11 Ways to Prevent Stroke INSIDE It’S Never Too Late to Strike out Against a Potentially Devastating Brain Attack

VOLUME 21 • NUMBER 7 march 2011

11 ways to prevent stroke INSIDE It’s never too late to strike out against a potentially devastating brain attack. Fish oil questioned as treat ment for heart disease . . . 3. ike close cousins, heart disease and the growth of artery-clogging plaque, or the Eating fish is a better strategy than stroke share a common lineage. Both development of atrial fibrillation. This long gulping pills. emerge from a mix of nature (genes), gestation means it is often possible to avoid a Hybrid heart surgery Lnurture (upbringing and environment), and stroke by fighting arterial corrosion. expands options...... 4. personal choice (smoking, exercise, etc). Collaborative approach aims to For most of us, personal choice largely de- Two types of stroke improve cardiac care. termines whether a stroke lies ahead. New A stroke occurs when blood stops flowing to Transfusion and heart surgery: guidelines on the prevention of stroke sug- part of the brain. Cut off from their supply of Only when needed. . . . . 5. gest that a healthy lifestyle can cut the risk of oxygen, brain cells begin dying within min- Unnecessary blood transfusion can having one by 80%. No drug, device, or other utes. Sometimes the damage is fatal—stroke do more harm than good. intervention can come close to doing that. is the fourth leading cause of death in the Heart beat...... 6–7. The term “stroke” conjures up a frightening United States, accounting for almost 135,000 Crashing stock market and heart bolt out of the blue. It certainly feels that way deaths each year. Most of the time, stroke isn’t attacks; Eyelids as windows into when it happens. But the sudden onset be- a killer. The American Heart Association es- the heart; Double-chamber pacemaker helps heart failure; Stay lies a stroke’s decades-long development due timates that there are more than six million lean, live longer; Rheumatoid to slow but steady damage to blood vessels, stroke survivors in the United States. Although arthritis and heart disease some have no physical or mental reminders of the attack, many have long-lasting speech loss, Ask the Doctor...... 8 Different types of stroke Why does my blood pressure rise paralysis, or other problems. In fact, stroke is Hemorrhagic stroke in the afternoon? and Is high a leading cause of disability—nearly one in potassium a problem? three survivors is permanently disabled, and many more need long-term care. Brain tissue Ischemic strokes occur when a blood clot Bleeding in or other debris blocks a blood vessel in the the brain brain or one leading to it. These account for Ischemic stroke more than 80% of strokes. The rest are hemorrhagic strokes. These occur when a blood Ischemic (oxygen- vessel in the brain bursts. The bleeding (hem- deprived) orrhaging) deprives downstream brain cells What’s New Clot brain tissue of oxygenated blood and can also damage 2011 Annual Report on Carotid cells by increasing pressure inside the brain. Prostate Diseases arteries Though ischemic and hemorrhagic strokes Understanding Depression require different treatments once they appear, There are two main types of stroke. Ischemic Special Health Reports strokes are more common and occur when a blood efforts to prevent them are very similar. from Harvard Medical School clot blocks an artery in the brain. In some cases, To order, call 877-649-9457 the clot develops in the vessel itself (thrombotic Three types of risk (toll-free) or visit us online at www.health.harvard.edu. stroke). In other cases, the clot forms in the heart You can change some, but not all, of the fac- or in an artery that carries blood to the brain; the tors that increase your odds of having a stroke CONTACT US clot breaks off and travels to the brain, where it (see “Risk factors for stroke” on page 2). lodges in a small artery (embolic stroke). Hemor- Write to us at rhagic strokes occur when an artery in the brain Nonmodifiable risk factors include your [email protected] ruptures, releasing blood into the brain tissue. age, gender, genes, birth weight, and race or For customer service, write us at

