Preventing Stroke Important for Independent Lifestyle

Tranquility - One way to relax and meditate. (Dr. Noorali Bharwani)
Tranquility - One way to relax and meditate. (Dr. Noorali Bharwani)

“There are many ways of breaking a heart. Stories were full of hearts broken by love, but what really broke a heart was taking away its dream – whatever that dream might be,” said Pearl S. Buck (1892–1973), a bestselling and Nobel Prize–winning author.

What stroke does to a person is to take away a dream. But where there is a will there is a way. Two basic things required for any kind of success are: patience and perseverance. With appropriate help from family, friends and caregivers much can be achieved, although it may take time.

What is more important is to prevent stroke in the general population and especially people who are at a high risk.

A commentary in the Canadian Medical Association Journal (CMAJ November 19, 2013) titled, “Stroke prevention in older adults with atrial fibrillation,” by Michiel Coppens, MD and colleagues, discuss the use of new oral blood thinners that reduced the risk of bleeding in the brain by 30 to 70 per cent compared with warfarin. The new medications were at least as effective as warfarin in preventing stroke due to reduced blood supply to the brain.

People with atrial fibrillation have irregular heartbeats, which make them prone to forming blood clots. Warfarin is the most commonly used drug (also used as rat poison) as a blood thinner in humans to prevent blood clots. The main drawback is that the patient has to have regular blood tests to make sure the blood is not too thin. It may cause internal or external bleeding.

The new oral blood thinners (dabigatran, rivaroxaban and apixaban) are approved in more than 80 countries for stroke prevention in patients with atrial fibrillation. Patients do not require blood tests to check if the blood is dangerously too thin.

According to the CMAJ article, the key points to remember are that many patients do not receive recommended blood thinner treatment. The new oral blood thinners offer consistent benefits over warfarin in older (age 75 years or older) patients with atrial fibrillation.

The article says the rate of internal brain bleeding, the most feared complication of blood thinners, is related to age and is sharply reduced by the new blood thinners relative to warfarin, making these agents particularly attractive for older patients.

Like any new medication, only time will tell whether the drugs are safe and superior to currently used warfarin or should I say rat poison? Talk to you again soon. Take care and don’t forget to listen to music, dance and laugh.

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Broken-Heart Syndrome is also known as Takotsubo (Stress) Cardiomyopathy

Nurse helping a senior patient. (Wavebreak Media)
Nurse helping a senior patient. (Wavebreak Media)

Takotsubo cardiomyopathy is a transient acute illness typically precipitated by acute emotional stress. It is also known as “stress cardiomyopathy” or “broken-heart syndrome.” In 2011, there was an article on this subject in a medical journal, Circulation, by Dr. Scott W. Sharkey and his colleagues from the Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN explaining the signs, symptoms and treatment of this illness.

In Japanese, “tako-tsubo” means “fishing pot for trapping octopus,” and the left ventricle (pumping chamber of the heart) of a patient diagnosed with this condition resembles that shape.

This is a fairly new condition recognized initially in Japan in 1990, with the first report emerging from the United States in 1998. Takotsubo cardiomyopathy starts suddenly, with symptoms of chest pain and, often, shortness of breath. The condition affects women older than 50 years of age (only 10 per cent in men). Most patients go to the emergency department thinking they have a heart attack.

Sharkey gives examples of emotional stressors which include grief (death of a loved one), fear (armed robbery, public speaking), anger (argument with spouse), relationship conflicts (dissolution of marriage), and financial problems (gambling loss, job loss). Physical stressors include acute asthma, surgery, chemotherapy, and stroke.

“Although patients with takotsubo do not have significantly narrowed coronary arteries, in the early hours takotsubo and heart attacks share many similarities in presentation, including chest pain and breathlessness, as well as abnormalities in both the electrocardiogram and blood biochemical tests,” says the article. But coronary angiogram will show normal coronary arteries but unusual shape of the left ventricle that has given takotsubo its unique name.

