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Author: Dr. Hassan Gargoum

Clinical Professor of Medicine, University of Saskatchewan Consultant, Cardiovascular Diseases

Fludrocortisone (Florinef) is ineffective in Vasovagal Syncope


 Vasovagal syncope (common faint) is a common disorder responsible for many hospital admissions and significant utilization of resources.

During a late-breaking clinical trial at the Canadian Cardiovascular Congress 2011 earlier this month in Vancouver, B.C., the results of a randomized trial involving the use of Fludrocortisone (Florinef) in vasovagal syncope were presented.

This study was conducted at 17 centers around the world (including Canada and the US) and  enrolled 210 subjects, most of them young women in their late 20s and early 30s who had experienced anywhere from two to 15 syncope episodes in the past year, with a mean of three to four.

Patients were randomized 1:1 to either fludrocortisone (0.05-0.2 mg daily) or matching placebo for 12 months.

After one year, the syncope rate was numerically lower in the fludrocortisone group in both the intention-to-treat and on-treatment analyses, but the difference was not statistically significant.  Adverse events, however, were minor and rare, occurring in just 16 patients.

It has been concluded that fludrocortisone did not provide a statistically significant benefit in preventing the first recurrence of vasovagal syncope and is unlikely to provide a clinically significant benefit.

 

Citalopram Linked to Abnormal Heart Rhythm


A US Food and Drug Administration (FDA) alert now warns that citalopram has been associated, in a dose-dependent fashion, to prolonged QT interval, particularly in patients at risk for hypokalemia and hypomagnesemia. The drug label has been revised to include new drug dosage and usage recommendations.

The FDA warns that citalopram (Celexa, Forest Laboratories) should not be used in doses higher than 40 mg per day because of concerns that it can cause potentially fatal changes in heart rhythm.

An alert issued to healthcare professionals and patients cautions that the drug has been linked to prolonged QT interval in a dose-dependent manner. Patients at particular risk for developing the condition include those with underlying heart disease and individuals who are predisposed to low levels of potassium and magnesium in the blood.

Citalopram should not be used in patients with congenital long QT syndrome. Patients with congestive heart failure, bradyarrhythmias, or predisposition to hypokalemia or hypomagnesemia because of concomitant illness or drugs, are at higher risk of developing Torsade de Pointes, a rare type of ventricular tachycardia.

Risk of heart disease rises with COPD

A study presented here at the European Respiratory Society (ERS) 2011 Annual Congress shows that patients with chronic obstructive pulmonary disease (COPD) or reduced lung function are at a significantly increased risk of developing cardiovascular disease (CVD).

Data on 993 patients were drawn from the Obstructive Lung Disease in Northern Sweden (OLIN) studies, together with 993 gender- and age-matched reference subjects without COPD. The subjects were followed by annual examination.

The researchers found that CVD (heart disease, hypertension, stroke, claudication) was more prevalent in patients with COPD compared with controls with normal lung function (50.1% vs 41.0%, p<0.001). In addition, they found that the combined prevalence of angina pectoris, heart failure, and MI was 18.5% and 13.7% (p=0.006) in individuals with COPD and those with normal lung function, respectively. Having both conditions might lead to a far worse outlook for patients.

The finding that patients with COPD have a high risk of CVD fits in with previous studies. This comorbidity has also been shown previously to be associated with higher mortality. Probably there is a common causal factor, affecting both the lungs and the vessels, namely smoking.

The Warning Signs of a Heart Attack

What are the warning signs of a heart attack?

According to the American Heart Association, the classic warning signs are:

  • An uncomfortable pressure, squeezing, fullness, or pain in the center of the chest that lasts for more than a few minutes, then disappears and returns
  • Pain that radiates to the shoulders, stomach, back, arms, neck, or jaw
  • Chest discomfort with dizziness, fainting, nausea, sweating, fluttering heartbeat, or shortness of breath
  • Women may also have these warning signs, which are less common:
  • Unusual chest pain, stomach, or abdominal pain, which may feel like indigestion or the need to belch
  • Difficulty breathing and shortness of breath
  • Unexplained weakness, fatigue, or anxiety
  • Palpitations (an irregular heart beat), rapid heart beat, paleness, or breaking into a cold sweat
  • Pain in the jaw or back
  • Nausea or vomiting

If you or anyone you know is having these symptoms, call 911 or get to a hospital IMMEDIATELY.

