Category: Medicine Hat News

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Statin Therapy for Your Heart

One more article on statin therapy? Yes, one more article. If you have had high cholesterol level then you know quite a bit about statin therapy. Statin therapy is extensively used for the management of high cholesterol level and in the management of coronary artery disease. One of the cholesterols is LDL (low-density lipoprotein cholesterol), also known as the “bad” cholesterol.

Recently, an article in the Canadian Medical Association Journal (CMAJ) discussed the efficacy and safety of intensive statin therapy in patients with high LDL cholesterol and coronary artery disease.

High LDL levels are associated with an increased risk for heart disease. Your doctor orders LDL testing as part of your routine check-up and it is often the first step in determining whether an individual is at risk for developing heart disease. In the management of high cholesterol level and coronary artery disease, LDL levels are often the major focus of cholesterol lowering diets and drugs.

The CMAJ article says high cholesterol level is the most important modifiable risk factor for myocardial infarction (heart attack) worldwide. High cholesterol level is directly related to high risk of dying from coronary artery disease. Studies have shown that reducing LDL cholesterol with statin therapy reduces events like heart attack by 21 per cent and death by 12 per cent.

Appropriate diet is the first line of treatment in the management of high cholesterol and high LDL. Avoid foods high in saturated fats and trans-fatty acids. Next line of treatment is cholesterol lowering medications. Commonest of these are statins. Statins reduce the bad cholesterol LDL by 30 to 50 per cent.

How low should the LDL blood level be to lower the risk of adverse events in patients with coronary artery disease? Current Canadian and American guidelines advocate LDL levels below 2.0 mmol/L in patients with coronary artery disease. Europeans guidelines differ a bit. They recommend LDL of 2.5 mmol/L in these patients.

Who should receive intensive statin therapy to lower the LDL blood level?

Analyses conducted by the authors of CMAJ article supports the use of more intensive statin regimens in patients with established coronary artery disease. What about patients who have LDL level higher than 2.0 mmol/L but have no coronary artery disease? The authors say there is insufficient evidence to advocate treating to particular LDL targets (i.e. 2.0 mmo/L) in patients without established coronary artery disease. What if these patients (the ones without coronary artery disease) have other risk factors making them prone to coronary artery disease? The authors say that there were too few clinical events in these trials to make definitive conclusions.

The authors of the article found more intensive statin therapy safe and well-tolerated. They also came to the conclusion that it helps in the prevention of heart attack and stroke in patients with known coronary artery disease, irrespective of their baseline LDL cholesterol levels. They said further research is needed to define:
-optimal LDL cholesterol targets (is 2.0 mmol/L the right target number?),
-the role of more intensive statin therapy in patients without coronary artery disease and
-the role of combination statin therapy (usually low LDL is achieved using two types of statins).

It would be a good idea to find out from your physician what your LDL level is every time you get your cholesterol level checked. If it is above 2.0 mmol/L then ask if you need statin therapy.

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Measuring Blood Pressure the Right Way

What is the accurate way to measure blood pressure?

After more than hundred years of measuring blood pressure with the use of a stethoscope and sphygmomanometer (yes, that is what your doctor uses in his office to check your blood pressure) you wonder why the question.

An article in the Canadian Medical Association Journal (CMAJ) makes the point that things have changed in the last 20 years as more and more automated blood pressure measuring devices have hit the market. Their reliability and accuracy have increased. You find them in people’s homes, in your local pharmacy and may be in your doctor’s office.

The blood pressure measurement by sphygmomanometer is called auscultatory method because the method uses a stethoscope to listen the pulse. The automated machine measures the blood pressure by oscillometric method; it detects and analyzes pulse waves to determine blood pressure.

Each method is an indirect way to measure the blood pressure. The accuracy and consistency of the measurement and its clinical relevance depends on the skill of the individual taking the pressure and proper functioning of the automated device.

