The Polypill

The Polypill

HEART HEALTH

One pill with many benefits

The Polypill has the potential to
reduce cardiovascular disease in
the places that need the most help

The are several barriers for patients in the healthcare system: taking time off for appointments, reliable transportation to your doctor’s office, have a working telephone number, can afford prescription medications, that you speak English, or understand your doctor’s instructions. For cardiac patients that live in remote or rural areas, these challenges seem more overwhelming when travel time or accessibility to a pharmacy or physician are considered. A low-cost, daily pill that combines four cardiac drugs known as “The Polypill” was recently tested in rural Alabama and across Iran and has shown promise to be a solution to undertreated heart patients.

What is the Polypill

Dr. Robert Benton is a board-certified cardiologist, Chief of Cardiology at Samaritan Hospital, and is the Director of Clinical Research at Capital Cardiology Associates. He broke down the Polypill on a recent episode of HeartTalk presented by Capital Cardiology Associates. “These are medicines that we know of: aspirin, a diuretic, a statin, and a blood pressure medicine. One of the questions here is, can we take medications to an at-risk population and combine low-doses of generic medications, which are inexpensive, to see if we can decrease cardiovascular outcomes? As this study in Alabama indicates, yes, yes, we can.” Just over 300 adults living in the Mobile, Alabama participated in The SCCS Polypill Pilot Trial. The trial was made up of adults 45 to 75 years of age without cardiovascular disease. 96% of participants were African-American, with an annual income under $15,000. Their blood pressure (140/83) and LDL cholesterol levels (113 mg) fell just above normal readings. Over 12 months, the study assessed medication adherence, systolic blood pressure, and LDL cholesterol. After one year, the patients on the polypill saw their blood pressure drop, on average, seven points. Their cholesterol fell by 11 points.

“This was more proof of concept trial,” added Dr. Benton. “The Alabama study was small, not an outcome study, but it does show that people who have difficulty accessing healthcare, these medicines can make a difference. We are seeing the cost-analysis of providing generic medications versus the cost of stroke or heart attack. Now we are talking about the cost of healthcare. These generic medications cost almost nothing, maybe $20 a month.” The cost of the polypill in the Alabama trial was $26 per month, although the drugs were free to study participants. Feedback from participants noted that remembering to take one pill was easier than the routine of multiple medications for blood pressure and cholesterol. “What’s really expensive is the cost of a heart attack or a stroke. That’s at least $25,000 to $50,000. We could also analyze congestive heart failure, or a pacemaker, or defibrillator expenses. The most effective thing to do is to take care of people before heart disease,” said Dr. Benton.

Reaching patients in remote areas

In another study, this a much larger trial featuring over 50,000 participants in Iran, looked at delivering drug therapy via a polypill (comprised of a statin, two drugs to lower blood pressure, and low-dose aspirin) to a large number of patients. The study was praised as a significant effort to combat a major global health problem. “What we found, in this case, was a risk reduction of about 30%,” noted Dr. Benton. The polypill in this study was effective in cutting the risk of cardiovascular events by 40% in people with no history of heart disease and by 20% in those with previous symptoms. “These aren’t new medicines,” Dr. Benton explained. “When you develop heart disease or have a cardiac event, you are going to have more than one prescription to take every day. These medications not only lower your blood pressure, cholesterol levels, or help regulate your heart rhythms, but they also decrease the likelihood of a future event. That’s the most important goal.”

Future of the Polypill

The history of the Polypill began in 1999 when Nicholas Wald, who was director of the Wolfson Institute of Preventive Medicine in London at the time, considered combining medicines to combat cardiovascular disease. Wald predicted that around 80% of heart attacks and strokes could be averted if his proposed polypill was taken by everyone aged 55 years and over, and everyone with existing CVD. The debate that followed since Wald’s idea has been over the cost, effectiveness, and practicality of using a mass-treatment approach on at-risk and low-risk populations. There are ethical, legal, and regulatory questions involved in this decision as well. For example, fixed-dose combination pills are not legal in some countries. Dr. Benton is hopeful that time will be on the side of medical science. “The polypill is not available here yet, but we have had some version of mixing a statin and a high blood pressure medication in the past. I think eventually, you will see something like this come around. I don’t think it will be a great product of major pharmaceutical companies; these are ultimately generic medicines. Most physicians will tailor a therapy that includes these medicines, just not in the form of one pill.” Research suggests that future use of a polypill will most likely be prescribed to high-risk patients or those without regular access to a family doctor to prevent future episodes.