Once the diagnosis is made (via several invasive investigations) patients are in the intensive care unit for at least 24 hours, during which time vital signs are monitored and blood is tested for troponin (a protein released by injured heart muscle). Medications are used to promote recovery of heart muscle and blood thinners are used to avoid a stroke caused by a blood clot traveling from the heart to the brain.

Major life-threatening complications are infrequent. Low blood pressure (hypotension), fluid buildup in the lungs (congestive heart failure) and a chaotic heart rhythm will require appropriate medications.

“Fortunately, with timely recognition and supportive therapy, takotsubo events are reversible, and recovery is usually rapid and complete. Heart function (contraction) gradually improves over several days and is usually normal by hospital discharge (3–7 days). The term stunned heart muscle is commonly used to indicate that injury in takotsubo, although initially profound, is only temporary. Drugs are discontinued once heart contraction has returned to normal,” says Sharkey.

Why would acute stress cause heart failure? This is an unresolved question. It may have something to do with the autonomic nervous system. It has been suggested that when powerful hormones such as adrenaline are released in excess, the heart muscle can be damaged in patients with takotsubo. Fortunately, the long term prognosis is good. Nearly all patients survive an acute takotsubo episode. In approximately five per cent of patients, a second (or third) stress-induced event may occur. Best thing is to avoid stressful situations. Relax, do deep breathing exercises and keep smiling.

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Low Dose Aspirin Increases the Risk of Upper Gastrointestinal Bleeding

Aspirin bottle. (iStockphoto)
Aspirin bottle. (iStockphoto)

Low-dose acetylsalicylic acid – also known as aspirin – (75 mg⁄day to 325 mg⁄day) is recommended for primary and secondary prevention of cardiovascular events, but has been linked to an increased risk of upper gastrointestinal bleeding (UGIB), according to a study published by Valkhoff and his colleagues (Can J Gastroenterol. 2013 Mar;27(3):159-67).

They analyzed several studies. All studies found low dose aspirin use to be associated with an increased risk of UGIB. The mean number of extra UGIB cases associated with low dose aspirin use was 1.2 per 1000 patients per year. Sounds like a small number when you think of the number of people who take aspirin all over the world. But the authors indicate use of low dose aspirin was associated with a 50 per cent increase in UGIB risk.

What about other anti-inflammatory drugs? Are they safe?

Commonly used traditional anti-inflammatory drugs like ibuprofen are also known as non-steroidal anti-inflammatory drugs (NSAID) are widely used for all kinds of pain. An editorial by Jacob Josh, Professor of Medicine, University of Ottawa, Ottawa, Ont. titled, “Anti-inflammatory drugs: What is safe?” (CMAJ August 29, 2006), says “Sixteen thousand deaths a year in the United States and 1900 a year in Canada were blamed on NSAID-induced gastric perforations, obstructions and bleeds. NSAID use was complicated also by numerous other side effects, including hypertension, heart failure and renal insufficiency.”

The risks are not limited to long-term use. Clinically significant adverse cardiovascular events are noted within the first 30 days of treatment.

Do you always have to take an NSAID if you are in pain and thus increase the risk of complications? Not really. You can try other modalities of pain relief by rest, application of ice and use of acetaminophen. Acetaminophen, up to 4 g/day, is as effective as an orally administered NSAID in about 40 per cent of patients with mild to moderate osteoarthritis.

Then there are occassions when pain cannot be relieved by what we call conservative measures. So we have to weigh our options. First, we should assess patient risk. There is an increased risk of gastric toxicity if:
-the patient is over 65,
-has had previous upper GI bleed,
-there is concurrent therapy with low-dose aspirin, corticosteroids or anticoagulants.

Under these conditions we should try prescribing a coxib (like Celebrex) or traditional NSAID with concurrent cytoprotection (to protect the stomach lining) with misoprostol or a proton pump inhibitor. If the patient has had a recent heart attack or episode of congestive heart failure, then he should not take NSAID or coxib.

