New High Blood Pressure Guidelines

Blood pressure 4The guidelines for treating high blood pressure (hypertension) were recently revised. In brief, the authors raised the acceptable limit for systolic blood pressure for individuals 60 years and older. Additionally, they questioned the previous recommendation of aiming for lower blood pressures for patients with diabetes and kidney disease. As was the case with cholesterol, the conclusions were challenged by many experts, particularly challenging the choice of studies that produced the conclusions.

The previous blood pressure treatment goal of less than 140/90 mm Hg for individuals 60 years or older has been raised by the new guidelines to 150/90 mm Hg. The former goal was based on studies showing an increased cardiovascular risk in individuals with blood pressure over 140/90 mm Hg and risk improvement when the blood pressure was lowered. For instance, lowering blood pressure by 10 mm Hg in patients with hypertension reduces the risk of cardiovascular and stroke death by 25% to 40%.

However, the studies documenting results such as the above often had a goal of less than 160 mmHg and often did not examine the subset of patients 60 years and older. Two recent relatively short-duration studies comparing a goal of less than 140 mm Hg with less than 150 mm Hg in patients over 65 years showed no outcome difference. Using a review of many studies, the guideline authors did not find sufficient evidence that the more aggressive treatment goal of 140/90 mm Hg vs. 150/90 mm Hg benefits older adults.

The obvious question is: What is the harm of a more aggressive goal since so many studies, however imperfect, document improvement with lower blood pressure? Medication side effects are the worry. Too many times physicians become cemented on a number and push medications to the point where an individual experiences dizziness (the most common antihypertensive medication side effect.) The risk from falls can exceed the more remote risk from hypertension. Therefore, on balance the guideline authors suggest flexibility when treating patients 60 years and older.

That said, if an older hypertensive individual tolerates a goal of 140/90 without side effects there is no reason to decrease or stop medication allowing an increase in blood pressure to 150/90. Furthermore, many think that there is reason to believe that the lower goal, absent the concern of medication side effects, probably is more beneficial.

New Statin Guidlines

Cholesterol

New guidelines from the American Heart Association and the American College of Cardiology have changed both the indications for taking statins and, in some cases, have suggested a lower dose. Also, the use of additional medications to assist in lowering cholesterol values has been called into question.

 

The new statin dose guidelines require in most cases a calculation of cardiovascular risk over the next ten years. This calculation includes age, sex, race, systolic blood pressure, blood pressure medication history, history of diabetes, smoking history, total cholesterol and HDL cholesterol values. The risk calculation does not include family history. Your risk can be calculated by using the formula included in the following link:

 

http://www.cardiosource.org/en/Science-And-Quality/Practice-Guidelines-and-Quality-Standards/2013-Prevention-Guideline-Tools.aspx

 

Within days of the announcement experts criticized the cardiovascular calculator as outdated and, as a result, overstating the risk of cardiovascular disease by up to 100%. All cardiovascular calculators rely on historical data which don’t adequately reflect the very significant decrease in cardiovascular risk in more recent years and this one is no exception.

 

The guidelines recommend abandoning the former goals of reducing LDL, or bad cholesterol, to below 100 or below 70 for people at high risk. The authors of the guidelines stated that those goals resulted in undertreatment of some patients and overtreatment of others.

 

Instead they suggest individualizing treatment based on risk. For an individual younger than 75 years and over 21 years with known cardiovascular disease high-intensity dosing of statin medication is prescribed with a goal of reducing LDL cholesterol by 50% or more not tied to a specific number. For an individual over 75 years with known cardiovascular disease the goal is an LDL reduction of between 30-50% (moderate-intensity dosing.).

 

High-intensity statin dosing with a goal of a 50% or more reduction in LDL is also suggested for people between the ages of 40 and 75 years with type 1 or type 2 diabetes, LDL cholesterol between 70 and 189 and a risk of cardiovascular disease that exceeds 7.5% over the next ten years. For people with diabetes between the ages of 40 and 75 years with LDL cholesterol between 70-189 and a less than 7.5% ten year risk for cardiovascular disease moderate-intensity statin dosing is suggested (an LDL reduction of between 30-50%.)

 

Moderate-to high-intensity statin dosing is indicated for those people between the ages of 40 and 75 years, LDL cholesterol between 70 and 189 and a 7.5% or more risk of cardiovascular disease in the next ten years.

 

Only individuals with LDL cholesterol values of 190 or more are designated to receive statin therapy in the absence of known cardiovascular disease, history of diabetes or a 7.5% or more risk of cardiovascular disease over the next ten years. In these situations high-dose statin therapy is suggested.

 

An example: A 45 year old woman with an LDL cholesterol of 150 and a less than 7.5% risk of cardiovascular disease over the next ten years would not require statin treatment.

 

Notes:

 

Cardiovascular disease is defined as acute coronary syndromes, or a history of myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, stroke, TIA, or peripheral arterial disease presumed to be of atherosclerotic origin.

