Hypertension Takes Huge Toll in Developing Countries

(HealthDay News) -- Roughly 80 percent of high blood pressure-related deaths in the world occur in developing nations, a new study by New Zealand researchers shows.

Once regarded as a problem only in high-income countries, high blood pressure is now a global problem that affects both rich and poor nations, the researchers said.

The researchers calculated that 7.6 million premature deaths (about 13.5 percent of the worldwide total) and 92 million disability-adjusted life years (DALYS) -- 6 percent of the worldwide total -- among people over age 30 were caused by high blood pressure in 2001.

About 54 percent of strokes and 47 percent of heart disease cases were attributed to high blood pressure. About half of those cases occurred in people with hypertension (greater than 140 mm Hg systolic), while the remainder occurred in people with lesser degrees of high blood pressure.

In high-income countries, the proportion of premature deaths due to high blood pressure was 17.6 percent, compared to 12.9 percent in middle- and low-income nations. The proportion of DALYS due to high blood pressure in high-income nations was 9.3 percent, compared to 5.6 percent in middle- and low-income nations.

However, 80 percent of worldwide high blood pressure-related deaths occurred in middle- and low-income nations in eastern Europe and Asia, including China and India. More than one-third of all deaths in lower-income nations in Europe and central Asia were related to high blood pressure.

In high-income countries there were 1.39 million high blood pressure-related deaths; 418,000 stroke deaths; 668,000 heart disease deaths; 109,000 deaths due to hypertensive disease; and 197,000 deaths due to other cardiovascular diseases.

In low- and middle-income countries, there were 6.22 million high blood pressure-related deaths: 2.5 million stroke deaths; 2.68 million heart disease deaths; 598,000 hypertensive disease deaths; and 445,000 deaths due to other cardiovascular diseases.

"Most of the disease burden caused by high blood pressure is borne by low-income and middle-income countries, by people in middle age, and by people with lesser degrees of high blood pressure. Prevention and treatment strategies restricted to rich countries or individuals with hypertension will miss much blood pressure-related disease," wrote the University of Auckland researchers.

The study is published in this week's issue of The Lancet.

"Middle-income countries and low-income regions have a five times greater burden of disease than high-income regions, with access to less than 10 percent of the global treatment resource... This travesty cannot continue to be ignored by those most able to bring about change," Stephen MacMahon, of the George Institute for International Health at the University of Sydney in Australia, and his international colleagues, wrote in an accompanying editorial.

More information
The American Heart Association has more about high blood pressure.

Even in Middle Age, Starting to Drink May Lower Heart Risks

(HealthDay News) -- If you start drinking moderate amounts of alcohol in middle age, particularly wine, you can lower your risk of heart attack by up to 68 percent, compared to nondrinkers, a new study finds.

While previous research had suggested that moderate alcohol consumption was good for the heart, it hadn't been clear whether starting drinking later in life confers a benefit.

"Among middle-aged people who began to drink alcohol in the middle age, we found considerable cardiovascular benefit," said lead researcher Dr. Dana E. King, a professor at the Medical University of South Carolina's Department of Family Medicine.

Current American Heart Association guidelines suggest that moderate drinking may be good for you, King noted. "But if you don't currently drink, you shouldn't start, because of the possible negative consequences of alcohol," he said, summarizing the guidelines.

But this new study will challenge that policy, King said. "The study shows, in a natural experiment, what did happen when people started to drink in middle age," he said. "Indeed, there was a considerable cardiovascular health benefit without paying the penalty in mortality or in higher blood pressure. In fact, it improved the cholesterol profile."

The findings are published in the March issue of The American Journal of Medicine.
For the new research, King and his colleagues collected data on 7,697 people taking part in the Atherosclerosis Risk in Communities study. All were between 45 and 64 years old and non-drinkers at the start of the trial.

During the study, 6 percent of the participants began moderate drinking, which was defined as one drink a day or less for women and two drinks a day or less for men.

After four years, those men and women who became moderate drinkers reduced their risk of developing cardiovascular disease or having a heart attack by 38 percent, compared to the non-drinkers.

However, the type of alcohol did matter, King said. "Wine-only drinkers had 68 percent fewer cardiovascular events, whereas the drinkers of beer, liquor and mixed drinks had only a 21 percent benefit, and that was not [statistically] significant," he said.

