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Stroke

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New Developments in Hormone Replacement Therapy

In July 2002, the government halted a major study of hormone therapy three years early because of a slight but significant increase in the risk of invasive breast cancer. Researchers concluded that the long-term risks of taking hormones outweigh the benefits for a woman who still has her uterus.

More than 16,000 women took part in the study, known as the Women's Health Initiative, the largest to compare postmenopausal hormones with a placebo. The therapy was a combination of estrogen and progestin (Prempro), a treatment used by an estimated six million women to replace the declining levels of hormones at menopause.

The study sought to determine whether this combination hormone therapy could prevent such ailments as osteoporosis and heart disease. But while there were small decreases in hip fractures and colorectal cancer, the increases in breast cancer, heart attacks, strokes, and blood clots were too unsettling.

The data suggested that for every 10,000 women on the estrogen-progestin combination, an additional 8 will develop invasive breast cancer, when compared with women not taking the therapy. An additional 7 will have cardiovascular disease, 8 will have a stroke, and 8 will have blood clots in the lungs (pulmonary embolism).

In the aftermath of the trial, it seems that many doctors will be reconsidering prescribing estrogen and progestin. Some women may want to lower their doses or limit the duration of the use of these combinations, while others will elect to try other treatments to combat their hot flashes, vaginal dryness, and other menopausal symptoms.

However, it is important for women already on hormone replacement therapy (HRT) to know that there is no urgency to stop, and waiting until an annual exam to discuss it with a doctor is fine. There is also no harm in stopping immediately, if a woman is more comfortable doing so.

It's important to remember that only combination therapy appears to have these effects. Estrogen alone taken by women who have had a hysterectomy has not displayed such risks. A separate trial, with 10,000 women who have had a hysterectomy randomly assigned to either estrogen or a placebo, has not indicated an increased breast cancer risk. The trial is scheduled to go until 2005.

The full report on the Women's Health Initiative appeared in the Journal of the American Medical Association on July 17, 2002.

July 2002 Update

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New guidelines for stroke prevention

With more than 700,000 Americans having strokes each year, doctors and patients need to focus on stroke prevention. In light of this, the American Heart Association (AHA) has issued a statement that details how to identify and modify risk factors. Here are the AHA's tips, along with other general guidelines for lowering stroke risk:

Blood pressure. You should get your blood pressure checked at least every two years because many people with high blood pressure don't even know they have it (130–139 mm Hg systolic pressure over 85–89 diastolic pressure is considered high-normal, while anything above 140 over 90 is considered high). If you have high blood pressure, the following lifestyle changes can help lower it:

  • Eat more fruits and vegetables. Potassium-rich foods like bananas and oranges may be especially good.
  • Pass on salt. Salt makes the body hold onto water, and the heart has to work harder to pump the extra fluid.
  • Lose weight. The heavier you are, the harder your heart has to work to pump blood to all parts of your body.
  • Exercise. Even if you don't need to lose weight, exercise can reduce high blood pressure and may even prevent it.
  • Limit your alcohol. Having more than two alcoholic drinks a day significantly increases your risk of high blood pressure.
  • Quit smoking. Smoking increases your risk of heart attack, as well as many other diseases. And if you live with a smoker, make sure he or she quenches his cravings outside. Exposure to secondhand smoke can double your risk of stroke.
  • Learn to relax. Various kinds of behavioral therapy, like biofeedback, yoga, and tai chi may lower blood pressure.

These lifestyle changes can also help with other causes of stroke, like
atherosclerosis (hardening of the arteries) and high cholesterol. If the changes don't lower your blood pressure, your doctor may prescribe a medication such as a diuretic or beta blocker.

Other conditions. The AHA recommends that patients with diabetes and children with sickle cell disease closely monitor their blood pressure with screenings every six months.

Non-modifiable risk factors. Black, Hispanic, Chinese, and Japanese people are at increased risk for stroke compared to whites. Men and postmenopausal women are also at higher risks than others. If one of your parents had a stroke, you are at greater risk as well, either because of genetics or shared lifestyle traits.

While you can't do anything about non-modifiable risk factors it's helpful to know if you fall into a high-risk group so you can carefully monitor controllable factors.

July 2002 Update

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Blood Pressure Medication May Affect Stroke Risk

Your choice of high blood pressure medication may affect your risk of stroke. Research published in the March 23, 2002, issue of The Lancet comparing the effectiveness of two high blood pressure is the first with solid evidence showing the importance of how we treat high blood pressure.

