How heart attacks became less deadly

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Diseases of the Heart
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Decades ago, a heart attack was often deadly, killing up to half of its victims within a few days. With only a vague understanding of the physiological processes underlying heart attacks, doctors couldn't do much but let nature take its course. Doctors were taught that what they should do for people having heart attacks was to keep them calm and quiet, ease their chest pain, do whatever was possible to prevent heart rhythm problems, and hope that another heart attack wasn't on its way.

Today, more than 90% of people survive myocardial infarction. That's the technical term for heart attack; it means an area of damaged and dying heart muscle caused by an interruption in the blood supply. Some of the decline in deaths is due to doctors' ability to diagnose and treat smaller, less deadly heart attacks. Some is due to the institution of specialized coronary care units in the early 1960s.

What changed?

Much of the improvement in heart-attack survival can be chalked up to the gradual understanding in the 1970s and 1980s that the main culprit behind heart attacks is the sudden formation of artery-blocking blood clots, and the new treatments that emerged from this knowledge. Growing use of aspirin, clot-busting drugs, and artery-opening angioplasty in the early stages of a heart attack account for more than half of the reduction in heart attack deaths since 1985, according to an analysis by Stanford researchers.

The improvement in survival hasn't come without a cost. More people surviving heart attacks means more people living with scarred and damaged hearts. This has contributed to the steady increase in heart failure, which now accounts for more than one million hospitalizations a year in the U.S. and costs nearly $40 billion annually.

Although we have come a long way, there is still much to be done:

  • Get more heart attack victims to the hospital — and to treatment — within an hour of the start of symptoms.
  • Develop faster and more accurate techniques for determining who is having a heart attack.
  • Find ways to protect and support the heart during a heart attack.
  • Devise treatments to rebuild and regenerate heart muscle after a heart attack.

More important, of course, is finding ways to prevent heart attacks and strokes from happening in the first place.

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2019 Annual Report on Prostate Diseases
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Osteoporosis and prostate cancer

Q. My 64-year-old wife was recently diagnosed with osteoporosis. Her doctor said medication would help, and he reassured her that having osteoporosis was not all bad since it indicates a reduced risk for breast cancer. I want to know if osteoporosis in men affects the risk of prostate cancer.

A. At first glance, a link between bones and the breast or prostate would seem far-fetched. In fact, though, there is a link; it depends on the fact that all three organs are affected by sex hormones.

Bones are dynamic tissues that undergo constant remodeling throughout life. In youth, bone formation outpaces bone resorption; that's how bones grow. In young adulthood, the two processes are balanced, and bones are at their strongest. But as we age, bone resorption gets the upper hand. As bones lose calcium, they become weaker. Doctors call mild bone calcium deficiency osteopenia and more advanced deficiency osteoporosis, the "thin bone" disorder that increases the risk of fractures.

Sex hormones help bones retain calcium. In women, estrogen levels plummet at the time of menopause, and bone loss accelerates. In men, testosterone levels drift down slowly; on average, they decline just 1% a year beyond age 40. That's why osteoporosis is so much more common in women.

Women with high estrogen levels tend to have stronger bones — but since estrogen also stimulates breast tissue, they tend to have a higher risk of breast cancer. The differences are small, but they explain the backdoor compliment from your wife's doctor.

Testosterone stimulates the prostate as well as the bones. Men with low testosterone levels (hypogonadism) also have an increased incidence of osteoporosis. But the link between testosterone and prostate cancer is complex, and researchers haven't identified a clear relationship between a man's hormone levels and his risk of cancer. Still, a study of 1,012 men did show that those with high bone density scores were up to 1.9 times more likely to develop prostate cancer than men with low bone densities. It's only one study, but if its results are confirmed, the next step will be to investigate the reason for the link. In addition to high male hormone levels, other possibilities include high levels of growth factors such as insulin-like growth factor or a high consumption of calcium.

Your wife should know that treating her osteoporosis with nonestrogenic medication will not boost her risk of breast cancer. In addition to medication, she should be sure to get her quota of vitamin D and calcium, along with lots of weight-bearing and resistance exercise. If you're like most men, you don't need routine bone density testing, but you should get plenty of exercise and 800 to 1,000 IU of vitamin D per day. (Older men need the larger amount.) Calcium is trickier for you than your wife, since some studies indicate that men who take calcium in large amounts have an increased risk of prostate cancer. At present, about 1,200 mg a day seems right for both your bones and your prostate.

— Harvey B. Simon, M.D.
Editor, Harvard Men's Health Watch

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