The Harvard Medical School Family Health Guide
Heart, Blood Vessels, and Circulation
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Diseases of the Heart Muscle and Lining

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Fish for Good Health

In April, three studies delivered powerful evidence that fish is good for you — and could even save your life. The key is omega-3 (or n-3) fatty acids, beneficial polyunsaturated fats provided by many kinds of fish and certain plant foods.

Researchers in the Nurses' Health Study examined 16 years of data involving almost 85,000 women and found an association between fish intake and a lower risk for heart disease and death. Women who ate fish just once a week had a heart attack risk 29% lower than those who ate it less than once a month. Women who ate fish five times a week had nearly half the risk of death from a heart attack.

The Harvard's Physicians' Health Study, which involves more than 22,000 male doctors who initially had no heart disease, analyzed blood levels of omega-3 fatty acids and risk for sudden cardiac death. Researchers found that such deaths were 81% less likely in men with the highest levels of omega-3s. Over half of such deaths occur in people without prior symptoms of heart disease — a compelling reason for adding more fish to your diet.

Finally, Italian researchers reported that heart attack survivors who took fish-oil supplements had a lower risk of sudden death. This trial studied omega-3 fatty acids and vitamin E in 11,000 men and women who had recently suffered heart attacks. Researchers found that 1 gram of omega-3 fatty acids daily reduced the risk for sudden coronary death by up to 42%. This benefit apparently reflects their calming effect on arrhythmias, potentially fatal heartbeat irregularities. Omega-3 fatty acids may also inhibit clotting and improve blood vessel function. The American Heart Association recommends four servings of fish per week but doesn't endorse supplements because of too few data on the subject.

May 2002 Update

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Periodontitis and Heart Disease

The question of whether gum disease is associated with heart disease is controversial. The first research to suggest a connection, published in 1989, found that even after controlling for such cardiovascular disease risk factors as smoking and diabetes, heart-attack patients had significantly worse dental health than control subjects. Since then, several studies have also suggested a link, but the nature of the relationship — is it causative or coincidental? — remains in question.

In 2001, researchers sought an answer to this question, examining data from 4,027 people who participated in the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. During 17 years of follow-up, there were 1,238 cases of heart disease, 538 of which proved fatal. The rate of heart disease was three times higher in those with periodontitis than in those with healthy gums.

However, the connection became less prominent once investigators adjusted the numbers to account for other risk factors for cardiovascular disease — smoking, cholesterol levels, high blood pressure, and diabetes. After this adjustment, the heart disease risk among people with and without chronic dental infections was similar.

In fact, even those people who had eliminated any potential of dental infection through extraction of all teeth didn't have a lower heart disease risk when compared to those diagnosed with periodontitis (inflammation of the gums). The risk of developing CHD didn't decrease over time among those with no dental infections or increase over time among people with periodontitis.

A higher rate of other heart-disease risk factors among people with periodontitis might explain this relationship between gum disease and heart disease. For example, those with periodontitis were more likely to have high blood pressure and diabetes, and to smoke cigarettes.

These findings support the theory that the presence of periodontitis may occur coincidentally with increased cardiovascular risk but it is not its cause.
March 2002 Update

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Side Effect Warning for New Rheumatoid Arthritis Drug, Remicade (Infliximab)

All drugs have side effects, but some of them don't become apparent until after the drugs have been approved and in use for some time.

Remicade (infliximab), a powerful new drug for rheumatoid arthritis, has been found to worsen congestive heart failure. The drug was actually being tested to see if it would help patients with congestive heart failure. Instead, the opposite was seen in a trial involving 150 people with moderate to severe congestive heart failure. Of the 101 subjects treated with Remicade, 7 died. In contrast, no fatalities occurred in the 49 patients being treated with the sugar pill placebo.

Some 2 million Americans suffer from rheumatoid arthritis, while 5 million have congestive heart failure. So an undetermined number must have both illnesses. As a result, Centocor, the company making Remicade, after consultation with the U.S. Food and Drug Administration, has sent letters to doctors urging that patients with both rheumatoid arthritis and congestive heart failure not be treated with their drug.
November 2001 Update

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More Encouraging Data on Alcohol and the Heart

Having a drink or two per day lowers your risk heart disease and stroke. Little surprise then that two new studies report people who drink alcohol also have lower risk of developing heart failure and better outcomes if they have heart attacks. The studies were reported in a recent issue of the Journal of the American Medical Association.