Written by Michael Arce, Marketing Coordinator
Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a healthcare professional.

Diabetes Awareness Month

Diabetes Awareness Month

HEART HEALTH

Diabetes Awareness Month

Striving for a life free of diabetes and its burdens

November is Diabetes Awareness month. The number of Americans living with diabetes is staggering: the Centers for Disease Control reported in July of 2017 that nearly 100 million people living in the U.S. have diabetes or pre-diabetes. The report finds that as of 2015, 30.3 million Americans – 9.4 percent of the U.S. population – have diabetes. As diabetes is becoming more prevalent in our communities, culturally, there is a concern that adults are treating their diagnoses as a condition that can be managed with medication, not as a disease that can cause long-term damage if left untreated. This month on HeartTalk presented by Capital Cardiology Associates, we discussed the impact of diabetes in the Capital Region from the medical and community health perspectives.

Theresa Beshara is a Nurse Practitioner in Family Health at St. Peter’s Hospital Diabetes and Endocrine Care Center. She has almost twenty years of experience working with diabetics, their families, and caregivers. Theresa attributes bad lifestyle choices as one of the main factors contributing to our nation’s diabetes problem. “We are more sedentary (than earlier generations); we don’t tend to exercise as much. Our diets are better than they were 20 years ago, but we still enjoy fast food meals. We do eat a lot more carbs, and it’s a matter of genetics: we can’t change that piece.” Diabetes does have a hereditary element; it tends to run in families. However, for most people living with diabetes, it is usually a combination of both genetics and lifestyle choices that influence risk factors.

“I think there is a stigma right now with Type 1 that you cause yourself to have it when really it is an auto-immune disease,” says Laura Greenaway, Development Director of the American Diabetes Association in Albany. On our recent HeartTalk episode, Laura shared her family history, how her sister was diagnosed with Type 1 and how different her childhood home went without sodas, sugary snacks, and candies that could be found in her friends and neighbors kitchens. “With Type 2, there is a misbelief that you ate too much, and people aren’t aware of the hereditary factor. Diabetes is a disease that isn’t talked about because it’s not visible. What we are trying to do is help educate people about the different causes, ways to prevent it, and what their risk is.”

As diabetes detection has improved through innovations in technology and testing, nothing replaces the importance of having a yearly discussion with your health care provider on your risk. It’s a talk that needs to happen earlier in life. “If we can get our teenagers to work with their parents to make better food choices, get them involved with an exercise program or school sports, those two things will help with prevention,” said Theresa Beshara. When we talk about the long-term damage unmanaged diabetes does to the body, it’s alarming how an excessive amount of sugar in the system, over time, affects the arteries and blood vessels. As the cardiovascular system stiffens, it causes the heart to work harder to push blood throughout the body. What takes years to develop eventually becomes high blood pressure or atherosclerosis, both triggers for stroke, kidney issues, peripheral vascular disease, and heart failure. This is the mission of the American Diabetes Association, a life free of diabetes and its burdens. “Diabetes is more than blood sugar monitoring; it is a disease that affects every organ in your body and can cause long-term damage if untreated. It is something we all should want to prevent,” said Greenaway.

Awareness. Education. Engagement. Prevention. Those are the goals for the American Diabetes Association during November. “When we talk with physicians or diabetes educators, our partners in the community awareness programs, we talk about the day to day things that people can do,” stated Felix Perez, Market Director for the American Diabetes Association. Capital Cardiology Associates is proud to join the cause to encourage at least 30-minutes of daily activity or exercise, a heart-healthy diet, living smoke-free, and making responsible choices with alcoholic beverages. If you’re ready to make a difference, stand up and be counted by clicking here.