In the trial, called the LIFE study, researchers compared the number of strokes, heart attacks, and deaths due to cardiovascular events in over 9,000 patients taking either losartan or atenolol.

According to the results, both losartan and atenolol decreased blood pressure effectively, but patients who took losartan had a 25% lower risk of stroke than patients taking atenolol. In an accompanying study, researchers found similar results in patients with diabetes and high blood pressure.

Researchers believe the difference in effectiveness may be a result of the mechanisms by which each drugs works. Losartan belongs to a newer class of drugs, called angiotensin II receptor blockers (ARBs). ARBs lower blood pressure by preventing the smooth muscles of the arteries from contracting. Atenolol, on the other hand, is a beta-blocker and works to lower blood pressure by blocking substances that would otherwise speed up the heart and increase the pressure at which it pumps blood.

Results of the LIFE study also showed that losartan provided benefits beyond lowering blood pressure and reducing cardiovascular events. Patients on this drug had a 25% lower incidence of new-onset diabetes compared to patients on atenolol. In addition, patients in the losartan group were less likely to discontinue the drug due to side effects than were patients in the atenolol group.

Based on these findings, losartan or another ARB may quickly become a vital part of the first line of treatment for high blood pressure. Up until now, treatment with a beta-blocker, such as atenolol, and a diuretic has been regarded as the best intervention. The results of an upcoming National Institutes of Health study (due out in December) comparing a larger array of high blood pressure medications may shed even more light on the subject.

June 2002 Update

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White-Coat Hypertension

Most people feel a bit anxious during a doctor's visit. But for some people, their anxiety causes temporary high blood pressure, detectable during the time of the visit. Physicians have been debating whether or not they should treat this phenomenon, referred to as "white-coat" hypertension. Some believe the short-lived blood pressure elevation is harmless, while others believe it should be treated like persistent high blood pressure.

In a recent study, researchers compared changes in the heart's function and size among people with persistent, untreated high blood pressure, "white coat" high blood pressure, and normal blood pressure. Participants were carefully matched by age, sex, and weight, as well as in-clinic and out-of- clinic blood pressures. Results of the study show participants with "white coat" hypertension, when compared to participants with normal blood pressure, had thicker walls in portions of their hearts, increased heart mass, and alterations in the diastolic (relaxing) portion of the heartbeat. Those people with persistent high blood pressure had even greater changes in the heart. These findings suggest "white coat" hypertension, while a temporary condition, may cause damage to the heart. This study reinforces the argument for treating "white coat" hypertension.

If you experience this condition, you should consult your doctor about treatment options. Simple lifestyle changes may be all you need or medication might be necessary. In any case, the possible benefits will outweigh the risks.
January 2002 Update

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High-Normal Blood Pressure Bad for the Heart

People with high-normal blood pressure are more likely to suffer a heart attack, stroke, or heart failure than those with lower blood pressure, according to recent findings from the Framingham Heart Study.

The researchers followed the cardiovascular events of 6,859 participants of the famed study, which has been monitoring subjects from the Boston suburb for more than 50 years. A third of participants had normal blood pressure (120–129 over 80-84 mm HG), a quarter had high-normal (130–139 over 85–89 mm Hg), and the remainder had optimal blood pressure (less than 120 over less than 80 mm HG). People with high blood pressure were excluded from the study.

Of those in the optimal category, 81 had cardiac events, over a ten-year time period, compared to 136 people in the normal blood pressure category and 180 in high-normal category. In all, people with high-normal blood pressure were two to three times more likely to suffer a heart attack, stroke, or heart failure than those with lower blood pressure. This held true in both men and women, and was consistent in both age groups (35 to 64 and 65 and over), even after researchers adjusted for other cardiovascular risk factors such as smoking and obesity. Indeed, the study found risk increases in a stepwise fashion as blood pressure increases.

Blood pressure reflects how hard your heart is working and what conditions your arteries are in. Risk factors include heavy drinking, smoking, eating a diet high in salt, obesity, and family history. Doctors generally get alarmed only if systolic blood pressure is above 140 mm Hg or if diastolic blood pressure is above 90 mm Hg. However, this study calls for further research to be done to see if patients in the high-normal group benefit from lowering their blood pressure.
December 2001 Update

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Salt Restriction More Potent Than Exercise

Physicians often give patients with hypertension a daunting list of lifestyle changes to help lower their blood pressure: lose weight, exercise more, eat less salt, drink less alcohol, eat more foods rich in calcium, potassium, and magnesium. Of course, these changes do work — people who follow them can reduce their need for medications or even do without blood pressure-lowering drugs. But which of these lifestyle changes gives you the biggest bang for your buck?