Not all the symptoms show up in every attack. Don’t wait, because the heart muscle starts to die during an attack and every minute counts. Remember: it’s better to be safe than sorry.

Have a Healthy Heart

No matter your age, your gender, or your past lifestyle, now’s the time to start building a healthier heart. Healthy living can help protect the heart against the ravages of disease and time. Chances are, there’s still room in your life for some heart-healthy changes. Here’s a look at the most important steps to take:

1. STOP smoking!

Cigarettes damage the arteries and speed the buildup of cholesterol and plaque, the first step toward a heart attack.  Studies have found that smoking just one to 14 cigarettes per day tripled the risk of heart trouble.   Other studies have found that smoking at least 25 cigarettes a day may raise the risk 15 times as much.  If you’re a smoker, quitting RIGHT NOW is the best thing you can do for your heart. Within two years, the threat of the heart attack will drop to the level of a person who has never smoked.

2. The right foods can provide dramatic protection.

For most people, the battle against heart disease should start in the kitchen. By getting about 30 percent of your calories from fat (less than 7 percent from saturated fats), eating five to seven servings of fruits and vegetables every day, and eating plenty of whole grains, you can lower your cholesterol level, protect your arteries, and slash your risk for a heart attack. Some types of fats, such as omega-3 fatty acids found in fish, may help lower triglycerides and provide other benefits.

The protection is especially strong among men who smoked or were overweight.

Eating right doesn’t have to be hard work. You probably already enjoy fruits and vegetables, so why not enjoy them more often? And if you think it’s hard to go low-fat, consider this: Most people can cut their intake of artery-clogging saturated fat in half by avoiding butter, margarine, mayonnaise, fatty meats, and dairy products made from 2 percent or whole milk.

If you eat a typical diet of 2,000 calories a day, no more than 30 to 35 percent of that should come from fat — and only 7 percent or less from saturated or “bad” fat. That amounts to no more than 16 grams of saturated fat a day. You can find your saturated fat intake by reading the labels on processed foods, which list the grams of processed fat they contain.

3. Regular exercise.

Regular exercise can strengthen your heart, increase your HDL cholesterol (the “good” cholesterol that helps keep your arteries clear), lower your blood pressure, burn off extra pounds, and just plain make you feel good.  The American Heart Association (AHA)  recommends at least 30 minutes of moderately vigorous exercise most days of the week. Of course, exercise can be risky for some people with heart disease. Check with your doctor before starting a new workout program, and work up gradually. Don’t be a “weekend warrior” at the gym after being a couch potato all week:  It’s a recipe for serious injury.

4. Monitor your cholesterol.

Since too much cholesterol contributes to plaque buildup in the arteries, it’s best to keep your total cholesterol level below 5.2 mmol per deciliter. The basic goal is also to keep your “good” HDL cholesterol high and your “bad” LDL cholesterol level low. The AHA recommends that HDL level of at least 1.0 mmol/l for men and, at least, 1.3 mmol/l for women. If you don’t already have coronary heart disease and if you have fewer than two of the major risk factors — obesity, high blood pressure, or a family history of premature heart trouble — your LDL cholesterol should be below 3.0 mmol/L (and preferably under 2.6). If you already have coronary artery disease or diabetes mellitus and your LDL is over 2.6 mmol/L, your doctor will probably recommend you take cholesterol-lowering drugs to get your LDL below the 2.0 mmol/L.

5. Watch your weight.

When it comes to the heart, bigger isn’t better. A little extra weight can put a strain on your heart, boost your blood pressure, and significantly raise the risk of a heart attack. Ideally, your body mass index (BMI) should be between 18.5 and 24.9. According to the AHA guidelines, a simpler alternative to BMI is to measure your waistline — men should measure 40 inches or less and women should measure 35 inches or less.  Even if you can’t reach that goal, a weight-loss program that combines exercise with a healthy, low-fat diet will do wonders for your heart.