Written by: Michael Arce, host of HeartTalk presented by Capital Cardiology Associates

Heart Failure in People Under 65

Heart Failure in People Under 65

HEART DISEASE

Too young for heart failure

Why more Americans under 65 are being diagnosed with heart failure earlier in life

Heart failure, also called congestive heart failure (CHF), is when the heart doesn’t pump blood as well as it needs to. While more than 200,000 cases are diagnosed every year, heart failure is typically found in patients over 65. The Journal of the American College of Cardiology published a article this summer that highlighted the rise in heart failure cases in people under the age of 65. According to experts, this is partially due to a “clustering of risk factors” in young adults, such as hypertension, high blood pressure, rising rates of obesity, and coronary artery disease.

The term heart failure is easily confused with cardiac arrest, which is when your heart suddenly stops beating. Heart failure is the result of long-term heart disease, like coronary artery disease, the buildup a fatty plaque in your arteries that can reduce blood flow, cause strain on your heart muscle, and trigger a heart attack. “What we also look for in heart failure patients is what caused the heart to get weak in the first place,” said Dr. Heather Stahura, a board-certified cardiologist at Capital Cardiology Associates. “Very infrequently, but it can happen, some medications can cause acute CHF. Some chemotherapies can cause heart failure to happen. In other people, once in a while, we’ll see a common cold virus that can attack the heart, making it function poorly. Most of the time, we see CHF as a continuum of a long-term process that stems from uncontrolled high blood pressure, cholesterol, and what I am seeing with young adults — hypertension.”

Heart failure risk for young adults

Researchers recently looked at the relationship between high cholesterol and blood pressure levels in early adulthood and the impact on heart health later in life. Their findings, published in the Journal of The American College of Cardiology found that “exposure to elevated (levels) during young adulthood (18 to 39 years of age) were associated with increased coronary heart disease and heart failure later in life.” The doctors cautioned young people that high blood pressure, diabetes, and smoking are modifiable risk factors, meaning that while genetics ultimately play a key role in your overall heart health, a healthy lifestyle can combat some risks. “What I am seeing with young adults is hypertension. They may be diagnosed with diabetes in their 30’s or 40’s and feel that a blood pressure reading of 170 is something they can take care of when they are older. But ten years or more of high blood pressure can weaken the heart and cause congestive heart failure,” noted Dr. Stahura.

Since heart failure is a long-term disease, daily activities like walking up the stairs, carrying groceries, or even walking from your car to your home can, over time, become a challenge. “The biggest symptoms that we see as cardiologists are shortness of breath either at rest or on exertion,” shared Dr. Stahura. “Fatigue, that’s the other symptom I see in a lot of people. Not being able to get out of bed, lacking the energy to play with your grandkids, loss of interest in things you used to do. Swelling in your lower extremities is something I will investigate. A little swelling around the ankles is common at the end of the day, but we’re talking about excessive swelling. Increase abdominal wall growth, where your pants are fitting tighter, could be an option. In advanced stages of congestive heart failure (CHF) where it is filling up your lungs, you can have pulmonary edema — fluid in your lungs — that can make breathing more difficult.”

The danger of heart failure is that there is no cure. This is why health care professionals stress the importance of regular visits with your doctor to monitor your risk, and if needed, recommend lifestyle changes to improve your heart health. It is possible to live with heart failure. Of the more than 6 million American adults living with heart failure, about 10 percent have advanced heart failure. Dr. Stahura outlined those treatment options. “There is a biventricular pacemaker that some patients respond well too. My electrophysiology colleagues at CCA would implant this device to try and re-synchronize the heart if the patient meets certain criteria. Our interventionists can place a mitral clip, a procedure where we cinch a very leaky heart valve. If you have a tight or stenotic heart value, like aortic stenosis, we will insert a TAVR valve, that alleviates the stress in your heart. We have plenty of options for each heart failure case. But always diet, exercise, and medication will be the cornerstone of therapy.”