"A sip of wine with dinner is part of a healthy lifestyle, even if you haven't been doing it previously," he added.

King cautioned that starting to drink isn't a wise choice for everyone. "There's a small percentage of people who, when they start to drink, will drink too much," he said. "People should discuss this with their physician if they have liver disease or a family history of alcoholism or other medical problems."

But Dr. Gregg C. Fonarow, a professor of cardiology at the University of California, Los Angeles, is one heart expert who doesn't think that studies have conclusively proven that alcohol reduces your cardiovascular risk.

People should stick to controlling known risk factors for heart disease -- such as cholesterol and blood pressure levels -- before taking up drinking, he advised.

"A number of observational studies have suggested moderate alcohol consumption is associated with lower risk of cardiovascular" problems, Fonarow said. "However, it has not been established whether it is the alcohol consumption itself or other factors that distinguish those with moderate alcohol consumption from non-drinkers which account for the lower cardiovascular risk."

The new study offered evidence that moderate alcohol consumption was linked to lower heart risks, but there was no difference in overall mortality between drinkers and non-drinkers, he noted.

"The findings suggest that for non-drinkers, adopting mild alcohol consumption may have cardiovascular benefits," Fonarow said. "However, until the potential cardiovascular benefits of moderate alcohol consumption are tested in a prospective randomized trial, there will continue to be debate as to whether this is advisable or not.

"Individuals wishing to lower their cardiovascular risk should stick to what is proven and recommended by the American Heart Association, including maintaining a healthy blood pressure, weight, and cholesterol levels, exercising, and avoid smoking," he advised.

More information
For more on the benefits of alcohol, visit the American Heart Association.

Biodegradable Stent Successful in Human Trial

(HealthDay News) -- A stent that biodegrades and vanishes from an artery in a matter of months has successfully passed a major test in humans, German researchers report.

The device, made of magnesium, is one of many different biodegradable stents that together represent the future of these artery-opening devices, said Dr. Raimund Erbel, professor of medicine at the West German Heart Center in Essen, and lead author of a report on the trial in the June 2 issue of The Lancet.

Stents are tiny, implanted mesh tubes that prop open failing arteries.

"In the long run, a biodegradable stent is best for those who need a coronary stent," Erbel said. "When such a stent has done its job, you don't need it any more. In the long run, its presence can cause problems."

A number of cardiologists and companies in countries across the world are working to develop stents that are broken down by the body once they have succeeded in keeping blood flowing through an artery. Most of this work is going on outside the United States, with reports on early trials coming from China, Japan, Finland, Germany, and elsewhere.

For example, at a heart meeting earlier this year, a group at Erasmus University in Amsterdam reported on a biodegradable stent they placed in 30 cardiac patients. The devices behaved very much like standard metal stents over the relatively brief period of a month, the researchers reported. The patients are still being followed to determine exactly when and how the stents disappear.

In this new trial, Erbel and his colleagues implanted 71 magnesium stents in 63 patients.
They reported that the safety record of the devices remained good after 12 months, with not a single case of clotting noted within the stent and no incidents of heart attack or death among patients. The diameter of the treated arteries increased slightly as the magnesium was absorbed by the body, being replaced by natural calcium and phosphorus.

As a bonus, the patients did not require treatment with clot-dissolving drugs such as Plavix and aspirin -- medicines that are typically needed with today's permanent metal stents.

The magnesium devices were far from perfect, however. Re-blockage of an artery occurred in 47.5 percent of patients, with 27 percent of them requiring artery-opening procedures.

One unexpected benefit of the magnesium stents was that it allowed the cardiologists to see what was happening inside the devices by using either MRI or CT scans. "Such views are hard to get with current devices, but we could get a wonderful visualization of an artery," Erbel said.

He views magnesium as a natural material for a degradable stent, because it is easily handled by the body. "After four months, everything is gone," Erbel said. "In fact, the degradation process was, in our opinion, too rapid, something we are researching," he said.

Joachim Kohn, director of the New Jersey Center for Biomaterials at Rutgers University, disagreed that biodegradable magnesium stents are the wave of the future.