6. Watch your alcohol intake.

One or two alcoholic drinks per day can help raise your good HDL cholesterol and help prevent dangerous blood clots. Women should limit their alcohol intake to up to one drink a day, since their bodies metabolize alcohol differently than men; men should limit their intake to no more than two drinks a day. However, any more than a couple drinks a day can increase your blood pressure. Extremely heavy drinkers can also suffer damage to the heart muscle (cardiomyopathy).

7. Monitor your blood pressure.

High blood pressure increases the risk of coronary artery disease and stroke.  It’s good to keep your blood pressure in the optimum range: less than 130/80. If you test 130-139/80-89, you have prehypertension and you should make arrangements to see your doctor right away, to discuss lifestyle changes you can make to bring down your reading. If you have high blood pressure, meaning 140/90 or more, your doctor will likely prescribe medication to keep it in check.

8. If you’re under too much stress or feeling depressed, seek out help from a psychologist or therapist.

Emotional distress is hard on the heart, and professional help can be a true lifesaver. Several studies suggest that depressed people who are otherwise healthy are more likely to develop heart disease than peers who aren’t depressed.

9. Teach your children

It’s not too soon to involve your children: You can help them prevent heart disease in later life by getting used to good habits right now. By exercising and playing with your kids, not smoking, and providing daily fruits, veggies, and whole grains rather than sodas and junk food, you’ll set a great example.

Involve the whole family in providing support for each other — don’t just focus on one “unhealthy” member. Don’t feel like you have to make all these changes at once, which can lead to frustration and overload. To ensure success, start with simple changes that are reasonable and doable.

10. Other advices for your heart protection:

Talk with your physician about the most important steps you need to take to protect your heart.

The AHA recommends a checkup every two years, ideally starting at age 20, where your doctor can measure your blood pressure, body mass index, waist circumference, and pulse.

Depending on your particular situation, you should have your cholesterol and glucose tested at least every 5 years. Ask your doctor if you should check it more frequently.

If you’re 40 or over, the AHA suggests that your doctor measures your risk factors and then calculates your chances of developing cardiovascular disease within the next 10 years.

It’s also important to seek professional help if you’re taking steps that involve some risk (such as beginning an exercise program in middle age) or that are tough to do on your own (like quitting cigarettes).

Remember, it’s never too late to develop healthy habits. The road to a strong heart begins at home, but it may have to take a detour through your doctor’s office. If you have high blood pressure, high cholesterol, or diabetes, you’ll need medical help to give your heart maximum protection. If you have diabetes, you can decrease your risk of heart disease by maintaining healthy blood sugar levels and by keeping your blood pressure and cholesterol under control.

 

Do I need heart bypass surgery?

The treatment of coronary artery disease depends on many individual factors, including the location of the blockage(s), the size of the coronary arteries and whether the blockages involve short areas of the blood vessel or involving the major part of the blood vessel, whether you have diabetes, and your overall heart function. That’s why you should learn everything you can about your condition and be prepared to ask many questions.

Do I need heart bypass surgery?

Many people with coronary heart disease owe their lives to heart bypass surgery.

In this operation, a surgeon uses a vessel from another part of the body (veins from the legs and sometimes an artery from behind the rib cage) to create a detour around a blocked artery, thus restoring blood flow to the heart. This operation was first pioneered in the 1960s.

Not everybody with coronary heart disease needs this operation. Many people can control their disease through diet and exercise, and others benefit from medication, angioplasty and stenting of the occluded blood vessel, or other nonsurgical treatments. After examining all the pros and cons of each approach, you and your doctor can decide on a treatment that’s right for you.

What are the benefits of bypass surgery?