Written by Michael Arce, Marketing Coordinator, Capital Cardiology Associates
Any medical information published on this website is not intended as a substitute for informed medical advice, and you should not take any action before consulting with a healthcare professional.

World Health Day

World Health Day

HEART NEWS

America’s heart problem is now the World’s

Heart disease is no longer an American problem

World Health Day is a global health awareness day celebrated every year on April 7th, under the sponsorship of the World Health Organization (WHO), to call attention to the advancement of health in all people. This year, I sat down with Dr. Brion Winston, who in addition to being a board-certified cardiologist, also has an area of interest in public health. Our discussion began with data from WHO that in 2016, more people died of heart disease than of AIDS/HIV, malaria, and tuberculosis. Heart disease is responsible for one-third of all global deaths.

Why is heart disease exploding in developing countries?

At least three-quarters of the world’s deaths from cardiovascular disease (CVD), or heart disease, occur in low- and middle-income countries. Heart disease very treatable and preventable if caught early. One factor affecting the poorest people in these places is the lack of detection. Dr. Winston explained how the diagnostic evaluation of heart disease in developing countries would be pretty basic, at best. “You would be able to find electrocardiography in many clinics but remember, in poor and developing nations, the standard of health care delivery is often a fee for service. If someone has a severe health problem, they will show up to the emergency department, often accompanied by their family, they will talk with the doctor and the patient. The doctor will say, ‘this is what I think is going on, and this is what it will cost’ and there is a fee for service right up front. With that in mind, the choices for diagnostic evaluation may be limited in some places.”

“Taking to the later phases of treatment, surgical treatment for heart disease in poorer nations are quite limited, maybe to aspirin, things like catheterization labs – you’ll find poorer countries don’t have them,” stated Dr. Winston. Treatment and procedures of heart disease like balloon angioplasty (where a small balloon-like device is threaded through an artery to open the blockage), coronary artery bypass or valve repair and replacement is costly once heart disease advances. “But, with the example of India, they have many hospitals which have prospered with the economic development over the last 30 years, these sites are considered ‘medical tourism’ where Americans will travel overseas for heart procedures in India. These are for-profit hospitals that run efficiently, conducting a high volume of surgical procedures. The costs of some of these procedures would be a fraction of what a patient would pay and there are some people willing to travel for this.”

Awareness and education are an important component that is missing in developing countries. The most important behavioral risk factors of heart disease and stroke are an unhealthy diet, physical inactivity, tobacco use and harmful use of alcohol. Americans are bombarded with public health messages informing us of the increased risks of a poor diet, smoking, and lack of exercise; this is not the case in other parts of the world. “In my practice and taking with my colleagues, many of whom are from South Asia (India and Pakistan), there is a high incidence of heart disease in people from these lands when they come to the US, if they follow a US diet that is high in fat, then we may see development of heart disease even earlier,” says Dr. Winston. “Overall, while we have made substantial improvements in reducing smoking in the United States but in South Asia and China, there is still a large amount of that population that still smokes, combine that with a richer diet – that will add to this problem as well.”

A “better life” might be a slow killer

Economics is an underlying cause of fostering the bad behavior that leads to heart disease. In some countries, soda is cheaper than bottled water. This year, Canada recently updated its Food Guide to offer advice on what to eat, what not to eat, and how to eat. Half of the plate is fruits and vegetables, a quarter for whole grain foods, the final quarter for protein. They also removed dairy as a category, urging citizens to have a glass of water with meals. In the African nations of Tanzania and Zambia, clean water does not flow from their taps. A can of Coke is less than and safer than clean water. This choice adds up; according to the Human Sciences Research Council the cost of eating healthy in South Africa is 69% more than the alternative.