High blood pressure is known to be a silent killer. The CMAJ article says that clinical practice guidelines set uniform standards to take the blood pressure so consistency and accuracy is maintained. This allows the clinician to predict the effect of abnormal blood pressure on the human body. The guidelines are based on the use of auscultation method using a bare arm – “roll up your sleeve so I can take your blood pressure.”

In another article in the CMAJ, the authors challenge the recommendation that blood pressure should be measured on a bare arm. In their study they found that taking a blood pressure reading over the sleeve of a shirt, blouse or light sweater was not statistically different than taking the blood pressure on a person’s bare arm.

The article also challenges the hypertension practice guidelines which require the use of different size blood pressure cuffs for different sized arms – some arms have a bigger circumference than others. The automated devices have cuffs which do not meet the clinical practice guidelines for measuring blood pressure by the traditional way.

The article says the use of automated blood pressure measuring devices in the clinic provides some real benefits. Well-working fully automated devices are:
-free of terminal digit bias,
-deflate at the correct rate,
-operate consistently over time,
– record the results,
-do not require good hearing and
-generally require less training to operate properly.

In spite of all these benefits, the automated device will not provide a correct reading if the patient or the individual is not mentally and physically relaxed. There are various human behaviours – emotional and physical – which affect a person’s blood pressure, albeit temporarily. So the reading taken may not be of much clinical use. Same problem applies when the blood pressure is taken by the traditional way.

So the jury is still out. The article says that in spite of advances in technology the accurate measurement of blood pressure depends on factors related to the patient, the equipment and the method used to take the blood pressure.

Have you had your blood pressure taken recently? If not, then better do so. Don’t forget, high blood pressure is a silent killer. You may not have any symptoms but your blood pressure may be high. See your doctor and roll up your sleeve or may be not.

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Are you constipated?

Chronic constipation is a very common problem. I see patients with stomach and bowel problems all the time and constipation is high on their list of complaints. Usually, it has been present for many years. We usually tell patients with chronic constipation to take high fiber diet, do regular exercise and drink plenty of fluids. But what really works for constipation?

Let us start by defining what chronic constipation is. Unfortunately, there is no simple definition. Most people complain of constipation if they do not have a bowel movement for a few days or if they have difficulty emptying. Generally speaking, constipation is defined as having a bowel movement fewer than three times a week. The bowel movements are usually hard, dry, and small in size.

We do not need a daily bowel movement to be healthy. We do not have to spend money on bowel cleansing with laxatives and enemas to get rid of so called toxins. Daily bowel movements are not important for overall health.

As part of my research for this column, I came across an article in the American Journal of Medicine (AJM) titled: Constipation in the Primary Care Setting: Current Concepts and Misconceptions. The article reviews what works and what does not work in patients with chronic constipation. Here are some important points discussed in the article.

Regular exercise, high fiber diet and fluids are good choices for a healthy life style. But if one of these choices is missing in your life then it would not be a major factor in causing chronic constipation.

High fiber diet increases stool weight and frequency in healthy individuals and decreases the time it takes for the stool to travel to the rectum. Increase intake of fiber has shown to help some chronically constipated individuals. High fiber diet does not help patients who have irritable bowel syndrome where constipation is the dominant symptom, patients who have slow large bowel transit time or have problem with emptying the rectum due to muscle weakness. That means all constipated patients will not benefit from high fiber diet.

What about fluid intake and exercise? The article says that adequate fluid intake and regular exercise improves general health but there is no evidence to support the use of these measures in treating constipation

What about the laxatives? Laxatives are among the most widely used medications in Western countries, says the AJM article. Laxatives are designed to increase the frequency and ease of bowel movement. They are easily accessible and sometimes abused as most of them can be purchased over-the-counter. There are three categories of laxatives:
-Bulk agents: psyllium, methylcellulose, Calcium polycarbophil
-Osmotic agents: polyethylene glycol, lactulose, sorbitol, glycerine suppositories magnesium citrate, magnesium sulfate
-Bowel stimulants: bisacodyl, senna

Bulk agents like psyllium work in similar fashion to high fiber diet. Studies have shown that osmotic laxatives like lactulose, sorbitol and polyethylene glycol are effective. Stimulant laxatives are also effective in many patients with constipation, although certainly not all. Except for bloating and flatulence, laxatives have few side effects. Once daily dosage should be encouraged for better compliance. There is no evidence to support the belief that stimulant laxatives like senna can damage colonic nerves if chronically used.