This Harvard Health Publication was prepared exclusively for ntavares - Purchased at http://www.health.harvard.edu/ Editor in Chief Thomas H. Lee, MD 11 ways to prevent stroke continued Editor P.J. Skerrett [email protected] Risk factors for stroke tack is even better. Here are 11 things you Associate Editor Richard T. Lee, MD can do to stay stroke-free: Editorial Board Eugene Braunwald, MD Factors you can’t change William P. Castelli, MD • Know and control your blood pressure. • Age Lawrence H. Cohn, MD • Don’t smoke; stop if you do. Roman W. DeSanctis, MD • Gender Stephen E. Goldfinger, MD • Race/ethnicity • Lose weight if needed. Samuel Z. Goldhaber, MD Caitlin Hosmer Kirby, MS, RD Factors you can change • Become more active. Jane W. Newburger, MD • Identify and manage atrial fibrillation. Patrick T. O’Gara, MD • High blood pressure Paul M. Ridker, MD • Lack of exercise • Be aggressive about treating a transient Harvey B. Simon, MD Walter C. Willett, MD, DrPH • Smoking ischemic attack (TIA, or mini-stroke). Peter Zimetbaum, MD • Diabetes • Treat circulatory problems like periph- Board members are associated with Harvard Medical School • High cholesterol eral artery disease, sickle cell disease, and affiliated institutions. They review all published articles. • Atrial fibrillation or severe anemia. Copy Editor Robin Netherton • Sickle cell disease Art Director Heather Derocher • Know and control your blood sugar Production Coordinator • Use of oral contraceptives Nicole Wall and cholesterol. Illustrator Harriet Greenfield • Obesity • Presence of other cardiovascular disease • If you drink alcohol, do so in mod Subscription questions • Alcohol abuse eration. Phone: 877-649-9457 (toll-free) E-mail: [email protected] • Drug abuse • Adopt a healthy diet low in sodium and Online: www.health.harvard.edu/customer_service Harder to change or emerging evidence rich in potassium. Mail: Harvard Heart Letter • Know the warning signs of stroke (see P.O. Box 9308 • Obstructive sleep apnea Big Sandy, TX 75755-9308 • Migraine “Stroke warning signs” below) and re- Subscriptions $32 per year (U.S.) • Certain infections spond immediately. Bulk subscriptions Gum disease StayWell Consumer Health Publishing • Starting early is best. Acquiring 1 Atlantic St., Suite 604 • Blood markers like factor V Leiden, healthy habits in childhood, the early Stamford, CT 06901 lipoprotein(a), others teens, or young adulthood sets the stage 888-456-1222, ext. 31106 (toll-free) 203-653-6266 for a healthy adulthood and old age. But [email protected] man who weighed less than 5.5 pounds if you are tardy in joining the prevention Corporate sales and licensing at birth and whose father had a stroke party, it isn’t too late. Even small steps StayWell Consumer Health Publishing 1 Atlantic St., Suite 604 is far more likely to have a stroke in the now can improve your health. Stamford, CT 06901 next 10 years than a 45-year-old Asian [email protected] woman who weighed 8 pounds at birth Stroke warning signs Editorial correspondence and who has no family history of stroke. E-mail: [email protected] Letters Even though you can’t change these fac- : Harvard Heart Letter If you notice one or more of the signs 10 Shattuck St., 2nd Floor tors, they set your risk baseline. The Boston, MA 02115 higher it is, the more important it is to below in yourself or someone else, or you’re really worried that you or some- Permissions control the things you can change. Copyright Clearance Center, Inc. one you are with is having a stroke, call Modifiable risk factors are things that Online: www.copyright.com 911 or your local emergency number affect stroke risk over which you have right away: Published by Harvard Health Publications, some control. These range from high a division of Harvard Medical School • sudden numbness or weakness of the Editor in Chief blood pressure and diabetes to smoking Anthony L. Komaroff, MD face, arm, or leg, especially on one Publishing Director Edward Coburn and a salty diet. side of the body ©2011 Harvard University (ISSN 1051-5313) Many emerging risk factors are under investigation. These include migraine, • sudden confusion or trouble speak- Proceeds support the research efforts of Harvard Medical School. ing or understanding Harvard Health Publications obstructive sleep apnea (breath holding 10 Shattuck St., 2nd Floor, Boston, MA 02115 during sleep followed by explosive snor- • sudden trouble seeing in one or both The goal of the Harvard Heart Letter is to interpret eyes medical information for the general reader in a timely ing), gum disease, blood markers such as and accurate fashion. Its contents are not intended lipoprotein(a), and infection. • sudden problem with walking, loss of to provide personal medical advice, which should be obtained directly from a physician. We are interested balance, or coordination in comments and suggestions about the content; 11 strikes against stroke unfortunately, we cannot respond to all inquiries. • sudden, severe headache with no PUBLICATIONS MAIL AGREEMENT NO. 40906010 You can fight stroke on many fronts. A known cause. RETURN UNDELIVERABLE CANADIAN ADDRESSES TO: single thrust is good; a many-pronged at- CIRCULATION DEPT., 1415 JANETTE AVE., WINDSOR, ON N8X 1Z1 E-mail: [email protected] 2 | Harvard Heart Letter | March 2011 www.health.harvard.edu This Harvard Health Publication was prepared exclusively for ntavares - Purchased at http://www.health.harvard.edu/ Fish oil questioned as treatment for heart disease It may be okay for prevention. But eating fish is a better strategy than gulping pills. ish oil has been flying high as a erties of oily fish and fish oil in the 1940s These findings don’t mean fish oil supplement for the past few years. by suggesting they helped keep the Inuit is a complete flop. It may work against It has garnered a reputation as (Eskimo) people healthy in spite of their heart disease if started earlier, before Fan easy way to protect the heart, ease in- high-fat diet. Some long-term follow- cholesterol or high blood pressure flammation, improve mental health, and up studies, such as the Nurses’ Health damages coronary arteries. It could lengthen life. Such claims are one reason Study, showed that people who eat one (stress on “could”) fight other types of why Americans spend more than $1 bil- or more servings of fish a week are less cardiovascular disease or problems lion a year on over-the-counter fish oil, likely to have heart attacks or heart like depression. And it is a good treat- and why food companies are adding it rhythm problems or die from sudden ment for high triglycerides. But if you to milk, yogurt, cereal, chocolate, cook- cardiac arrest. A few randomized trials already have heart disease, taking fish ies, juice, and hundreds of other foods. in the 1990s that added fish or fish oil oil doesn’t seem to do much good. But as has happened with so many to the diet supported this notion. other supplements, fish oil may have So why do the results of the latest Eat fish hit its “Black Tuesday.” In a two-week trials tell a different story? The early Medical research tends to practice period at the end of November, reports trials were done before the widespread what philosophers of science call from four randomized controlled use of heart-protecting medications reductionism—trying to understand trials—the gold standard of medical such as statins, ACE inhibitors, aspirin, the nature of something complex (like research—showed that fish oil in one and beta blockers. Without them, fish nutrition and health) by reducing it to form or another didn’t work any better oil by itself could have made a differ- the interactions of its parts. Early stud- than placebo at preventing recurring ence. The use of state-of-the-art medi- ies showing that eating more fruits and heart problems among heart attack cal therapy in the four most recent tri- vegetables was good for health led to a survivors or people with atrial fibrilla- als could have drowned out any small focus on food components, such as fi- tion. (We’ve summarized the results of benefit provided by fish oil. ber, vitamins, and antioxidants. None these four trials below). Of course, it is also possible that the come close to offering the benefits of trials weren’t large enough or didn’t food itself. The same story appears to Flip-flop on benefits last long enough to have shown a be playing out with fish and fish oil. British physiologist Hugh Sinclair kin- benefit from fish oil. If that’s the case, If you have heart disease, taking fish dled interest in the heart-healthy prop- any benefit from fish oil is small. oil doesn’t seem to replace eating fish, says Dr. Robert H. Eckel, past president Latest fish oil trials of the American Heart Association and former member of its nutrition com- Omega-3s for atrial fibrillation: Men and women with occasional (paroxysmal) mittee. The benefit could be due to fish or continuous (persistent) atrial fibrillation (AF) took 4 grams per day of Lovaza, a oil in its natural state (in fish), some- prescription form of omega-3s, or a placebo for 24 weeks. Lovaza was no better thing else in fish, or maybe the fact that than placebo at suppressing new episodes of AF among people with paroxysmal eating fish means eating less red meat. AF, and was slightly worse than placebo for preventing AF symptoms in participants What if you just don’t like fish? Then with persistent AF (JAMA, Dec. 1, 2010). make sure your doctor has prescribed SU .FOL .OM3 trial: Among survivors of a heart attack or ischemic (clot-caused) the best medical therapy for your con- stroke, or those with unstable angina (chest pain at rest), taking 600 milligrams (mg) dition and you are following his or her of omega-3s a day for almost five years was no better than placebo at reducing nonfa- advice. That is far more important tal heart attacks, strokes, or deaths from cardiovascular disease (BMJ, Nov. 29, 2010). than taking fish oil. Alpha Omega trial: Daily use of a margarine made with an extra 400 mg of omega-3 And what about the American oils for more than three years was no better than the same margarine minus the added Heart Association’s recommendation omega-3 oils at preventing heart attack, stroke, the need for angioplasty or bypass sur- that people with documented coronary gery, or heart-related death (New England Journal of Medicine, Nov. 18, 2010). artery disease take in at least 1 gram of OMEGA trial: Among heart attack survivors, 1,000 mg of purified omega-3 oils a omega-3 fatty acids per day from oily day for one year was no better than olive oil at preventing sudden cardiac arrest, death, heart attack, stroke, or the need for bypass surgery or angioplasty (Circula- fish or a supplement? “I think the time tion, Nov. 23, 2010). has come to reconsider those guidelines,” says Dr. Eckel.