 

The authors of the guidelines do not recommend adding additional medications (such as Zetia) to achieve LDL cholesterol goals.

fish

Fish Oil and Prostate Cancer

A recent report in the Journal of the National Cancer institute concluded that men with a high blood concentration of fatty acids (omega-3) had an increased prostate cancer risk. The conclusion is concerning since it appears to contradict the assumption that fish oil and fatty fish consumption improve the overall health of men.

Moreover, the authors had previously found that high concentrations of trans-fatty acids (yes, the ones now restricted in food processing because of a clear association with heart disease) were associated with a decreased risk of aggressive prostate cancer. Trans-fatty acids are found in margarine and frying oils. Omega-6 fatty acids were associated with a lower risk of total prostate cancer.

Other studies have shown numerous health benefits of omega-3 fatty acid. One study showed a two- to three-fold greater risk for prostate cancer in men who ate no fish compared with those who consumed large amounts of fish in their diet. Other studies have also shown a decreased risk of prostate cancer and of metastatic prostate cancer in men who eat fish more than three times a week.

There are a number of problems with the recent study associating omega-3 fatty acid concentration with prostate cancer. We don’t know the source of the fatty acids in the study patients; there was no information on dietary habits or supplements taken. We don’t know anything about the subject’s risk factors for prostate cancer such as ethnicity, PSA levels, age and weight. Additionally, the study was based on a single blood test, not an analysis of concentrations over time.

Of interest, Japanese men consume the most omega-3 fatty acids from their diet in the world and yet are experiencing a declining risk for death due to prostate cancer. Additionally, many studies have demonstrated the cardiovascular benefits of omega-3 fatty acids.

Until more information is available to the contrary, in my opinion, it is prudent for patients with cardiovascular disease to consume oil fish several times a week and use fish oil if a dietary source is unavailable or unappealing.

Reappraising Vitamin D and Calcium Supplementation

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Recently the U.S. Preventive Services Task Force (USPSTF) issued a recommendation against routine daily supplementation with vitamin D and calcium in most circumstances. They conclude that there is adequate evidence demonstrating the taking 400 units of vitamin D and 1,000 mg of calcium does not prevent fractures in postmenopausal women. In addition, they note that the aforementioned supplementation does cause an increase in kidney stones and, therefore, is associated with harm.

It is unclear whether higher doses of vitamin D and calcium prevent fractures in men and postmenopausal women. Oddly, vitamin D supplementation is effective in preventing falls in community-dwelling adults aged 65 or older who are at risk for falls. The USPSTF does recommend vitamin D for this group.

Although the routine use of vitamin D and calcium supplements have been called into question the need for adequate levels of vitamin D in the body remains a constant. Those who lack enough vitamin D suffer from inadequate bone formation and, in addition, lack the beneficial effects of vitamin D on muscle strength and balance.

Obtaining vitamin D from dietary sources is best, just as we find that all vitamins are most effective when obtained from dietary sources. Good sources of vitamin D include: fatty fish and fortified foods, such as milk, yogurt and orange juice.

For individuals at risk for vitamin D deficiency supplementation is essential. This group would include the chronically ill, patients with intestinal malabsorption, pregnant women and those being evaluated for osteoporosis.

For now, the best approach might be to measure vitamin D levels in individuals at risk for vitamin D deficiency, including those mentioned above, older women, and women with risk factors for osteoporosis, and use vitamin D supplementation to bring the levels to normal.

Risk factors for osteoporosis include bone fracture, a family history of fractures or osteoporosis, smoking, excess alcohol consumption, malabsorption, the use of certain medications, sedentary life style and small body frame.

Lyme Disease: The Basics of Prevention

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Lyme disease is a tick-borne illness with a peak incidence in the eastern United States during the summer months of June, July and August. The late manifestations, such as arthritis, can appear at any time during the year. It is most common in the northeast and mid-Atlantic states (from Maine to Virginia), the Midwest (Minnesota, Wisconsin and Michigan) and on the west coast in northern California.

The ticks are carried by mice and deer and are more likely to infect when they are quite small (the size of a poppy seed.) When the ticks change and become larger they are less likely to transmit infection. Ticks are most commonly found on the underside of low-lying shrubs or grass, particularly between grass and forest. They are not common on well-cut lawns, such as a golf course. A tick can attach to a pet and then attach to a human, thereby transmitting the disease. If the tick is removed before it becomes large (engorged with blood) it is very unlikely to transmit Lyme disease.

If a tick is on the skin, but does not bite it cannot transmit disease. If a tick is removed within 48 hours the risk of transmission is quite small. The risk of transmission in one study where a tick was removed before it was engorged in an area where 15% of ticks carried Lyme disease was only 1%.

The best way to remove a tick is with tweezers or your fingers covered with some protection, such as a disposable rubber glove. It is important not to crush the tick. After removing the tick wash the area and your hands with soap and water.

