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

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Stenting versus surgery for angina

Patients with angina — chest pain caused by plaque build-up in the coronary arteries — have a few choices of treatment. Though that choice may bring freedom, it can also bring confusion. Should you treat it with drugs, bypass surgery, angioplasty, or stents? A study published in the August 22, 2002 issue of the New England Journal of Medicine may help you and your physician start to make that decision. This study focused on two of the treatments — minimally invasive bypass surgery and stenting.

Minimally invasive bypass surgery, a relatively new technique, involves a smaller incision than traditional bypass surgery. This offers the doctor limited access to the heart. As in traditional bypass surgery, the surgeon takes a blood vessel from another part of the patient’s body and either replaces the clogged artery with it, or uses it to reroute blood away from the blocked section, much like a detour reroutes traffic away from a blocked roadway. Using this technique, doctors don’t need to stop a patient’s heart as they do in traditional bypass surgery. Stenting involves widening the narrowed artery by temporarily inflating a tiny balloon in the blood vessel. The surgeon then places a circular wire mesh in the artery to flatten the plaque and hold the artery open.

In the study, researchers randomly assigned 220 heart disease patients to receive either the surgery or stenting. Doctors monitored the subjects following the procedures and saw them again six months later. Both treatments proved to be effective, but their success rates and longevity differed. Stenting was successful and without complication in all of the 110 patients who got it, whereas surgery was successful in 95% of the patients. Five of the 110 patients in the surgery group experienced complications during the procedure and a few required reoperation soon after their initial surgery.

While surgery had more early complications, its effects lasted longer than the effects of stenting. At six months 79% of the patients in the surgery group were free from angina, compared to only 62% of patients in the stenting group. Narrowing of the arteries reoccurred in a larger number of patients who received stents than those who underwent surgery. This caused 29 of the patients in the stenting group to require further intervention, compared to only five patients in the surgery group.

The results of this study offer perspective on two of the available treatments for angina. Of course, when making this decision, you and your doctor should also take into account your age, your medical history, and the condition of your coronary arteries.

October 2002 Update

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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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Aggressive Therapy for Older Hearts

There's no question coronary artery bypass grafting and angioplasty can relieve the pain of angina, prevent heart attacks, and add years to the lives of people with blocked coronary arteries. But most studies have excluded people over age 70, so the benefits of aggressive therapy is less clear in the older patient.

Two studies from Switzerland and Canada provide good news for older people who may need bypass surgery or angioplasty. Swiss researchers compared the effects of medical therapy and invasive therapy among more than 300 men and women with angina, all of whom were age 75 or over. They reported the results in the journal Lancet. After six months, the frequency and severity of chest pain had lessened and the quality of life had improved in both groups. But the improvements were substantially greater, and the heart attack rate substantially lower, among those who had undergone bypass surgery or angioplasty.

The Canadian study, which appeared in the Canadian Medical Association Journal, compared the effects of bypass surgery on patients in their 80s and those in their 70s. The investigators found it as safe and effective for octogenarians as it was for septuagenarians and reported that it cost about the same in either group.

Neither of these studies provides blanket assurance that an invasive procedure like bypass surgery or angioplasty is right for every older person with blocked coronary arteries. Older candidates for bypass surgery or angioplasty may want to focus on quality-of-life issues. Recovery, for example, may be a completely different experience for older people.
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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Reducing Your Risk of Deep Vein Thrombosis During Airline Travel

Deep vein thrombosis (DVT), recently featured in the news as "economy class syndrome," is the formation of a blood clot in the deep veins of the legs while sitting — particularly in the cramped seats of an airplane (be it economy class or first class), car, bus, or train — for long periods. You move less in tight quarters, causing circulation to decrease and allowing blood to collect and form a clot. The blood clot may cause pain and swelling in the legs. Serious, even fatal complications can occur if the blood clot breaks loose in the blood stream and travels to the heart or lungs. Older people, and those who are obese or have a family history of DVT tend to be at the highest risk.

While a blood clot can result from a number of causes, some studies suggest an association between blood clots and airplane travel. Many doctors believe this connection is simply a result of being unable to move around, and not from sitting in economy class seats or in an airplane, per se. However, it is possible that pressurized air and dehydration may also play a role in the connection between air travel and blood clots.

Many airlines have already begun to address this health issue by preparing warning pamphlets for their passengers, including articles in their in-flight magazines, posting notices on their Websites, or creating in-flight videos offering exercises aimed at prevention. A member of the parliament in Australia has even called for treadmills to be installed in airplanes that carry passengers for six or more hours.

