Polypill and Polymeal

How much do you know about Polypill and Polymeal?

If you are like me, then not much. So I did some research. Allow me to share this with you. It may give a new meaning to the word prevention and may stimulate your taste buds as well!

It is no secret that cardiovascular disease (CVD) is a leading cause of death and disability in the affluent societies. There are several risk factors which cause heart disease and stroke. Four of these risk factors (LDL cholesterol, blood pressure, homocysteine, and platelet function) account for most CVD and can be reduced by drugs or vitamins.

So, in 2003, two Professors from the University of London, England published an article in the British Medical Journal (BMJ) titled, “A strategy to reduce cardiovascular disease by more than 80 percent.” And they introduced the concept of the Polypill.

The Polypill will be one pill containing six pharmacological components of commonly used drugs to prevent CVD. These are the drugs used by people at high risk for heart problems and stroke – a statin (to lower cholesterol level), aspirin (as a blood thinner), folic acid (to lower homocysteine), and three anti-hypertensives (a thiazide, a ß blocker, and an angiotensin converting enzyme inhibitor), all at half dose.

The authors proposed that the Polypill should be taken by everyone aged 55 and older and everyone with existing CVD. And they felt that it would be acceptably safe and with widespread use would have a greater impact on the prevention of disease in the Western world than any other single intervention.

Recently, BMJ reported that at a meeting of experts organized just before Christmas by the US Centers for Disease Control in Atlanta generally supported the idea of a Polypill but would like to see a series of trials to test its safety and efficacy before it is given to the whole population without screening. Sounds like a good idea!

What about the Polymeal? Sounds tastier than Polypill? May be!

From Netherlands comes a paper (BMJ DEC 18, 2004) titled “The Polymeal: a more natural, safer, and probably tastier (than the Polypill) strategy to reduce cardiovascular disease by more than 75 percent.”
The authors of the article say that pharmacological interventions are not the only option for preventing heart disease. A healthy diet and an active lifestyle reduce CVD as well. Certainly, they have a point. Many experts feel that the side-effects and cost of Polypill may be prohibitive. Polymeal may be a safer and tastier alternative.

They looked at the scientific literature and felt that the evidence based recipe should included wine, fish, dark chocolate, fruits, vegetables, garlic, and almonds. This variety of food has been enjoyed by humankind for centuries.

They calculated that a daily consumption of 150 ml of wine, 114 grams fish four times a week, 100 grams of dark chocolate daily, 400 grams of fruit and vegetables daily, 2.7 grams of fresh garlic daily, and 68 grams of almonds daily could reduce CVD by more than 75 percent.

The authors feel that the Polymeal and active lifestyle will bring us happiness and spare us a future of pills and hypochondria. That may be so. Only time will tell. In the meantime, I better learn to pronounce those names on the wine bottles! I don’t want to be left out.

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Diagnosis of Chest Pain

Dear Dr. B: Your last column discussed the symptoms of heart attack and immediate actions required to increase survival if one was having chest pain. What I would like to know is how often an ER physician would miss a diagnosis of a heart attack?

ER physicians are not infallible. The diagnosis of a heart attack can be missed. How often does this happen? This subject is well covered in an article published in the recent issue of the Canadian Medical Association Journal (CMAJ). Here is the summary of the article.

Approximately half a million people present to Canadian emergency department s with chest pain. About 62,000 Canadians are admitted to hospital with acute heart attack. Probably an equal number are admitted with unstable angina.

There are good assessment protocols for ER physicians to use in patients with chest pain but none helps clinicians determine which patients can safely be discharged from the emergency department after a brief assessment, says the CMAJ article.

U.S. studies have shown that approximately two percent of patients are discharged home where the diagnoses of a heart attack has been missed.

The authors of the CMAJ article studied 1819 patients at St. Paul’s and Vancouver General hospitals. The mean age of the patient was 58 years. Fifty eight percent of the patients were males. Thirty one percent of the patients arrived to the department by ambulance.

Twenty two percent (398 out of 1819) of patients had a diagnosis of acute heart attack or unstable angina on admission or confirmed within 30 days. Unfortunately, five percent of patients had been discharged from the emergency department because the diagnosis was missed.

The authors of the article indicate that the number of missed diagnoses in Canadian ER is higher than in U.S. where a study found the rate of missed diagnoses around two percent. The authors feel that the existing diagnostic pathways and guidelines do not include clear guidance for the early discharge of patients with chest pain.

The authors conclude that opportunities exist to improve both safety and efficiency by developing clinical tools to help clinicians identify patients who can safely be discharged after a short period of investigation. Ideally, the rate of missed diagnosis should not be more than two percent.

The study shows that if a patient presents with chest pain or discomfort to an emergency department in a Canadian hospital then 95 percent of the time you will have an appropriate diagnosis and treated accordingly. As better diagnostic tools become available the number of patients discharged with a missed diagnose will be much less.

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Heart Attack in Women

Dear Dr. B: I am a 60 years old woman. Few months ago, I felt nauseated and broke out in a sweat. My back went into spasm. After a few seconds, everything subsided. I just felt weak. I think I had a slight heart attack. Is it true that a woman’s symptoms of a heart attack are different from a man’s symptoms?

On an average, our heart beats 72 times a minute. That is 4320 times an hour. In 24 hours, our heart beats 103,680 times. That is lot of work. The work load increases as our activities increase.