"I'm familiar with this and don't think it will work very well, in spite of the early positive results," Kohn said. "We are going to see a number of complications in the end stages of the degradation of magnesium. It is a revolutionary and very innovative idea, but, in the end, we are better off with a body-like material than with a metal."

Kohn has developed a stent that uses just such a synthetic "biomaterial." It has been licensed to a small company, REVA Medical, with first human tests scheduled to begin this month.

Almost all the degradable stents now under development use such synthetic materials, which helps explain why so little is being done in the United States, Kohn said.

"Biomaterials were hot in the 1990s," he said. "Everyone in the United States was interested in biomaterials. But a field has to be matured, and before that happened, we moved on to other things, such as nanomaterials."

Wherever the work is done, "there is no question that we will want a biodegradable stent eventually," Kohn said. "There are persistent issues with permanent stents." It will take years to get such stents into routine medical use, he said, because careful human testing will be required.

More information
For more on stents, visit the American Heart Association.

Pregnant women restricted to bed rest can and should do safe, specially-designed physical activity, say experts at the American Ph

(HealthDay News) -- Cardiologists should be giving more of the clot-preventing drug Plavix than is now recommended before performing the artery-opening procedure called angioplasty, a new study says.

The analysis of 10 previous studies found that giving angioplasty patients double the current recommended dose of Plavix -- 600 milligrams rather than 300 -- cut the combined risk of heart attack and cardiac death by half, according to Dr. Anthony Abbate.

Abbate, an assistant professor of medicine at Virginia Commonwealth University, was expected to present the findings on Friday at the Society for Cardiovascular Angiography and Interventions' annual meeting, in Orlando, Fla.

The higher dose did not increase the risk of serious bleeding, a major concern with Plavix, the analysis found.

"The evidence shown by this meta-analysis is very powerful," said Dr. Gregory Dehmer, president of the society and a professor of medicine at Texas A&M College of Medicine. "Although Plavix is powerful stuff, the meta-analysis did not find an excessive amount of bleeding. So we have a lower risk of myocardial infarction [heart attack] with no significant increase in adverse side effects."

The 10 studies analyzed by Abbate and Dr. Giuseppe G. Biondi-Zoccai, an assistant professor of cardiology at the University of Turin in Italy, included 1,500 patients who had angioplasty. Most had either 300 milligrams or 600 milligrams of Plavix before the procedure.

The incidence of cardiac death or nonfatal heart attack was 50 percent lower in the following 30 days in those getting the higher dose of Plavix. Only 3.1 percent of those getting the 600-milligram dose had in-hospital heart attacks, compared to 6.4 percent of those getting the 300-milligram dose. The overall 30-day incidence of death or heart attack was 3.8 percent for the higher dose and 7.3 percent for the lower dose, according to the study.

"This research has important clinical and cost implications," Biondi-Zoccai said in a prepared statement.

Current guidelines by the American Heart Association, the American College of Cardiology and the Society for Cardiovascular Angiography and Interventions say that physicians should "strongly consider" giving 300 milligrams of Plavix before angioplasty, a medical procedure to open narrowed or blocked blood vessels of the heart.

"Those guidelines are in the process of having an update," Dehmer said, adding that new guidelines are expected "in the next few months."

"In practical terms, many practitioners are concerned about the current recommendations," Dehmer said. "One concern is that should the patient require elective bypass surgery, does a higher dose of clopidogrel [the generic name of Plavix] increase the risk of excessive bleeding?
"Also there is the bleeding risk. It is addressed in this meta-analysis, which shows very minimal potential downside," he added.

But the final word is not in yet, said Dr. Marc S. Sabatine, associate professor in the cardiovascular division of Brigham and Women's Hospital in Boston. That will come from a major international study, to include up to 14,000 angioplasty patients, which is still enrolling participants, he said.

The smaller studies included in the current meta-analysis aren't definitive, Sabatine said, because there can be "publication bias," meaning that studies showing a positive result are more likely to get into print.

Timing also plays a role in treatment, he noted. Plavix must be activated in the liver, which takes about six hours, so giving it earlier makes it more effective.
But even with those side considerations, "many laboratories are considering switching to 600 milligrams," Sabatine said.