The main indication for coronary bypass surgery is treatment of angina (chest pain) that is not responding to optimal medical therapy. Bypass surgery can quickly cure the symptoms of coronary heart disease, including disabling bouts of angina (chest pain). The relief, on average, lasts 10 to 15 years, after which point the patient may need another bypass if more blockages occur. And if you have a severe case of coronary heart disease — for instance, you have several blocked arteries and some weakness in your left ventricle — bypass surgery could help extend your life.

What are the complications of bypass surgery?

Like any other major operation, heart bypass surgery carries some risks. In fact, a small number of patients don’t survive the operation. The death rate is less than 1 percent for patients who are under 65 and in relatively good health, but it climbs steadily for older patients and patients with damaged hearts, diabetes, or previous heart surgeries.

By briefly interrupting the normal flow of blood, bypass surgery opens the door to several severe complications such as stroke, which occurs during the operation in about 3% of all patients. Another 3 percent of patients will lose some mental sharpness. Complications are especially common in older patients and those with diabetes, hypertension, unstable angina, arrhythmia, heart failure, or previous bypass surgeries.

Remember, bypass surgery is not a cure. Unless patients take other steps to control the buildup of plaque in their arteries, the bypass will meet the same fate as the original artery. Half of all vein bypasses become clogged with plaque within 10 years. Arterial bypasses (from the arms or from inside the chest) are now being used more often for bypass surgery, and the arteries are less likely to be clogged after 10 years.

What are the alternatives to bypass surgery?

If you have severe coronary artery disease, bypass surgery may be your best hope for survival. Most patients, however, will have several other options to consider.

Percutaneous coronary intervension (e.g. balloon angioplasty with inserting a stent inside the blood vessel) is one common alternative to bypass surgery. In this procedure, doctor threads a tube called a catheter through the clogged artery. Once the catheter is in place, a small balloon is inflated to widen the artery. The doctor then removes the catheter and balloon, but may leave in place a small metal scaffold, called a stent, to keep the artery from clogging again. Like bypass surgery, angioplasty restores blood flow to the heart and eases symptoms of coronary heart disease.

Medications that lower blood pressure and cholesterol are another alternative. Heart drugs such as beta blockers and angiotensin-converting enzyme (ACE) inhibitors can relieve angina and ward off heart attacks. Statins, cholesterol-lowering drugs, can slow down the buildup of plaque and greatly reduce your risk for a heart attack. Your doctor may also recommend a daily dose of aspirin. By thinning the blood and preventing blood clots, aspirin provides powerful protection to your heart.

Of course, a heart-healthy lifestyle makes sense no matter what treatment you receive. If you smoke, eat a high-fat diet, and shun exercise, any procedure or medication will be a temporary fix at best.

Do doctors overprescribe bypass surgery?

Many people worry that their doctors may hastily recommend bypass surgery without fully exploring other options. But according to a study published in the New England Journal of Medicine in 2001, the opposite seems to be true. This study found that 43 percent of patients who were good candidates for bypass surgery (meaning patients with severe coronary heart disease) never underwent the operation, often because their doctors recommended other treatments.

 

 

Questions if considering Heart Surgery!

What to ask your cardiologist…

  • What is coronary artery disease? How many heart vessels are blocked?
  • What are my treatment options and what are the risks and benefits of each?
  • Why are you recommending this treatment over the others?
  • What lifestyle changes will I need to make and what community resources are available to help?
  • If I decide not to have open-heart surgery, will you support my decision?
  • Will I be given some time to put my affairs in order prior to the heart surgery?
  • Should I complete an Advance Directive?
  • Should I avoid caffeine and other stimulants for 48 hours prior to surgery?
  • (If diabetic) How often should I be monitoring my blood sugar?
  • If I opt to have surgery, will I need to take medication afterwards? If so, for how long?