www.health.harvard.edu March 2011 | Harvard Heart Letter | 3 This Harvard Health Publication was prepared exclusively for ntavares - Purchased at http://www.health.harvard.edu/ Hybrid heart surgery expands options Collaborative approach aims to improve cardiac care. eart problems tend to come in eral anesthesia can now be done with can now be repaired using minimally clumps. Arteries clog. Valves minimally invasive techniques because invasive techniques. As the Heart Let- don’t open or close all the way. these operating rooms have the equip- ter reported a few months ago, one HThe heart’s rhythm becomes irregular. ment we need to convert to a standard example is aortic valve replacement, Many people face not one but two or operation should the need arise.” which is now being done with less in- more treatment decisions. Dr. Arvind Agnihotri, a cardiac sur- vasive surgery, or even with a nonsur- Just a few years ago, someone who geon at Harvard-affiliated Massachu- gical method similar to angioplasty. required multiple cardiac procedures setts General Hospital, sees another (This experimental approach, known might have had separate procedures advantage. “A hybrid operating room as transcatheter valve replacement, is done by specialists working in different allows us to go back still being evaluated parts of a hospital. In a catheter lab, a and forth between and is not yet widely cardiologist would insert a stent to re- open surgery and available.) Such mini open an artery. Later, in an operating image-guided pro- mally invasive ap- room, a cardiac surgeon would fix or cedures.” These view proaches require the replace a faulty valve. Hours might pass the heart from the sort of on-site, high- in between, involving transport from a inside using a flexible resolution digital sterile environment to an unsterile one wire called a catheter imaging equipment and back again. In some cases, the two that is inserted into a available in hybrid procedures might even require sepa- blood vessel. operating rooms. rate hospital visits. Arrhythmia ablation. One approach This fragmented approach to care is Hybrid scenarios to fixing a heart rhythm abnormality starting to change, thanks in part to a To get a sense of what this means for (arrhythmia) involves catheter abla- much-needed innovation in hospital someone needing several cardiac fixes, tion. This involves threading into the design: the hybrid operating room. By consider a few of the typical proce- heart a catheter tipped with an energy including all the equipment needed for dures that take place in a hybrid oper- source. The catheter is maneuvered diagnostic imaging, minimally invasive ating room. to destroy (ablate) the source of the procedures, and traditional surgery, it Stent/valve. A man goes to a hos- rogue impulses that are causing the ir- lets heart surgeons, cardiologists, elec- pital because of chest pain. Doctors regular heartbeat. Although this is usu- trophysiologists, and other specialists discover that he has both a partially ally a minimally invasive procedure, it work together in the same space, at the blocked right coronary artery and a can sometimes cause dangerously low same time. Specialists now travel to narrowed aortic valve (aortic valve blood pressure that requires temporary the patient, rather than the other way stenosis). In a hybrid operating room, support on a circulatory assist device. around. These high-tech operating a cardiologist inserts a stent to restore “Most of the procedures we do in suites make it possible for physicians blood flow in the blocked artery. Im- a hybrid operating room are cus- to treat higher-risk patients and to ex- mediately afterwards, a cardiac surgeon tomized for each individual,” says Dr. pand the treatment options available. replaces the faulty valve. Kamal Khabbaz, chief of cardiac sur- Hybrid cardiac surgery is mainly Combination revascularization. A gery at BIDMC. “Hybrid cardiac sur- available at academic medical centers woman has a partial blockage in one gery fosters a collaborative approach for now, but the trend is catching on. coronary artery and a complete block- that should reduce risk of complica- “Hybrid cardiac surgery is part of age in another. In this case, a combi- tions, shorten recovery times, and im- a larger effort to make interventions nation approach might work best to prove outcomes.” safer and less traumatic for the patient,” restore blood flow to the heart muscle. To know that for certain, research to says Dr. Peter Zimetbaum, director of A cardiologist inserts a stent into one evaluate the results of many hybrid pro- clinical cardiology at Harvard-affiliated coronary artery to open it up, then a cedures is needed. As with any major Beth Israel Deaconess Medical Center surgeon grafts a bypass vessel to let procedure, you may not want to be the (BIDMC) and a member of the Heart blood flow around the other blockage. first on the block for new hybrid proce- Letter editorial board. “Some proce- Minimally invasive procedures. dures. Make sure you ask your doctors dures that previously required large Many people have heart problems that how many times they’ve done it this incisions and long periods of gen- once required traditional surgery but way, and what their outcomes are.

