Diseases of the Arteries
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Stenting versus surgery
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
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
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
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 cant 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
- 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
- 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
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
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 livers ability to produce or breakdown substances that
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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