University of Colorado researchers recently compared the impact of exercise or moderate salt restriction in 35 healthy older women with high-normal blood pressure or mild hypertension (systolic blood pressure 130–159 mm Hg), none of whom were using drugs to lower their blood pressure. Half the women exercised for three months — starting at 30 minutes a day three or four times a week and working up to 45 minutes a day every day, if possible. The other half tried to reduce their daily salt intake to less than 2.4 grams of sodium (the amount in a level teaspoon of table salt) without otherwise changing their diets. All were asked to try to avoid gaining or losing weight.

The clear winner, reported in the American Journal of Cardiology, was sodium restriction. Among the women who ate less salt, average systolic blood pressures fell 16 mm Hg, compared with a still-respectable 5 mm Hg in the exercise group. By the study's end of the study, systolic blood pressure was lower in 88% of the women who ate less salt and in 55% of the exercisers.

So if you're trying to lower your blood pressure, should you just forget about exercise and work harder at eating less salt? No. Exercise has other benefits besides lowering blood pressure — it can help control weight, improve the cholesterol profile, stave off diabetes, and keep bones strong. The real message from this study is that everyone should exercise, but that people who are trying to control blood pressure should lower their sodium intake, too.
December 2001 Update

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Statins Associated With Lower Dementia Risk

Most people who develop dementia - poor memory and intellectual functioning that often accompanies old age - have Alzheimer's disease. But a small, yet sizable group of people appear to develop dementia from a narrowing of the arteries supplying the brain. The lack of blood can lead to many small areas of damage to the brain; each too small to be noticeable as a "stroke," but collectively devastating in their effect. This syndrome is called "vascular dementia" to differentiate it from Alzheimer's disease and other types of dementia.

Presumably because high cholesterol levels contribute to the damage of brain's blood vessels, researchers have looked for evidence that people who use statins might have a lower rate of dementia. Statins are the most widely used cholesterol-lowering drugs. In addition to protecting the brain's arteries from atherosclerosis, some scientists believe statins may also help protect the brain against non-vascular forms of dementia, including Alzheimer's disease.

A recent study examined the relationship between statin use and types of dementia among people living in the United Kingdom. The researchers identified 284 people with dementia, and matched them with 1,080 "control" subjects of similar age and sex, but without dementia. After adjusting statistically for a wide range of clinical information, the researchers found statin use was associated with a 71% reduction in dementia risk.

Could statins really cut the risk for dementia by two-thirds or more? It seems unlikely, since other studies haven't suggested protective effects of this size. On the other hand, this study adds to several other laboratory and epidemiological investigations that suggest statins might provide some benefit in the protecting the brain - if for no other reason than lower cholesterol levels lead to healthier brain arteries. No one should start taking statins as a strategy for preventing dementia, but these data do provide another reason for people with elevated cholesterol levels who are on these medications to be sure they take them as prescribed.
October 2001 Update

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Study Shows Fish Consumption Protects Against Stroke, But FDA Suggests Pregnant Women Should Take Caution

A large study in the Journal of the American Medical Association (JAMA) recently showed that regularly eating fish might protect against ischemic stroke, which is the most common type of stroke. Numerous studies have already shown an association between fish consumption and a reduced risk of heart disease. But there is a caveat. The Food and Drug Administration (FDA) recently warned that pregnant women and women who are of childbearing age who may become pregnant, should avoid certain types of fish that contain high levels of mercury, which may be harmful to their unborn children.

Results of the Nurses' Health Study, published in the JAMA article, involved nearly 80,000 women. It showed that women who ate fish two to four times a week had a 48% lower risk of ischemic stroke — the kind caused by blood clots — than women who ate fish less than once per month. Even women who ate fish only once a week or less had a risk reduction, but it was not statistically significant. These results held true primarily among women who did not regularly take aspirin, which prevents the formation of blood clots. Omega-3 fatty acids, the protective substances found in fish, reduce levels of fats related to cardiovascular disease and help prevent blood clotting. Dark, oily fish such as mackerel, salmon, and sardines are a good source of omega-3 fatty acids.