The opposite is true in other parts of the world. “As standards of living have improved in South Asia as well as in China, people are following more of what we tend to think of as a Western Diet, a high fat, high energy diet – we rating to see more diabetes and related heart disease. It’s both an issue that we have made progress of infectious disease as well as the economic shift which has lead to people eating richer diets putting them at greater risk for heart disease,” notes Dr. Winston.

A global problem

Heart disease is the number one killer of men and women in America. It is also responsible for one-third of all global deaths. This global problem is going to need a large solution that addresses access to health care and preventative treatment. A WHO report estimates that Africa has about one doctor for every 5000 people. In underdeveloped nations, community health care workers fill the void of serving patient’s who don’t have access to a doctor or even a hospital. In South Africa, Mexico, and Guatemala, a study shows that these health care workers were able to screen adults for cardiovascular disease when access to a physician was not available. Armed with a mobile app, instead of traditional paper, these volunteer professionals were able to diagnose patients efficiently and at less cost compared to standard care.

There is hope in solving the global heart health problem. While there will certainly be a growing demand for cardiologists worldwide, it wasn’t that long ago that the HIV/AIDS crisis seemed impossible to contain. Money for research, governments pushing for public health policies, and dedicated medical professionals will need to unite around the world to fight heart disease – together.

Written by: Michael Arce, Capital Cardiology Associates Any medical information published on this website is not intended as a substitute for informed medical advice, and you should not take any action before consulting with a healthcare professional.

Luke Perry Stroke

Luke Perry Stroke

PATIENT EDUCATION

Stroke is no longer
an “old age” risk

Adults as young as
40 are now at risk.

Here’s what you need
to ask your doctor.

Luke Perry’s death, just four days after FOX announced that it would be re-booting “Beverly Hills, 90210”, the TV show that made him 90’s icon, came as a surprise to fans who were hoping he would return as “Dylan McKay.” This role cemented Perry’s iconic image as the standard of cool for the generation who grew up after Jim Stark, the troublemaking teen played by James Dean in the epic 1955 film “Rebel Without A Cause.” The two characters not only shared similar backstories, dangerous loners who lived on the edge; the actors also shared a striking similarity in appearance.

The news report that The Los Angeles Fire Department responded to a “medical assistance” call at Perry’s home on Wednesday, February 27, dominated the headlines. At first, officials say Perry was talking to first responders and was fully conscious. This was just days after TV announcement; fans were shocked to learn that the star, at 52 years old was hospitalized due to a massive stroke. We were all saddened when the news broke the following Monday of his passing.

Redefining stroke

Stroke, as with many other forms of heart disease, is often thought of as an “old person’s” health concern. While there are more than 200,000 stroke cases in the US every year, making it the fifth leading cause of death in our country, the primary age affected is 60 years old and up. However, recent health trends have shown a growth in diagnosis with adults aged 41-60. “People can have strokes at any age,” says Maryellen King, Nurse Practitioner at Capital Cardiology Associates. Ultimately, if you have a concern about your risk of stroke, heart attack, or heart disease make an appointment with your doctor or primary care provider, today.

The traditional factors that put you at risk for stroke are lifestyle, diet, physical activity – which are controllable — tobacco use and smoking double the risk of stroke when compared to a nonsmoker. Smoking increases clot formation, thickens the blood, and increases the amount of plaque buildup in the arteries. Abusing alcohol and drugs (cocaine, amphetamines, and heroin) have been associated with an increased risk of stroke. The uncontrollable risk factors are your family history, age, race, gender, and prior heart health history.

There are also uncommon causes of stroke which are usually congenital (birth disorders) or rare vascular blood vessel diseases.

The recommendations for adults in their 40’s who are concerned about lowering their risk of stroke, heart attack or heart disease are:

• Eat a healthy diet, including reducing salt intake.
• Engage in regular physical activity and maintain a healthy weight.
• Manage stress.
• Avoid tobacco smoke.
• Take your medication as prescribed.
• Limit your alcohol consumption.

What is a stroke?