The article says that although tolerance to laxatives has not been studied extensively in humans, it seems to be uncommon in the majority of laxative users. Tolerance to stimulant laxatives occurs in patients who have constipation due to slow transit time and whose colons have poor neurological function. Can you get addicted, habituated or dependent on laxatives? The answer is no. Most laxatives are not absorbed in the system so there is no risk of addiction.

So, high fiber diet, adequate fluid intake, regular exercise and psyllium should work for most patients with chronic constipation. If you are resistant to these measures then you can add something like lactulose or a stool softener. If that does not work then add senna.

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An Angel with Ovarian Cancer

Recently, an angel was diagnosed with ovarian cancer. She is 87-years-old. I have known her for many years. She is an angel because she is kind, she is generous, she is caring and she believes in miracles. She has been an excellent wife, mother and grandmother. She lost her husband 17 years ago but managed to survive in Canada without speaking any English. She is one tough lady.

But now her time is up. Doctors have said her prognosis is poor. Once cancer has spread it is usually a losing battle. But how long the battle will last is anybody’s guess. In the meantime my angel is wasting away – slowly and sometimes painfully. Her sprit is high but the energy level is low. What keeps her going is her family and friends. Some of them have flown from all over the world. They are here to say thanks for the memories and good-bye. They want to pay their last respects.

Each year, about 2400 Canadian women or angels are diagnosed with ovarian cancer. Sadly, 1700 women with the disease die each year. In North America, ovarian cancer is the second most common gynecologic malignant disease and is the leading cause of death among women with gynecologic cancer.

Why do so many women die of ovarian cancer? More than 60 per cent of the women are in advanced stage when first diagnosed. Their five year survival rate is less than 30 per cent. Their prognosis is poor and they have very few treatment options. Some studies have reported higher survival rates of greater than 90 per cent in women with stage one disease. Only 25 per cent of the women are diagnosed early.

Is there anyway we can detect ovarian cancer early? In early stages symptoms are usually non-specific and vague, but as the disease progresses they may include abdominal distention or pain, change in bowel and/or bladder habits, and gynecologic complaints such as pain during intercourse. Pelvic examination does not help in early cases but generally detect ovarian cancer that is at an advanced stage. So, early diagnosis is difficult.

There have been several studies to examine the efficacy of routine ultrasound and screening using blood test CA125 for early detection. Unfortunately, these techniques have not been clearly shown to be effective for early detection. Therefore, there is no recommendation to use ultrasound or CA125 blood test for screening.

There are two risk factors for ovarian cancer: first, 10 per cent of women with ovarian cancer have a family history of the same disease and second, a much larger group includes postmenopausal women who are over 50 years of age, in whom 90 per cent of ovarian cancer occurs sporadically.

One study suggests that women who do not have regular medical check-ups or pelvic examinations and who have no regular family physician or health care provider are at increased risk of ovarian cancer. The authors of the study say that although the exact mechanism of this association is unknown, women, especially those who are postmenopausal, should be encouraged to maintain regular medical care. Women who are found to have benign diseases of the ovary are also thought to be at a higher risk for ovarian cancer.

Many aspects of ovarian cancer are poorly understood. So screening is not currently recommended for the general population. There are a number of trials going on which may give us answers in the future. But this may take many years.

For now, there isn’t much good news for women in general and my angel in particular. I hope she does not suffer for too long. Some days pain and vomiting is unbearable. Some days things are not bad. I worry and have sleepless nights about my angel because she is precious and she is my mother.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!