4 | Harvard Heart Letter | March 2011 www.health.harvard.edu This Harvard Health Publication was prepared exclusively for ntavares - Purchased at http://www.health.harvard.edu/ Transfusion and heart surgery: Only when needed Unnecessary blood transfusion can do more harm than good. lood transfusion deserves a For years, doctors relied on a “30/10” cur during storage increase the likeli- prominent place in the pan- rule of thumb, ordering a transfusion hood that transfused blood will cause theon of medical advances. It if the hematocrit fell below 30% or inflammation or make blood vessels Bhas saved countless lives on the battle- the hemoglobin below 10 g/dL. A constrict. Stored red blood cells lose field and in hospital emergency depart- growing body of evidence is chal- their flexibility and can get stuck in ments. It is a life-prolonging treatment lenging the wisdom of this arbitrary capillaries, the tiny blood vessels that for people with conditions that prevent rule and suggesting that liberal use connect arteries and veins. A new the body from making blood or blood of transfusions may do more harm European study showed that mixing components, from kidney disease than good. stored blood with fresh blood acti- and cancer to disorders such In an eye-opening British study vates platelets, making them stick to- as hemophilia and sickle published in 2007, people who gether (European Heart Journal, Nov. cell anemia. But whether received a transfusion during 22, 2010). Sticky platelets can form the blood should be routinely or after heart surgery were six kind of blood clots that cause heart at- transfused during or after times more likely to have tacks and strokes. In addition, blood heart surgery is a question developed a complication from another person can trigger an that more and more people related to ischemia (insuf- immune reaction and inflammation. are asking. The answer is ficient oxygen delivery to These aren’t the kinds of stresses you tilting toward “no.” the tissues), such as heart want to add when the heart is more attack, stroke, kidney trouble, fragile than usual. Questioning 30/10 and even death, when compared with The theory behind transfusing blood those who did not get a transfusion. In Talking about transfusion during and after coronary artery by- a more recent clinical trial, individuals In some hospitals in the United States, pass grafting, heart valve repair or re- undergoing cardiac surgery were ran- more than 90% of people undergoing placement, aortic aneurysm repair, or domly allocated to one of two groups. coronary artery bypass grafting re- other cardiovascular surgery makes Those in the liberal transfusion group ceive a transfusion of red blood cells; perfect sense. Loss of blood during were given blood if their hematocrit in other hospitals, under 10% get one an operation depletes the number of dropped below 30%, while those in (JAMA, Oct. 13, 2010). This huge varia oxygen-delivering red blood cells in the restrictive group were given blood tion indicates that the transfusion de- circulation. That could mean less oxy- only when the hematocrit fell below cision is as much about a doctor’s gen available to tissues throughout the 24%. The restrictive strategy was just training and preferences as it is about body, especially to surgically trauma- as effective as the liberal strategy, and medical necessity. tized heart muscle. led to fewer deaths and complications Minimizing the need for transfu- Doctors measure the blood’s ability such as shock, breathing problems, or sion is not only possible, but safe to deliver oxygen in two ways: kidney failure (JAMA, Oct. 13, 2010). and effective. Working with Jehovah’s Hematocrit. Blood is made up Witnesses, whose religion does not of red blood cells, white blood cells, Your blood is best allow transfusion, surgeons have platelets, and plasma (the liquid com- Blood banks across the country collect, developed so-called bloodless surgery ponent). Hematocrit measures how store, and deliver more than 14 million programs. These aim to improve a much of the volume of whole blood is units of blood each year. They are used person’s hematocrit and hemoglobin made up of red blood cells. A normal by the five million or so Americans level before surgery, and then mini- hematocrit is typically set at 36% or who require transfusions. Blood banks mize blood loss and maximize blood higher for women and 40% or higher rigorously check blood to make sure it recovery during surgery. These strate- for men. isn’t carrying hepatitis C, HIV, or other gies are being used at hospitals across Hemoglobin. Hemoglobin is an infectious agents. What they can’t do the country to reduce the need for oxygen-carrying protein found in red is provide blood that is as good as transfusions among people who are blood cells. In women, a normal he- your blood. not Jehovah’s Witnesses who need moglobin level is 12 grams per deciliter Stored blood isn’t nearly as effective heart surgery. of blood (g/dL) or higher; in men, it is as fresh blood at delivering oxygen to There isn’t much you can do about 14 g/dL or higher. tissues. Chemical changes that oc- whether you get a transfusion during