What to ask your heart surgeon…

  • What are the risks and complications associated with this surgery?
  • What are my specific risks? How risky is my surgery?
  • Did I have a heart attack? If so, how will this affect my surgery?
  • How many other (men / women) have you operated on with my same condition and what were their outcomes?
  • How many patients do you operate on each year? How many of your patients were women?
  • Can my chest and leg scars be minimized or can vessels be taken from a less visible location?
  • How long is my expected recovery? When will I be able to resume normal activities? Drive a car? Return to work? Have sex? Be independent in activities of daily living? Make plans for help in the home for the first full two weeks following your discharge from the hospital. Ask for a social service referral to help assist your family with sharing duties.
  • What is your fee? Will you accept my insurance as payment in full?
  • If I decide not to have blood products administered, does the hospital follow Bloodless Care Protocols?
  • What accommodations are available for my family’s stay on the hospital campus so that they can support me throughout the operation?
  • When will you be available to answer some of my concerns about the operation? Write down your appointment time to speak with your surgeon or the cardiac team nurse:Date _________ Time__________

Tell your heart surgeon…

  • If you want bloodless care;
  • If you want your Advance Directives postponed during surgery. This is the usual procedure. It will be reinstated after you are stable and transferred to intensive care;
  • If you have had a vein stripping operation. The doctor will need to look elsewhere for vessels;
  • If you would like to hear reassurances during the operation that “all is going well”;
  • If you would like to employ holistic measures to help you relax, for example therapeutic massage, aroma therapy, reflexology, bio-feedback or music therapy.
  • If you would like to play a relaxing CD during the surgery. You may need to bring in your own headphones and CD player, but this may be well worth the trouble.

Discuss with your anesthesiologist any health history that could affect how you respond to anesthesia, for example, if you…

  • Have panic attacks
  • Experience chest pains not related to activity
  • Take medication for anxiety
  • Excessively drink, binge drink or do weekend drinking
  • Take herbal supplements
  • If you or a family member (blood relative) has ever had a serious reaction to anesthesia;
  • If you have a drug allergy or sensitivity or you are allergic to latex.

List drug allergies here:

_____________________________________________________

 

Source: Women’s Health Foundation

Chocolate is good for the heart and the brain!!

 

In a presentation at the European Society of Cardiology (ESC), August  2011 Congress, British investigators are reporting that individuals who ate the most chocolate had a 37% lower risk of cardiovascular disease and a 29% lower risk of stroke compared with individuals who ate the least amount of chocolate.

In the study, published online August 29, 2011 in the British Medical Journal (BMJ) to coincide with the ESC presentation, Dr Adriana Buitrago-Lopez (University of Cambridge, UK) and colleagues state: “Although over consumption can have harmful effects, the existing studies generally agree on a potential beneficial association of chocolate consumption with a lower risk of cardio-metabolic disorders. Our findings confirm this, and we found that higher levels of chocolate consumption might be associated with a one-third reduction in the risk of developing cardiovascular disease.”

In this meta-analysis of six cohort studies and one cross-sectional study, overall chocolate consumption was reported. Chocolate in any form was included, such as chocolate bars, chocolate drinks, and chocolate snacks, such as confectionary, biscuits, desserts, and nutritional supplements. Chocolate consumption was reported differently in the trials but ranged from never to more than once per day. Most patients included in the trials were white, although one study included Hispanic and African Americans and one study included Asian patients.

Overall, the pooled meta-analysis results showed that high levels of chocolate consumption compared with the lowest levels of chocolate consumption reduced the risk of any cardiovascular disease 37% (RR 0.63; 0.44-0.90) and stroke 29% (RR 0.71; 0.52-0.98). There was no association between chocolate consumption and the risk of heart failure, and no association on the incidence of diabetes in women.

Buitrago-Lopez and colleagues concluded that these favorable effects seem mainly mediated by the high content of polyphenols present in cocoa products and are probably accrued through the increasing bioavailability of nitric oxide, which subsequently might lead to improvements in endothelial function, reductions in platelet function, and additional beneficial effects on blood pressure, insulin resistance, and blood lipids.

 

Apixaban: a new oral anticoagulant

In the trial (the ARISTOTLE trial), presented on August 28, 2011, at the European Society of Cardiology (ESC) 2011 Congress and simultaneously published online in the New England Journal of Medicine, apixaban was superior to warfarin in preventing stroke or systolic embolism (the primary end point) and was also associated with less bleeding and lower mortality than warfarin.