More information
For more on angioplasty, visit the U.S. National Library of Medicine.

The Cardiovascular Cure: How to Strengthen Your Self-Defense Against Heart Attack and Stroke - Book Review

BY JOHN P. COOKE, M.D., PH.D., AND JUDITH ZIMMER; B
ROADWAY BOOKS; $25

SOME MAINSTREAM DOCTORS are bucking the system and suggesting that surgery or drugs may not be the best treatment for stroke, heart disease, and atherosclerosis (hardening of the arteries). One of these doctors, John P. Cooke, M.D., Ph.D., director of the vascular medicine section at Stanford University Medical School in Palo Alto, Calif., has written a book to help us trigger our body's remarkable capacity to heal itself.

Cooke and co-author medical journalist Judith Zimmer explain that a healthy endothelium, the innermost single-cell-thick lining of human blood vessels, releases a substance that packs benefits galore. Called nitric oxide (NO), this substance keeps blood vessels supple, prevents platelets from snagging on vessel walls, hinders the buildup of plaque, and even helps to reduce existing plaque deposits. Cooke says people with heart disease or the risk factors for it have elevated levels of an amino acid that impedes NO production.

To ensure that your endothelium pumps out plenty of NO, Cooke recommends a modified Mediterranean-style diet supplying 1,800 calories a day. The evidence-based diet features whole grains, beans, nuts, legumes, fruits, and vegetables, and emphasizes foods rich in L-arginine, an amino acid used by the endothelium to make NO. His book includes a two-week eating plan with recipes, and detailed information on supplemental nutrients and phytochemicals.

The other component of Cooke's simple plan is aerobic exercise, which increases blood flow through your vessels. Increased blood flow stimulates the production of NO and keeps the endothelium smooth so plaque accumulation is less likely. He advocates at least 30 minutes of aerobic exercise four days a week.
This book manages to be both comprehensive and lively. Cooke presents just the right amount of detail about the scientific underpinnings of his conclusions, which are based on a Nobel-prize-winning theory. He claims you will have vascular improvement in just two weeks--and I believe him.
COPYRIGHT 2002 Weider Publications
COPYRIGHT 2002 Gale Group

The Cardiovascular Cure

The Cardiovascular Cure

Written by John P. Cooke, M.D., Ph.D. and Judith Zimmer
Category: Medical - Diet Therapy
Publisher: BroadwayFormat: Trade Paperback, 336 pagesPub Date: August 2003
Price: $15.95
ISBN: 978-0-7679-0882-5 (0-7679-0882-1)

ABOUT THIS BOOK
The Cardiovascular Cure offers a groundbreaking approach to preventing heart attack and stroke by enhancing your body’s own natural defenses. Dr. John Cooke, head of Stanford Medical School’s vascular unit, has devised a powerful new method for fighting cardiovascular disease without bypass surgery or angioplasty.

Drawing on his own investigations, as well as Nobel Prize-winning research from a team of American scientists, Dr. Cooke provides heart patients with a diet, supplement, and exercise program that will help them feel better in as little as two weeks.

His program also works to prevent heart disease in those at risk.

In 1998, the Nobel Prize in Physiology or Medicine was awarded for the discovery of EDRF (endothelium-derived relaxing factor), a chemical produced in the lining of the blood vessels, which keeps them free of plaque. Dr. Cooke and other investigators have found that specific nutrients can enhance EDRF production and improve blood flow in people with high cholesterol, high blood pressure, diabetes, or other risk factors for heart disease.

This potentially life-saving book shows how anyone can achieve healthier blood vessels (the key to preventing heart disease). A two-week menu plan contains recipes that emphasize EDRF-enhancing foods, and there is detailed information on supplemental nutrients and vitamins that are useful in strengthening the cardiovascular system. Recipes from breakfast (Banana Date-Nut Bread; Blueberry Oat Pancakes; Pineapple Ginger or Tropical Smoothies; Pumpkin Muffins) to dinner (Moroccan Red Snapper; Chicken Wrap with Refried Beans; Soy-Glazed Salmon; Turkey Meatloaf) feature healthy fats found in fish, nuts, and olive oil.