www.health.harvard.edu March 2011 | Harvard Heart Letter | 5 This Harvard Health Publication was prepared exclusively for ntavares - Purchased at http://www.health.harvard.edu/ or after surgery—if your doctors think All three experts stressed that there before surgery and replacing it with you need one, you’ll get it. What you are definitely times when the benefits fluids called volume expanders. The can do is have a conversation about of transfusion during or after heart blood is held at your bedside and then transfusion beforehand, say doctors surgery far outweigh the risks. They given back to you during or after sur- at Harvard’s three main teaching hos- also agreed that transfusion should be gery to replace any blood lost during pitals who have given a lot of thought done only when medically necessary. the operation. This self-transfusion to transfusions: Dr. Adam B. Lerner, If your doctor thinks you are likely avoids the chance of acquiring an director of cardiac anesthesia at Beth to need a transfusion, ask if there infection from a donor, developing Israel Deaconess Medical Center; is anything you can do beforehand an immune response, or facing the Dr. Thomas E. MacGillivray, surgical to minimize the need for one. Also potential hazards of stored blood. director of the adult congenital heart ask what transfusion-sparing steps “In many parts of the world, blood is disease program at Massachusetts the surgical team will take during a precious resource,” says Dr. Deepak General Hospital; and Dr. James D. the operation. Bhatt, associate professor of medi- Rawn, director of the cardiac surgery One possibility is to capture lost cine at Harvard Medical School and intensive care unit at Brigham and blood and return it to the blood- chief of cardiology for the VA Boston Women’s Hospital. In this conversa- stream. Another possibility is a tech- Healthcare System. “It is time we tion, ask your surgeon how his or her nique known as acute normovolemic begin to view it the same way here, team decides who needs a transfusion, hemodilution. It involves taking one and be far more thoughtful about who or if there is a hospital policy. to three units of your blood right should get a transfusion.”