Although pregnant women need not give up fish — and its beneficial health effects — altogether, they should be careful about what types of fish they eat. The FDA has advised that pregnant women and those who may become pregnant stop eating shark, swordfish, king mackerel, and tilefish. These large, long-living fish contain hazardous levels of methyl mercury, a form of mercury that can accumulate in a woman's body and affect the developing central nervous system of an unborn child. This can lead to babies with slower cognitive development. As an extra precaution, the FDA advised that nursing mothers and young children also avoid these fish. Mercury gets into both fresh and salt water through industrial pollution.

Some critics feel the FDA's mercury warnings are not strong enough. A report by the National Academy of Sciences suggested the exposure limits for mercury should be four times stricter.

While this controversy remains unresolved, the FDA encouraged pregnant women to continue to eat a variety of other fish, containing very low levels of mercury, as part of a balanced diet. Among other health benefits, the fatty acids in fish enhance brain development. According to the FDA, women can safely eat up to 12 ounces of fish per week. Fish that contain low levels of mercury include shellfish, canned fish, smaller ocean fish, and farm-raised fish. Women who eat fish caught by family or friends should contact their local health department for advice on the safety of fish from local waters.
May 2001 Update

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Products Containing Phenylpropanolamine (PPA) Pulled From Shelves

Responding to concerns that phenylpropanolamine (PPA), an ingredient found in many over-the-counter medications, may increase risk of hemorrhagic stroke (see the Family Health Guide online update on phenylpropanolamine), the U.S. Food and Drug Administration has asked manufacturers to remove drugs containing PPA from the market. The following list may not be complete and does not include drug store and supermarket brands, so please check the label or ask your pharmacist. You should also discard any items in your medicine cabinet that contain PPA.

Drugs Pulled From the Market:
Acutrim Diet Gum Appetite Suppressant Plus Dietary Supplements
Acutrim Maximum Strength Appetite Control
Alka-Seltzer Plus Children's Cold Medicine Effervescent
Alka-Seltzer Plus Cold Medicine (cherry or orange flavor)
Alka-Seltzer Plus Cold Medicine Original
Alka-Seltzer Plus Cold & Cough Medicine Effervescent
Alka-Seltzer Plus Cold & Flu Medicine Effervescent
Alka-Seltzer Plus Cold & Sinus Effervescent
Alka-Seltzer Plus Night Time Cold Medicine Effervescent
BC Allergy Sinus Cold Powder
BC Sinus Cold Powder
Comtrex Deep Chest Cold & Congestion Relief
Comtrex Flu Therapy & Fever Relief Day & Night
Contac 12 Hour Cold Capsules
Contac 12 Hour Cold Caplets
Coricidin D Cold, Flu & Sinus
Dexatrim Caffeine Free
Dexatrim Extended Duration
Dexatrim Gelcaps, Dexatrim Vitamin C / Caffeine Free
Dimetapp Cold & Allergy Chewable Tablets
Dimetapp Cold & Cough Liqui-Gels
Dimetapp DM Cold & Cough Elixir
Dimetapp Elixir
Dimetapp 4-Hour Liqui-Gels
Dimetapp 4-Hour Tablets
Dimetapp 12-Hour Extentabs Tablets
Naldecon DX Pediatric Drops
Permathene Mega-16
Robitussin CF
Tavist-D 12 Hour Relief of Sinus & Nasal Congestion
Triaminic DM Cough Relief
Triaminic Expectorant Chest & Head Congestion
Triaminic Syrup Cold & Allergy
Triaminic Triaminicol Cold & Cough
January 2001 Update

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Subarachnoid Hemorrhages Run in Families

Roughly one in 10,000 people experience subarachnoid hemorrhages (bleeding onto the surface of the brain). This condition often affects individuals in their 30s through 60s without warning. Subarachnoid hemorrhages are life-threatening: about a third of people who suffer such hemorrhages die. Of those who survive, more than half have major neurological deficits.

Very little can be done to prevent a hemorrhage, but it helps to know your family history. A Danish research team has concluded that first-degree relatives (parents, children, siblings) of people who've suffered subarachnoid hemorrhages are more likely to have one themselves. The researchers identified 9,367 patients admitted to the hospital for the first time with subarachnoid hemorrhages during the study period. They were able to identify nearly 15,000 first-degree relatives for 6,175 of the cases. When they compared discharge data, the team found that these relatives had a threefold risk of developing the condition compared with the general population.