The results have been positioned as the most positive yet for one of the new oral anticoagulants in atrial fibrillation (AF) and appear to give apixaban the edge over its two major competitors, dabigatran (Pradaxa) and rivaroxaban (Xarelto). Both dabigatran and rivaroxaban have also shown benefits over warfarin in the RE-LY and ROCKET-AF trials respectively, but apixaban is the first of these three agents to have shown definite reductions in each of the major outcomes of stroke, bleeding, and mortality.

The ARISTOTLE trial randomized 18, 201 patients with atrial fibrillation to apixaban (5 mg orally twice daily) or warfarin (target INR of 2.0 to 3.0). After a median follow-up of 1.8 years, results showed that apixaban was associated with a 21% reduction in the risk of stroke or systemic embolism, a 31% reduction in bleeding, and an 11% reduction in all-cause mortality.

Addressing the question of whether these new oral agents will completely replace warfarin, Mega points out that that they overcome the need for monitoring with warfarin and have shown encouraging results in many different subgroups, but “switching to a newer agent may not be necessary for the individual patient in whom the INR has been well controlled with warfarin for years.”

The superior data for these new drugs presents a challenge for anyone to continue on warfarin. However, switching to a newer agent may not be necessary for the individual patient in whom the INR has been well controlled with warfarin for years. Another important issue that might prevent people from switching is cost. These new drugs will be much more expensive. It would be more reasonable to give these new drugs to new patients and switch over those not managing well on warfarin.

 

Angina Pectoris and Nitroglycerine Use!

Angina pectoris is a clinical syndrome characterized by chest discomfort, usually described as a pressure, heaviness, tightness, squeezing, burning, or choking sensation. In some patients, the discomfort can be either localized to or radiates to the arms, neck, jaws, or upper back. Angina is most commonly caused by reduced myocardial perfusion due to coronary artery narrowing. Chronic stable angina is the most common manifestation of ischemic heart disease (IHD), the leading cause of death in the United States. IHD affects an estimated 17.6 million Americans. A substantial proportion of these patients (~10.2 million) are diagnosed with angina. Angina secondary to IHD is also the most common clinical presentation of cardiovascular disease encountered by general practitioners and cardiologists. As risk factors for cardiovascular disease (metabolic syndrome, obesity, diabetes, and hypertension) become increasingly prevalent, so too will the number of patients with angina and IHD.

Nitroglycerin is the oldest and most commonly prescribed of the antianginal agents; it has been in clinical use since 1878. Nitrates lower angina symptoms by reducing myocardial oxygen demand and improving myocardial perfusion. They act by relaxing arterial smooth muscle, thereby causing dilation of epicardial coronary arteries, even when the arteries are partially narrowed. The nitrates differ in their mode of delivery and their onset and duration of action. The short-acting nitrates (eg, sublingual nitroglycerin tablets and nitroglycerin sprays) have a fast onset of action, between 1 and 5 minutes, and are thus suitable for immediate relief of effort or rest angina. They can also be used for prophylaxis to avoid ischemic episodes when taken several minutes before planned exercise. Although sublingual nitroglycerin tablets and nitroglycerin sprays are thought to be equivalent in their actions, a study that compared these 2 agents in healthy participants found differences in their actions. This study showed that the sublingual spray is superior to the sublingual tablet in terms of rapidity, magnitude, and duration of vasodilatory action, as assessed by brachial artery ultrasound. Intravenous nitroglycerin, administered in hospital, has an onset of action between 1 and 2 minutes. The long-acting nitrates (eg, isosorbide dinitrate, mononitrates, transdermal nitroglycerin patches, and nitroglycerin ointment) have an onset of action ranging from 20 to 60 minutes and are used for the prevention of recurrent angina. Nitrate tolerance is the major concern with long-term use of nitroglycerin and long-acting nitrates. Tolerance develops within 12-24 hours and may be avoided with a nitrate-free period of about 8 hours each day. Optimum nitrate therapy requires a good understanding of the properties of the various formulations, particularly onset and duration of action and propensity to induce tolerance.

 

Source: Heartorg.com