Heart beat

When stocks crash, heart attacks go up Eyelids as windows into the heart The country’s financial downturn has caused a lot of economic People who develop yellow bumps on their eyelids often visit a pain, usually measured in terms of lost jobs and home foreclo- dermatologist to get them removed. They may want to see a car- sures. It may be time to add a health dimension to the misery diologist as well. index, with heart attacks soaring as the stock market crashes Such a skin lesion is actually a cholesterol deposit known (American Journal of Cardiology, Dec. 1, 2010). medically as xanthelasma (ZAN-thuh-LAZ-muh)—derived from Researchers at Duke University reviewed medical records for the Greek word for yellow. (The plural is xanthelasmata. You can 11,590 people who had undergone testing for heart disease see what they look like at www.health.harvard.edu/166.) Xan- during a three-year period, and then compared monthly heart thelasmata are strikingly similar to the cholesterol deposits that attack rates with stock market levels. Heart attacks increased develop inside blood vessels and contribute to atherosclerosis. steadily during one eight-month period—September 2008 to This raises the question of whether the eyelids might provide a March 2009—that was particularly bad for the stock market diagnostic window into the heart. (see graph). A large study on this topic generated a lot of interest at the While you can’t control the stock market, you can take extra American Heart Association’s annual meeting. Danish research- precautions to protect your heart when the economy tanks. The ers found that folks diagnosed with xanthelasmata were 40% basics consist of a healthy diet, regular exercise, stress manage- more likely than their fellow Danes to develop heart disease—and ment, and taking medications as prescribed. Think of these life- 51% more likely to have a heart attack—even after the research- style habits as a long-term investment in your health. ers took established cardiac risk factors into account. In a sur- prise, half of the people who developed one or more xanthelasma 26 Heart attack rate Stock market had normal cholesterol levels, suggesting that these skin lesions 24 (Nasdaq-100) might indeed be an independent sign of heart disease. But this 22 preliminary research has to be confirmed before doctors will 20 know for sure. 18 It’s not clear why xanthelasmata develop on the skin. One theory is that cholesterol may leak into the skin from small blood 16 Nasdaq-100 vessels known as capillaries. Another is that the structure of skin 14 Heart attack rates/ and internal tissue somehow allows the seepage. 12 Until more is known, it’s best to be on the safe side. If you Sep Nov Jan Mar May Jul develop a xanthelasma, ask your doctor whether you should have ’08 ’08 ’09 ’09 ’09 ’09 your heart checked along with your skin.