Although past studies had reached similar conclusions, selection and recall bias may have skewed the results. Here, the researchers reduced selection bias and used national registries rather than asking patients for information.

To learn more about subarachnoid hemorrhages, see page 350 of the Family Health Guide.

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Combining Forces to Prevent Strokes

The U.S. Food and Drug Administration recently approved a new combined medication that helps prevent a full-blown stroke in people who have had transient ischemic attacks, (TIAs), or "mini-strokes" due to blood clots in the brain. It also helps prevent a second stroke in patients who have already had one ischemic (blood-clot related) stroke.

The new drug combines aspirin with another antiplatelet drug, dipyridaimole (Aggrenox). (Antiplatelet drugs reduce blood clotting.) Research shows that the combination works better than either drug alone and certainly better than a placebo. A 24-month study evaluated aspirin alone, dipyridimole alone, the combination drug, and placebo in 6,602 patients with a history of either mini-stroke or stroke. The combination reduced stroke risk by 36.8% when compared with placebo, 22.1% when compared with aspirin alone, and 24.4% when compared with dipyridimole alone. The most common side effects included headache and upset stomach, and the combined drug carried a higher risk of bleeding than either drug alone or placebo.

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Aspirin for Preventing Stroke and Other Vascular Problems

An aspirin a day keeps a stroke away in patients with a history of heart disease, but a recent review in Archives of Neurology reveals the drug’s stroke-preventing properties may not extend to healthy people.

Researchers from the University of Texas Health Science Center and three other institutions have concluded aspirin does not reduce the risk of stroke in people without heart disease. Indeed, their results suggest regular aspirin use might even slightly increase the risk in people at low risk for vascular problems. These conclusions were reached after the investigators performed a meta-analysis on five existing studies examining the preventive effects of aspirin. (A meta-analysis is a mathematical method used to compare the results of similar studies.) The researchers also reviewed four large observational studies that looked at regular aspirin use and stroke risk in low-risk individuals.

The five trials used in the meta-analysis involved a total of 52,251 participants with a mean age of 57 years. Three of the studies excluded women, though women accounted for roughly 20% of the total number of patients. Three studies used people at high risk for vascular disease, such as those with high blood pressure or diabetes, while the other two used healthy males at low risk. Dosage varied from 75 mg to 650 mg per day. The mean rate of stroke was 0.3% per year during an average study period of five years.

The meta-analysis found no significant risk reduction for patients taking aspirin compared with those taking a placebo. In contrast, the participants still enjoyed a 26% decrease in heart attack risk.

The researchers' review of four observational studies found aspirin modestly increases the risk of bleeding into the brain in low-risk patients — such bleeding can cause hemorrhagic stroke. However, hemorrhagic stroke accounts for only 10-15% of all strokes. Most strokes are ischemic, meaning they are caused by a temporary interruption in the blood flow to brain. When the four studies were pooled, no significant increase in risk of ischemic stroke was apparent.

The researchers stress that more information is needed before guidelines regarding stroke risk and aspirin use can be generalized. Certainly, people with a history of heart disease or whose risk of a heart attack eclipses their risk of stroke can benefit from aspirin. However, the majority of the subjects in the reviewed studies were middle-aged males. Men in this age group are more likely to suffer heart attacks, not strokes. Women and the healthy elderly were underrepresented, yet they are more prone to strokes rather than heart attacks. As a result, it’s still unclear whether anyone with a low risk of heart problems should be regularly taking aspirin.

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Phenylpropanolamine Safety Concerns

A recently released study reports that use of phenylpropanolamine (PPA) — an ingredient in many over-the-counter medications — is associated with an increased risk of hemorrhagic stroke (stroke caused by bleeding into the brain). Phenylpropanolamine causes blood vessels to contract, which can help relieve nasal congestion. It also stimulates the central nervous system, thereby acting as an appetite suppressant. Many cold and allergy products (for example, Contac, Sudafed, and Robitussin-CF) and diet aids (Acutrim, Dexatrim) contain PPA.

Over the past 20 years, more than 30 published case reports have linked PPA intake with bleeding in the brain. One of the earliest reports concerned a diet pill (which is no longer available) that contained both PPA and caffeine. The report’s authors concluded that PPA might cause brain bleeding more often than believed and may trigger episodes of high blood pressure. Later reports implicated products that contained only PPA. Most of these were related to PPA in diet pills, although at least five involved PPA found in cold remedies.