The National Stroke Association defines a stroke as “a brain attack.” Essentially, you have an instance where you’re losing blood flow to a part of the brain. “There are different types of stroke, hemorrhagic (bleeding in the brain), embolic (a blood clot that travels),” says King. Hemorrhagic strokes are less common; only 15 percent of all strokes are hemorrhagic, but they are responsible for about 40 percent of all stroke deaths. They can occur as a cerebral aneurysm, a congenital malformation of the arteries in the brain that can rupture. “There is no way to know if you have an aneurysm or not. If it ruptures, you can have bleeding on the brain, and people can die from that. They would experience sudden severe headache, the bleeding in the brain, patients will say the worst headache of their life. It’s not a warning sign, that’s a symptom,” stated King.

The other form of stroke is called an ischemic stroke. This can happen when a sticky, fatty material called “plaque” builds up in a blood vessel in your brain. Plaque slows your blood flow. It may cause your blood to clot. This can stop the flow of blood completely. This kind of stroke can also happen when a clot travels to your brain from another part of your body, even if you don’t have plaque buildup in your vessels. The most common cause of this type of stroke is A-Fib (atrial fibrillation) when your heart has an abnormal rhythm that produces the opportunity for a clot to form in the left side of the heart, dislodge and travels up and through to the brain.

A patent foramen ovale (above) is a hole in the heart that didn’t close the way it should after birth. The condition affects about 25% of Americans, but many do not know it.

The other type of embolic stroke would be a patent foramen ovale (PFO) or some different kind of congenital hole in the right and left sides of the heart. “The sides of your heart are supposed to be separate; blood comes from the right side of the heart is pushed to the lungs. It comes to the left side of the heart and gets pushed through the body. When there is a hole between the two sides, clots form and can travel from one side to the other,” said King. Most patients with a PFO do not have any symptoms. However, the condition may play a role in migraine headaches and it increases the risk of stroke, transient ischemic attack and heart attack.

Advances in testing

For patients who present stroke symptoms (Numbness or weakness in your face, arm, or leg, especially on one side. Confusion or trouble understanding other people. Difficulty speaking. Trouble seeing with one or both eyes. Problems walking, staying balanced, or loss of coordination. Dizziness. Severe headaches that come for no reason.) there are testing procedures. “The only way to find the holes in the heart would be with an echocardiogram, an ultrasound of the heart, to evaluate to see if a PFO has formed,” said King. Echo tests are performed by specially trained technicians at Capital Cardiology Associates. The test is painless, has no side effects, and usually takes an hour. “Using an echocardiogram (ECG) we can inject ‘fizz’ essentially, a trace amount of agitated saline that we call a ‘Bubble Study.’ These tiny bubbles can be seen on an ECG moving across the septum,” King explained. An ECG allows a physician to view the heart’s structure and check how the heart functions.

The other test available is the Transcranial Doppler (TCD), a non-invasive ultrasound method used to examine the blood circulation within the brain. A specially trained technician at Capital Cardiology Associates Imaging Suite performs this test to determine the amount of blood flow to specific areas of your brain. “The main reason that we started doing this is to detect a shunt or a hole in the heart,” shared Dr. Jeffrey Uzzilia of Capital Cardiology. “Patients that had a stroke, one of the reasons why they had a stroke that is not obvious at the time, is they can have a hole in their heart where a blood clot can form somewhere in the body and cross through that hole from the right side of the heart to the left. Once that blood clot is on the left side of the body it can travel anywhere in the body, including the brain and cause a stroke. Something like a PFO that everyone is born with, for most people it will close, for about 25% of people it will stay open. The TDP is the most accurate, sensitive test to detect that. It’s a very easy thing to see. There’s a good portion of patients, like Luke Perry, that you are shocked as to how young they are when they have a massive stroke,” said Dr. Uzzilia.

Written by: Michael Arce, Marketing Coordinator, Capital Cardiology Associates Any medical information published on this website is not intended as a substitute for informed medical advice, and you should not take any action before consulting with a healthcare professional.