6 | Harvard Heart Letter | March 2011 www.health.harvard.edu This Harvard Health Publication was prepared exclusively for ntavares - Purchased at http://www.health.harvard.edu/ Heart beat

Dual-chamber pacemaker helps heart failure A heart attack, high blood pressure, and other insults can therapy is an increase reshape the heart in ways that derail the “beat now” sig- in hospitalizations nals that are vital to a healthy heartbeat. The two lower due to problems with chambers, the right ventricle and left ventricle, should the devices. contract and relax together. In many people with heart This dual therapy failure, though, they don’t. This loss of synchronized isn’t for everyone squeezing costs the heart some of its pumping power. with heart failure. Pulse generator A biventricular pacemaker can fix this problem. It sends Instead, it could be carefully timed signals that make the right and left ventricle a good option for Leads contract and relax in unison. This is called cardiac resyn- those with moderate chronization therapy. Biventricular pacemakers were ini- to severe heart failure tially approved for people with severe heart failure. Greater who have a low ejec- experience with them will almost certainly broaden the tion fraction (a sign of imperiled pumping in the left ven- population of folks who could benefit from one. tricle) along with changes on an electrocardiogram that Results of an international trial suggest that combining a suggest the ventricles aren’t beating together (a wide QRS biventricular pacemaker with an implantable cardioverter- interval). And it definitely isn’t a replacement for medi- defibrillator (ICD)—a device that can shock the heart out cations, watching what you eat and drink, and balancing of a potentially lethal rhythm—helps prevent deaths from rest and exercise. But in combination with those strate- sudden cardiac arrest and hospitalizations for heart fail- gies, a biventricular pacemaker and an ICD can help you ure better than an ICD alone (New England Journal of feel better by keeping your heart in sync and help you live Medicine, Dec. 16, 2010). The downside of this double longer by halting potentially deadly rhythms.

Stay lean, live longer Rheumatoid arthritis should heighten For the past few years, the “obesity paradox” has been getting a heart awareness lot of attention. It began when several studies suggested that peo- Rheumatoid arthritis begins in the joints, but it doesn’t end there. ple who packed on the pounds with age lived longer than those The inflammation that causes swelling and pain in fingers, wrists, who stayed thin. But the research didn’t properly account for fac- knees, and other joints can also affect the heart. A large study tors such as cigarette smoking or an underlying serious illness from Sweden suggests that a new diagnosis of rheumatoid ar- that can trigger weight loss and contribute to an early demise. thritis should get you thinking about your heart, too. An analysis of studies that followed 1.5 million Americans In a group of 7,500 men and women with new rheumatoid over time may finally resolve the issue (New England Journal of arthritis whose health was followed for up to 12 years, more Medicine, Dec. 2, 2010). After excluding smokers and people people than expected had a heart attack, developed chest pain with underlying illnesses, the researchers found that the death with activity or stress (angina), or needed a procedure to open or rate across various age categories was lowest for people whose bypass a blocked heart artery within five years of their diagnosis body mass index (BMI*) was in the normal range (20 to 24.9), (Journal of Internal Medicine, December 2010). and then increased steadily with BMI. People who were morbidly This work emphasizes how important it is for everyone with obese (a BMI of 40 or greater) were 2.5 times more likely to rheumatoid arthritis, including those just learning they have it, have died during the study period than those who maintained a to focus on improving heart health while coping with their joint normal weight. Of interest to Heart Letter readers, cardiovascular problems. Although an arthritis-specific approach to warding off disease was the most common cause of death among people heart disease doesn’t yet exist, the basic steps for protecting the who were overweight or obese. heart and arteries are a great start: The study wasn’t perfect. It was based on white Americans, • exercise so the results may not apply to African Americans, Hispanics, or • follow a healthy diet other ethnic groups. Still, at a time when 68% of Americans are overweight or obese, this new study provides a reminder that it’s • manage your weight important to keep your weight within the healthy range, or work to • control your blood pressure and cholesterol. move it in that direction, to protect your heart and live longer. It’s possible that taking a baby aspirin or a cholesterol- * To calculate your BMI, multiply your weight in pounds by 703. Divide that lowering statin may be good options for people with rheumatoid number by your height in inches. Divide again by your height in inches. arthritis, but these and other drug-based strategies haven’t yet Or you can look it up at www.health.harvard.edu/bmi. been tested. www.health.harvard.edu March 2011 | Harvard Heart Letter | 7 This Harvard Health Publication was prepared exclusively for ntavares - Purchased at http://www.health.harvard.edu/ ASK THE Doctor