While treadmills may or may not appear on airplanes in the near future, you can address this issue on your next lengthy flight by taking a few simple measures to help prevent blood clotting.

  • Wear loose-fitting, comfortable clothing during the flight.
  • Eat a small meal and drink plenty of fluids to help increase blood circulation. Avoid alcohol and caffeine, as these contribute to dehydration.
  • Do not cross your legs while seated and make sure you adjust your position every half hour.
  • You may want to wear elastic support hose to increase circulation in your legs.
  • Most importantly, try to walk up and down the aisle at least once an hour. Even standing in front of your seat and gently shaking out your legs or slowly rising up on your toes can help.
  • If you can’t get out of your seat, you can do the following exercises in your seat to increase blood circulation. Perform each exercise for 15 seconds, once an hour.
    • Ankle rotations: Draw a circle with your toes, rotating clockwise and then counterclockwise with both feet.
    • Foot pumps: Slowly alternate between flexing and pointing your toes.
    • Leg lifts: With your knee bent, lift your leg up off the seat and hold for a few seconds. Alternate legs.
    • Head and shoulder rotations: Gently roll your head clockwise and then counterclockwise, keeping your shoulders relaxed. Then gently roll your shoulders forwards and backwards.
    • Toe reach: Slowly bend forward and extend your arms down towards your toes and then gently sit back up.
  • People who are at high risk for blood clotting due to other conditions should speak with their physician for additional advice before traveling.

Studies do not agree on how long a flight needs to be to pose a risk of blood clotting. A few studies even suggest that there is no association between blood clots and air travel. Clearly, more research is necessary. However, while we wait for a definitive answer to these questions, heeding these simple instructions may help prevent problems.
March 2001 Update

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Sustained-Release Nifedipine for Raynaud's Disease

Recently, the results of a clinical trial comparing the effects of sustained-release nifedipine with the effects of biofeedback on patients with Raynaud's disease suggest that nifedipine offers a clear benefit over biofeedback therapy.

Participants in the trial reported a minimum of two attacks per day at the start of the trial. After two winters on the sustained-release nifedipine, participants reported a more than 60% reduction in the number of attacks, as well as overall improvement in their symptoms. Although participants in the biofeedback therapy group reported no significant reduction in the number of attacks and no improvement in symptoms, researchers believe further study of this method's effectiveness would be worthwhile. This would be especially true for patients who could not tolerate vasodilators or who prefer nondrug treatments.

Some participants in the trial did report side effects such as rapid heartbeat, swelling, flushing, and headache, though there was a lower incidence of these side effects over time. In addition, the percentage of study volunteers experiencing these side effects from sustained-release nifedipine was significantly lower than for patients in trials looking at immediate-release nifedipine. Participants in previous trials studying immediate-release nifedipine also reported having 50% fewer attacks, but immediate-release nifedipine was found to be less effective over time, while sustained-release nifedipine was found to maintain its effectiveness.

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Hormone Replacement Therapy and the Risk of Blood Clotting

Researchers have found yet another factor for women to consider when deciding whether or not to take hormone replacement therapy. A recent study shows that taking estrogen and progestin after menopause increases the risk of venous thromboembolisms. (A venous thromboembolism occurs when blood clots formed in the deep veins become dislodged.) The clots travel through the blood stream and can become lodged in smaller vessels where they block blood flow.

In the Heart and Estrogen/progestin Replacement Study (HERS), researchers evaluated the effect of postmenopausal hormone therapy on the rate of coronary events in women with heart disease. According to the results, women receiving the hormone therapy had a threefold risk of thromboembolic events compared to women receiving a placebo. Since both estrogen and progestin were part of the hormone therapy, researchers were unable to detect which substance was responsible for the increased risk. However, estrogen seems the most likely culprit because similar results appeared in studies involving oral contraceptives and estrogen-like drugs such as tamoxifen. Researchers do not know precisely how estrogen increases the risk of venous thromboembolism, but some believe that estrogen may affect the liver’s ability to produce or breakdown substances that prevent clotting.

The study also found that fractures to the lower limbs, cancer, heart attacks, surgery, and hospitalization increased the risk of blood clots. These findings suggest that women with these risk factors should try to stay active and may need drugs to reduce clotting. In addition, the results showed that women who take aspirin or lipid-lowering drugs called statins have a 50% lower risk of clotting.

Women who are considering taking hormone replacement therapy should discuss the risk of blood clots with their doctors. The benefits of therapy may outweigh the risks in some cases. However, women who have cancer, a lower limb fracture, or a history of blood clots should avoid hormone therapy.

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