Under normal circumstances and activities there is no chest pain, shortness of breath or discomfort when the heart is doing its work at a regular rate and rhythm.

But heart is very venerable to disease. Women are not immune to that. Newsweek reports that every year a quarter of a million women die of heart disease- more than the total number killed by breast cancer, diabetes and Alzheimer’s combined – making it Americas No. 1 killer of women , as well as men. Statistics in Canada are no different.

It is alright for women to worry about breast cancer and cervical cancer. But the risk of dying from heart disease is higher. And sometimes you don’t get a second chance. So if you have any symptoms suggestive of heart disease then talk to your doctor.

What are the typical symptoms of a heart attack?

If you are having a heart attack then you feel crushing chest pain – usually very severe. This may be associated with sweating, dizziness, shortness of breath and radiation of pain to the jaw, left shoulder and arm. There may be nausea and vomiting. There is fear of dying.

But not everybody has such classical symptoms. Twenty five percent of the people experience no chest pain during a heart attack. They may have other symptoms like shortness of breath, sweating and fainting. This is called “silent infarction”.

Some women fall in this category of “silent infarction”. They may feel tired, short of breath, nausea, indigestion, back pain or abdominal pain. Women tend to ignore these symptoms not realizing it could be a heart attack. And that is where the danger lies.

Heart disease in women is a real thing. After the age of 60, coronary heart disease is the main cause of death among women. In this age group, 25 percent of the women die of the disease – same as men.

What to do if you are having a chest pain or think you are having a heart attack?

Dial 911 and call an ambulance. Do not wait for self-diagnosis or drive in your own car. Chances of surviving a heart attack are better in an ambulance with paramedics at hand than in your own vehicle. If you are having a heart attack then the outcome of your illness may be dictated by:
-The speed and mode of transportation to emergency department.
-Your previous history of heart problems.
-Rapid evaluation of your condition by emergency physician.
-The use of “clot busting” drugs in a timely fashion.

How to prevent heart disease?

Make sure your cholesterol level and blood pressure is under control. Exercise regularly. Eat a healthy diet with lots of fruits and vegetables, fish and chicken. Take an aspirin a day – check with your doctor first to make sure it is safe for you to do so.

So, remember, if you think you are having a heart attack then dial 911 and call an ambulance. While waiting for it, have an aspirin. A telephone call and an aspirin may save your life.

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Exercise With Care

Dear Dr. B: My friend and I go to a gym regularly. At the end of a strenuous session my friend feels nauseated. What is the reason?

Answer: Regular exercise has many benefits. Those benefits are achieved if the exercise is done properly. Otherwise, exercise may harm you. Let us try and understand what happens when we exercise.

Exercise considerably increases muscle metabolism (break down of substances to yield energy). To meet this increased metabolic activity, muscles require more nutrition and more oxygen. Blood carries nutrition and oxygen to the muscles. That means more blood is pooled to the muscles at the expense of other vital organs.

The body responds to this need immediately. The body ensures that the metabolic needs of exercising muscles are met, that hyperthermia (overheating) does not occur, and that blood flow to essential organs is protected.

This protective mechanism is achieved by the circulatory system (heart and blood vessels). It involves a complex series of adjustments resulting in a large increase in cardiac output (blood flowing out of the heart) proportional to the increased metabolic demands. The increased metabolic activity rapidly increases the heart rate.

During a tough workout in a hot environment, the body can lose two liters of fluid per hour through sweat. There is also loss of electrolytes. This can result in severe dehydration which can be dangerous.

Hyperthermia can be a problem as well. It causes lightheadedness, nausea, headache, hyperventilation, fatigue, and loss of concentration. Heatstroke is the most dangerous complication of hyperthermia.

Those who use anabolic steroids to stimulate production of muscle tissue are also at an increased risk of complications.

What are the other dangers of strenuous exercise?

Heart attack and sudden death from strenuous exercise has been reported. One American report says that an estimated 1.5 million heart attacks occur every year; of these, 75,000, or about five percent, occur after heavy exertion, leading to 25,000 deaths.

Strenuous exercise or high-impact aerobics can cause injuries to bones and muscles.

High-impact exercise can also damage the inner ear, causing dizziness, ringing in the ear, motion sickness, or loss of high-frequency hearing.

The risk factors which are associated with complications during exercise are age, presence of heart disease and intensity of exercise.

How can you exercise safely?

Most important thing is to listen to warning signs. It is estimated that at least 40 percent of young men who die suddenly during a workout have previously experienced, and ignored, warning signs of heart disease: irregular heartbeat, undue shortness of breath, chest pain and weakness.

Be careful to warm up, cool down, and stretch; flexibility is the key to preventing many muscle strains. Vary training and alternate easy and harder workouts.

Don’t eat two hours before vigorous exercise. Drink plenty of fluids before, during, and after a workout. Adjust activity according to the weather and reduce it when fatigued or ill.

When exercising, listen to the body’s warning symptoms, and consult a physician if exercise induces chest pain, irregular heartbeat, undue fatigue, nausea, unexpected breathlessness, or light-headedness.

My advice to your friend is to review his exercise regime, listen to body’s warning signs and symptoms and consult a physician.

Finally, it is February. It is Heart Month. Today is Valentine’s Day. Let me wish you all a Happy Valentine’s Day. Take care of your own hearts and the hearts of your loved ones! And support Heart and Stroke Foundation.

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