An epidemiological study of PPA and stroke was published in 1984. This research looked at the number of cerebral hemorrhages that occurred among HMO patients who had filled a prescription for phenylpropanolamine between 1977 and 1981. This analysis concluded that PPA users were no more likely to experience bleeding in the brain than people who hadn’t used PPA. Yet, the FDA and the manufacturers of products containing PPA agreed that more study was needed. In 1992, they commissioned the Hemorrhagic Stroke Project (HSP) in which investigators compared 702 individuals who had experienced a brain hemorrhage with 1,376 control subjects. The study volunteers included men and women ages 18-49 years old.

After researchers adjusted for the impact of race, history of high blood pressure, cigarette smoking, and educational level, they found users of cold-remedies or diet pills containing PPA were 49% more likely to have a hemorrhagic stroke when compared to individuals who had not taken PPA. Users of PPA in cold medicines (but not diet pills) had a 23% higher risk of hemorrhagic stroke when compared to non-users.

PPA consumed in diet pills increased that risk substantially, however, being 15 times greater for users than nonusers — even after statistical adjustments. For women, the association between PPA in appetite suppressants and hemorrhagic stroke was 17 times higher (after statistical adjustment) for users versus nonusers. For first dose PPA users, the statistically adjusted risk for brain bleeding was three times greater than for controls.

Study investigators also observed that bleeding in the brain was more likely to occur in people who took greater than the median dose (75 mg). Interestingly, when compared to control subjects, case subjects were significantly more likely to have other risk factors for hemorrhagic stroke. For example, they were nearly twice as likely to have a history of high blood pressure, a family history of hemorrhagic stroke, heavy alcohol use, and were also more likely to report cocaine use. The PPA users were more likely to have taken aspirin (which may raise hemorrhagic stroke risk) and more than twice as likely than controls to have consumed caffeine and more than 10 times as likely to have had recent nicotine exposure. Like PPA, caffeine and nicotine also constrict blood vessels, perhaps exaggerating this effect and contributing to bleeding risk.

Certainly, this research strongly suggests that taking PPA in diet pills might increase hemorrhagic stroke risk. Because weight loss achieved through the use of these drugs is not apt to be healthy or long lasting, there is little to justify the apparent increased risk of using PPA-containing diet pills. The associated risk for stroke with PPA use in cold medicines is not as dramatic, yet these data are a sobering reminder to take seriously the directions and warnings on products containing PPA. Specifically, people with heart disease and high blood pressure should not take PPA without consulting their doctors. Individuals who take monoamine oxidase inhibitors (used for depression, psychiatric or emotional conditions, and Parkinson’s disease) — or who have stopped taking them only within the last two weeks — also should not take products containing PPA until they clear it with their physicians. Finally, these data bring home the message that over-the-counter drugs are drugs, and like prescription medications, they come with potential risks and side effects.

Right now it is uncertain whether the FDA will vote to restrict medications with PPA to prescription-only status, but it is taking these results under advisement.

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Ramipril for Diabetics with Heart Disease

The incidence of heart disease in the general population has been dropping. This is good news of course, but for individuals with diabetes, the statistics are not so promising. In fact, men with type 2 diabetes have experienced only a modest decline in heart disease rates, while women with diabetes have actually experienced an increase.

Heart disease accounts for 70% of deaths in people with diabetes. So, the outcome of a recent study, which demonstrated that the angiotensin-converting enzyme (ACE) inhibitor, ramipril, significantly lowered the incidence of heart disease, stroke, and death in people with diabetes who had a history of heart disease and hypertension, should be welcome news.

The Heart Outcomes Prevention Evaluation (HOPE) study included people with and without diabetes. More than one third of the participants had diabetes. Of the participants with diabetes, the average age was a little over 65 years old, and one third were women. All had a history of heart disease and half had a history of high blood pressure as well. All study volunteers were randomly assigned to either ramipril or a placebo. While ramipril did not lower the blood pressure of participants much — as it was originally intended to do — it did lower their risk for heart attack by 22%, their risk for heart disease by 37%, and their risk for stroke by 33%. Other studies conducted to evaluate the effects of ACE inhibitors on blood pressure in people with diabetes have had similar outcomes.
October 2000 Update

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