues. She should follow her physician’s recommendations for lifestyle and medications to address the issues.

Finally, a woman should know as much as she can about what to expect after childbirth. Not just taking care of the baby, but how to take care of her body, and the warning signs that something may not be right. When in doubt, check it out; better an unnecessary phone call than an unnecessary health crisis.

Let’s be practical. The MMR is rising but the risk is still very low at about 21 out 100,000 births in the U.S. If a woman does all she can to take care of herself before and after she gives birth, not only will it reduce the risk of MMR, it will result in healthier babies and mothers as well. That alone is worth the effort.

What are you prepared to do today?

Dr. Chet

 

References:
1. Obstetrics & Gynecology: August 2017;130(2):366–373.
2. http://bit.ly/2BZ1pOx

 

Why Is the MMR Rising?

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Based on the trends of the past 15 years, the maternal mortality rate (MMR) is increasing. There doesn’t seem to be any single cause that can be identified as “the” reason. Having looked at the research, I think there are three categories that contribute to the increase in MMR.

  • Access to prenatal and postnatal healthcare is inconsistent. In short, we don’t seem to spend enough time teaching mothers how to have a healthy baby, and then we don’t follow the mom’s health as well as we should to make sure she stays healthy. No single reason stood out, but the factors that stood out are the closing of rural hospitals, race and ethnicity, and limited access to healthcare coverage.
  • Women are waiting to have children later in life. While that’s a personal decision and can be related to the economy of the 21st century, every year older raises the risk of complications.
  • Women who wait to have children have a higher rate of obesity; along with that come a higher rate of prediabetes, hypertension, and an increased risk of cardiovascular disease.

Those seem to be the contributing factors to the increase in MMR. The question is what can be done about it? I’ll cover that on Saturday.

What are you prepared to do today?

Dr. Chet

 

References:
1. Beckers Hospital Review. December 2016.
2. America’s Health Rankings. 2016.
3. Obstetrics & Gynecology: August 2017;130(2):366–373.

 

The Rising Maternal Mortality Rate in the U.S.

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Paula recommended I read an article on maternal mortality rate (MMR). I had heard of the infant mortality rate but the MMR was new to me, so I dug into the details. This week, we’re going to take a look at the MMR, why it’s a cause for concern in the U.S., and what can be done about it.

The MMR is the number of women who die in the first year after childbirth. The problem is that there has been a rise in the U.S. MMR over the past 30 years from 7.2 women per 100,000 births to just over 26 per 100,000 births in 2015 (1). The MMR in the U.S. is moving in the wrong direction; other modern societies, such as Japan, the U.K., Finland, and Italy, have lowered their rates to fewer than five per 100,000 women. In Canada, deaths rose from six per 100,000 births in 1990 to 11 in 2013.

To use one of my favorite Vince Lombardi quotes, “What the hell is going on around here?” Why is this happening in the U.S.? The reasons are complicated, and that’s what I’ll talk about on Thursday. If you’d like to read the article that began this search for answers, check out the second reference.

What are you prepared to do today?

Dr. Chet

 

References:
1. Lancet 2016; 388: 1775–812.
2. http://n.pr/2EjqtvV

 

My Verdict on D3 vs. D2: A Draw

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The medical community and the health gurus agree, and the research appears to agree with them: vitamin D3 is better than vitamin D2. A no-brainer, it would appear.

No. My call at this point: it’s a draw. Here’s why.

The Current Research

The research on vitamin D and absorption is a mess. There’s little to no consistency. You saw the number and attributes of subjects, quantity of the supplemental forms of vitamin D, and the length of the studies. The bulk of the studies use therapeutic doses, 50,000 IU and up, to see how the forms of D are absorbed to treat serious deficiencies of vitamin D in people. Vitamin D2 has been used for treatment for decades that way and still is today.

It’s true, that vitamin D3 does increase blood levels of vitamin D more and it seems to last longer than D2. So what? This is not a medication, it’s a nutrient. Why would anyone stop taking it? What the research proves is that levels of both forms of D decline after a person stops taking the supplement. I could have predicted that without doing a single study.

The study that came closest to reality that D3 is better than D2 was the study on hip fractures—at least that lasted three months. The studies that last longer give higher doses, up to 500,000 IU in a dose, and see what happens over a year. Why? What will that tell you? No one takes supplements like that.

The Ideal Study

If I could construct a study, I would track a large group of people divided into a placebo group, a group taking vitamin D3 only, a group taking vitamin D2 only, and a group given half the dose each of D3 and D2. It would also use off-the-shelf dietary supplements; when researchers have specific products formulated that are not for sale, the resulting info is worthless to us as consumers. The dose should be reasonable such as 2,000 or 5,000 IU. Subjects should be followed for at least a year. Several variables should be checked regularly.

The Bottom Line

Based on my assessment of the current research, vitamin D3 is better absorbed and converted to active vitamin D than D2, but there’s no evidence that D2 is not effective or that it’s harmful—it’s been used nearly 100 years! In my opinion, it may require a third more D2 to equal D3 to get equivalent effectiveness. Other than that, if you want the vitamin D you take to be effective, the only thing you need to do is take it consistently.

The Super Bowl Webinar is tomorrow. Time to start getting rid of the body fat you’ve been wanting to lose.

What are you prepared to do today?

Dr. Chet