The first study involved 1913 adults who were admitted to 45 different U.S. hospitals between August 1989 and September 1994 for heart attacks. The researchers, who were based at Harvard Medical School and Harvard School of Public Health, interviewed the patients an average of 4 days after their heart attacks, inquiring about a range of issues including their alcohol consumption.

About half (47%) reported they didn't drink alcohol during the year before their heart attacks. Another 36% said they drank fewer than 7 drinks per week. The remainder (17%) said they had 7 or more drinks per week. Those who drank the most were younger, and more likely to be male, current or former cigarette smokers, and have physically active life styles.

Survival rates were lowest for those who did not drink at all before their heart attacks and best for those who drank 7 or more drinks per week. For every 100 people, 6.3 of the abstainers died each year, compared with 3.4 of those who drink 1-6 drinks per week and 2.4 of those drank 7 or more drinks.

Heart failure

The second study was based on 2,235 elderly people (average age 74 years) who participated in a long-term epidemiological survey in New Haven, CT. None of the subjects had heart failure at the time of enrollment in the study in 1982. And the researchers excluded heavy drinkers (those drinking more than four drinks per day).

Half of the subjects reported no alcohol consumption in the month before enrollment, while 40% reported consumption of 1-20 ounces (up to 1 or 1.5 drinks per day), and 10% reported drinking 21 to 70 ounces (about 1.5 to 4 drinks per day).

During the next 14 years, 281 people developed heart failure, including 28 fatalities. The rates of heart failure for every 1000 people per year were 16.1 for abstainers; 12.2 for those who drank 1-1.5 drinks per day; and 9.2 for those who drank more heavily. Statistical analyses that adjusted for other differences among these groups concluded that light drinking reduced one's risk for heart failure by 19%, and moderate or heavy drinking reduced the risk by 53%.

Because moderate drinking can easily progress to problem drinking, no experts feel comfortable in encouraging nondrinkers to take up alcohol for medical reasons. However, researchers are debating whether some people who have given up alcohol might be encouraged to resume it. Future research may also define certain subgroups who can benefit most from alcohol, perhaps by raising their HDL cholesterol.
September 2001 Update

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An Old Drug Offers New Benefits for Heart Failure

While many exciting innovations in treating disease can be found in new and better medications, every now and then an old drug is rediscovered and found to have benefits in treating conditions other than those for which it was originally intended. Recently, a major study found that spironolactone (Aldactone), commonly prescribed to help reduce the abdominal fluid buildup that often occurs in severe liver disease, also helps people with heart failure feel better and live longer. This research trial began in March 1995 and was to continue until the end of 1999. However, in August 1998, the researchers stopped the study because spironolactone proved too beneficial to withhold from patients.

The Randomized Aldactone Evaluation Study (RALES) enrolled 1,663 patients whose activities were quite limited due to symptoms of heart failure. For example, they all experienced shortness of breath with mild or no exertion, and their hearts pumped significantly less blood than normal. All the study volunteers were taking ACE inhibitors and diuretics for their heart failure. None of them had kidney problems or high potassium levels.

Researchers randomly assigned patients to receive either spironolactone or a placebo. During the study, 46% of the patients taking the placebo died (certainly a high percentage, but a reflection of how sick the study patients were). Yet, only 35% of those in the spironolactone group died (a 30% reduction in risk). Fewer people were dying due to worsening heart failure or from sudden abnormal heart rhythms. Study investigators also noted that patients on spironolactone were about 30% less likely to be admitted to the hospital for heart problems. In addition to staying alive and out of the hospital, the spironolactone group felt better; 41% reported improvement in their quality of life, compared with only 33% of those in the placebo group. Only 38% of those on spironolactone reported a worsening of symptoms, compared with 48% of the others. (The New England Journal of Medicine, Vol. 341, No. 10, pp. 709-717.)

Physicians have been hesitant to try spironolactone in heart failure patients because of potential interactions with ACE inhibitors, a class of drugs of known significant benefit in treating heart failure. However, with careful prescribing and monitoring, serious side effects were rare. Only 2% of the patients assigned to spironolactone developed high potassium levels, the most feared complication.

The patients in this study were quite ill, and no one knows whether spironolactone will be useful for patients with milder heart failure. The danger of high potassium levels makes spironolactone too risky for patients with kidney disease or another medical condition that raises potassium. However, this drug is definitely worth considering for people with moderate or severe symptoms due to heart failure. Provided close attention is paid to potassium levels in the weeks and months after the drug is started, spironolactone may help these patients live longer, better lives. For more information on heart failure, see page 683 in the Family Health Guide.

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