Josh says, “In case of uncontrolled hypertension, we should not choose an NSAID or coxib until the blood pressure is well controlled. If the patient has controlled blood pressure that becomes elevated while taking an NSAID or coxib, even by 5 mm Hg systolic, adjust the antihypertensive medications or stop the anti-inflammatory, or both.” Monitor renal function as well.

Josh says there is nothing like a safe NSAID or coxib. In high-risk patients, we should avoid them. Concomitant use of low dose aspirin does not protect you from cardiac side-effects of NSAID or coxib. There is adequate data to suggest aspirin enhances the gastric toxicity of anti-inflammatory drugs as mentioned earlier.

If you are in pain, careful use of painkillers is very important. If you are taking aspirin as a prophylaxis against cardiac problems then weigh your risk factors and your options. If you are taking NSAID for chronic pain then you need to know your risks. Discuss risk vs. benefits of the medications you are taking with your doctor.

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Sugar… Sugar… You Are Not My Honey Anymore

Ice cream and fried bananas. (Dr. Bharwani)
Ice cream and fried bananas. (Dr. Bharwani)

Many experts believe sugar is a poison. So does the Mayor of New York city, Michael R. Bloomberg. The mayor has been trying to improve the health habits of New Yorkers for some time, with actions like bans on smoking in bars and city parks and the posting of calorie counts on menus in chain restaurants.

Bloomberg’s recent project was to reduce the obesity rates of his citizens by restricting the amount of sugary drinks they can buy. So, last week, the New York City Board of Health approved a ban on the sale of large sodas and other sugary drinks at restaurants, street carts and movie theaters, the first restriction of its kind in the U.S. Now sugary drinks cannot be sold in containers larger than 16 ounces – some exceptions apply.

Dietary sugar is not good for your health. There are nine reasons why you should quit on sweetie sugar. It may cause hyperactivity, raise blood sugar level, suppress immune system, lead to obesity and diabetes, cause cardiovascular disease, Alzheimer’s disease, dental decay and macular degeneration.

Like many things in science, you can dig out statistics which have contradictory conclusions. This leads to confusion. The World Health Organization and others have said there are contrasting impacts of sugar in refined and unrefined forms. So there are at time no comparable studies to draw conclusions from.

Some experts believe hyperactivity is due to sugar consumption. Others have refuted the idea. Until we get a final word on it, you can stop feeding sugar to kids and adults – especially if they get sugar-high. Your blood sugar level goes up as soon as you eat sugary stuff. Consuming too much sugar suppresses the immune system. The white blood cells that attack bacteria are less effective. Immune system is also suppressed if a person is obese.

Consuming large amount of dietary sugar does not cause diabetes but it does cause obesity which is a risk factor in diabetics. A meta-analysis of several studies found sugar-sweetened beverages may increase the risk of metabolic syndrome and type 2 diabetes not only through obesity but also by increasing dietary glycemic load, leading to insulin resistance, β-cell dysfunction, and inflammation. Metabolic syndrome is a combination of medical disorders that, when occurring together, increase the risk of developing cardiovascular disease and diabetes. It is estimated the syndrome is present in 25 per cent of the the U.S. population.

There is indirect evidence to suggest consuming a diet with a high glycemic load is strongly associated with an increased risk of developing coronary heart disease. The glycemic index ranks foods on how they affect our blood glucose levels.

It is suggested that Alzheimer’s disease is linked with the western diet. Animal studies suggest controlling the consumption of sugar-sweetened beverages may be an effective way to curtail the risk of developing the disease. There are links between free sugar consumption and macular degeneration in older age. There is convincing evidence from human studies to show an association between the amount and frequency of free sugars intake and dental decay.

Bloomberg’s next project should be to do what Japan did in 2008. A law in Japan requires overweight individuals or individuals who show signs of weight – related illnesses to go to dieting classes. If they fail to attend the classes then the company and/or the local government would be fined.

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