Taking the antibiotic doxycycline to prevent Lyme disease makes sense only under certain conditions: that the tick is a deer tick; that the tick has been attached for more than 36 hours; that doxycycline can be started within 72 hours after the tick has been removed; that the tick bite has occurred in areas of the US where Lyme disease is common; and that the person does not have a contraindication to the use of doxycycline (a tetracycline.)

If a person cannot take doxycycline then no antibiotic should be prescribed as prophylaxis against developing Lyme disease after a suspicious tick bite. Doxycycline is usually given as a single 200 mg dose.
The time between a tick bite and the onset of Lyme disease symptoms is 2 to 3 weeks. The first manifestation is usually a rash. Lyme disease also can cause arthritis, neurological problems, heart conduction abnormalities and other problems. Unfortunately, it takes two weeks for antibodies to appear in the blood making a blood test for Lyme at the time of the tick bite useless.

Are Extra Vitamins a Good Idea?

multi_vitamin

The standard authorities state that for most healthy adults consuming a well-balanced diet, multivitamins (which usually contain 50%-150% of the recommended adult daily requirement of the standard vitamins) are not needed. However, some evidence suggests that taking a daily multivitamin causes a small decrease in cancer risk.

All authorities agree that there are important areas where extra vitamins are needed:

It is very important for women who might become pregnant to take a supplemental dose of 400 mcg of folic acid daily. The extra folic acid insures against inadequate reserves and prevents neural tube defects in the newborn such as spinal bifida.

A multivitamin is important for individuals with malabsorption (such as celiac disease, gluten-sensitivity), a vegan diet, alcoholism and certain other chronic conditions.

For other adults folic acid supplementation is unnecessary and perhaps unwise. An increased level of folic acid can mask vitamin B12 deficiency, a very serious deficiency problem, and may stimulate the growth of some cancers.

In order to prevent osteoporosis and decrease the risk of falls (a curious, but substantiated association) adults need a minimum of 800 units of vitamin D daily, taken either through dietary sources or as a supplement. Unlike all other vitamins, vitamin D can be produced by humans internally. In this case sunlight is needed, and exposure is often insufficient.

Dietary sources of vitamin D include milk, yogurt and soy milk—all of which are usually fortified with vitamin D. Salmon, sardines, tuna and cheese are other good sources of vitamin D.

Since vitamin D levels are often low in adults and since vitamin D deficiency causes bone problems and has been possibly linked to other diseases, taking 600-800 units daily, particularly in older adults, seems prudent.

Vitamin A levels are usually normal in the industrialized world and supplementation is not needed and, indeed, may be harmful. Excessive doses in pregnant women can cause abnormalities in the newborn. Additionally, in all adults excessive doses can cause osteoporosis as well as possibly increasing the risk of cancer and cardiovascular disease.

Likewise, vitamin E levels are usually adequate and high dose vitamin E (more than 400 units daily) supplementation is unwarranted since excessive vitamin E levels are associated with increased all-cause mortality.

Vitamin C supplementation is safe, but has no proven benefit.

Older persons should consider taking a B12 supplement since levels of this very important vitamin can drop with age. Liver, fish, beef, cheese and eggs are dietary sources of vitamin B12. A vegan diet eliminates many dietary sources, making supplementation necessary.

Statins and Grapefruit

grapefriut

If you’re taking a statin medication for your cholesterol, you have undoubtedly heard the warning against consuming grapefruits or grapefruit juice. This restriction also applies to a number of other medications including certain cardiovascular medications, anti-cancer agents, antibiotics, antidepressants and others. For a more detailed list and approximations about the extent of the interaction with particular medications click on to the following site: http://www.cmaj.ca/content/suppl/2012/11/26/cmaj.120951.DC1/grape-bailey-1-at.pdf.

The discovery of the interaction was serendipitous. Researchers noticed a higher drug concentration in certain test subjects than others when a medication was initially being tested. Those with an elevated drug level were eventually found to have also consumed grapefruit. Pomelo, lime and marmalade can also produce the same effects.

The compounds in grapefruit responsible for the effect are called furanocoumarins and act by blocking the enzymes in the intestines responsible for the degradation of certain medications. It only takes one glass of grapefruit juice to produce the maximum effect, an effect that persists for longer than 24 hours. Therefore, taking grapefruit juice at a time well-separated from the medication dose is ineffective in solving the problem.

How big an issue does this represent? That depends on a number of factors, particularly on how dependent the medication is on the enzyme that is blocked by the juice. Some medications have a wide “therapeutic range.” In other words, increased blood levels don’t represent much of a concern. On the other hand, some medications have a narrow therapeutic range, with increased concentrations causing serious problems.

Although most statins should not be taken in combination with grapefruit products Crestor (rosuvastatin) and Pravachol (pravastatin) are exceptions since they are not significantly metabolized by the enzyme blocked by grapefruit.

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