Why does my blood pressure rise in the afternoon? I am a 50-year-old woman with newly diagnosed need the beta blocker for some other cardiac condition, Q high blood pressure. As diets go, mine is definitely adding a diuretic or ACE inhibitor to the beta blocker on the healthy side. I do not exercise at a health club, makes sense. In fact, combining low doses of medica- but I do a lot of housecleaning and gardening, and I tions that fight high blood pressure in different ways is do walk a fair amount, which I feel is equal to what I probably a more effective way to do it than with a high would accomplish at a health club. I weigh 150 pounds dose of a single medication. and my height is 5 feet, 6 inches. I take Toprol-XL. My I commend you for staying active, but want to add blood pressure seems to be normal in the morning, av- that the more activity you get, the better. Your blood eraging 121/74, but in the afternoon the upper number pressure might fall, and cardiovascular health might is often in the 140s to 150s. Is it normal for blood pres- improve even more, if you regularly did some aerobic sure to rise like this as the day goes on, especially while exercise, like brisk walking. Your body mass index (a on a medication? measure of weight for height) is 24.2, putting you just in the healthy weight category. My guess is that if you It’s great that you are paying close attention to lost a few pounds and exercised more, it would help A your blood pressure readings. Beta blockers like your blood pressure, and you might not need any addi- metoprolol (Lopressor, Toprol-XL) are not great medi- tional medications. cations for lowering blood pressure when used all by themselves. So, as the day goes on, and you eat and ex- ert yourself physically, my guess is that the metoprolol is just not strong enough to control your blood pressure. Thomas Lee, M.D. One option is to switch to another medication, such as a Editor in Chief diuretic or an ACE inhibitor. If your doctor thinks you Harvard Heart Letter

Is high potassium a problem?

You have written about low potassium in the blood on to potassium. These include potassium-sparing Q and ways to improve it, but I never read about too diuretics such as spironolactone (Aldactone, generic) much potassium in the blood. Can you tell me why it and triamterene (Dyrenium, generic); ACE inhibitors; happens and what is done about it? angiotensin-receptor blockers (ARBs); and nonsteroidal anti-inflammatory drugs such as ibuprofen or naproxen. Relatively few people develop high levels of potas- Two other causes of high potassium include using a salt A sium in the blood, since the kidneys are normally substitute that contains potassium or taking a potas- quite effective in clearing this mineral from the blood- sium supplement. stream. A normal blood potassium measurement is 3.7 Treating high potassium depends on the severity to 5.2 milliequivalents per liter. and the cause. Severe hyperkalemia requires emergency High potassium or, as doctors call it, hyperkalemia, treatment, since too much potassium in the blood can can occur for several reasons. Problems with the cause lethal heart rhythm problems. Milder cases are kidneys, such as kidney failure or glomerulonephri- usually treated by halting medications that elevate potas- tis, can elevate potassium in the bloodstream. So can sium, adopting a low-potassium diet, and treating under- taking medications that cause the kidneys to hold lying conditions such as kidney or adrenal disease. –T.L.

Send us a question for Ask the Doctor Visit the Harvard Heart Letter blog online: Dr . Thomas Lee, Editor, Harvard Heart Letter http://www.health.harvard.edu/blog By mail: Harvard Heart Letter By e-mail: [email protected] 10 Shattuck St., 2nd Floor (Please write “Ask the doctor” in the Boston, MA 02115 subject line.) Because of the volume of correspondence we receive, we can’t answer every question, nor can we provide 8 | Harvard Heart Letter | March 2011 personal medical advice. This Harvard Health Publication was prepared exclusively for ntavares - Purchased at http://www.health.harvard.edu/