There is also welcome news that red wine and chocolate can be good for you (there are recipes for Double Chocolate Cake and Chocolate Raspberry Surprise). The exercise program consists of the same therapeutic plans Dr. Cooke has prescribed for even his most severely ill patients, many of whom begin to walk and even exercise more vigorously without pain after two weeks. In addition, there are aerobic workouts designed for more active patients.

Dr. Cooke also provides state-of-the-art information (pro and con) on conventional drugs–from aspirin to beta blockers–and medical tests and procedures to further combat cardiovascular disease. With an introduction by Sir John Vane, a Nobel Prize-winning cardiovascular scientist, this book will provide anyone concerned about his or her cardiovascular health with new hope for a pain-free, disease-free life.

From the Hardcover edition.PRAISE“In The Cardiovascular Cure, Dr. Cooke has translated the research of our field into life-saving information that we can all use. If you really care about your cardiovascular health, you must read this book!”--Louis J. Ignarro, Ph.D., 1998 Nobel Laureate in Physiology or Medicine for the discovery of Nitric Oxide“This authoritative book appropriately points out why everyone should worry about the health of their endothelium and, better still, do something to protect it if it shows signs of damage.

Early identification and treatment of reduced nitric oxide release should be the preventive agenda for the new millenium.”--Jay N. Cohn, M.D., Professor of Medicine, University of Minnesota Medical School“This book should be read by all patients with heart disease as well as anyone at increased risk for a heart attack or stroke.

The comprehensive risk reduction program recommended by Dr. Cooke uses the most advanced research to help everyone improve the health of their blood vessels.” --William L. Haskell, Ph.D., Stanford Center for Research in Disease Prevention“The Cardiovascular Cure is a lucidly written description of EDRF and endothelial dysfunction.

Treatment with exercise and a diet rich in arginine, vitamins, and anti-oxidants is important to the many patients prone to develop heart attacks or stroke.”--Dr. Ferid Murad, M.D., Ph.D., Director of the Institute of Molecular Medicine at the University of Texas, 1998 Nobel Laureate in Physiology or Medicine“Helping yourself prevent a heart attack means knowing more than your ‘cholesterol count.’

In this clearly written book, Dr. Cooke introduces you to the important role played by the endothelium (the lining of your blood vessels) in this process, and what you can do to keep this vital organ as healthy as possible.”--Gerald Reaven, Professor of Medicine, Stanford University School of MedicineFrom the Hardcover edition.

ABOUT THIS AUTHORJOHN P. COOKE, M.D., Ph.D., is Associate Professor of Medicine and Director of the Section of Vascular Medicine at Stanford University’s Medical School. He trained at the Mayo Clinic, earning a Ph.D. in physiology there, and he was on the faculty of Harvard Medical School before he was recruited to Stanford to spearhead the program in Vascular Biology and Medicine.

He is a sought-after consultant and has served on numerous national and international committees dealing with cardiovascular diseases, including those of the American Heart Association and the National Heart, Lung and Blood Institute. JUDITH ZIMMER has been a medical journalist for more than fifteen years.

She has contributed to such publications as the New York Times, and Self and Fitness magazines, and she currently writes for academic medical centers in New York City.
From the Hardcover edition.

Calculator Helps Users Gauge Heart Attack Risk

(HealthDay News) -- A new online heart disease risk calculator that can help you understand and gauge your heart attack risk is available from the Mayo Clinic.

The risk calculator on MayoClinic.com asks several questions about your lifestyle and health and then determines your 10-year risk of a heart attack. The risk score is based on a number of factors, such as age, gender, tobacco use, cholesterol levels, and blood pressure.

You can find the risk calculator by heading to MayoClinic.com and looking under "Heart Disease Risk Factors," in the Web site's Heart Disease Center.

About one in 10 people with a risk level of 12 percent will have a heart attack or die of heart disease within the next 10 years, experts say.

Here are five heart disease prevention tips:

• Don't smoke or use tobacco products.
• Get exercise. Regular, moderately vigorous physical activity can reduce the risk of fatal heart disease by 25 percent. Combining physical activity with other positive lifestyle habits, such as maintaining a health weight, can provide even more heart health benefits.
• Eat a heart-healthy diet that includes plenty of fruits, vegetables, whole grains, and low-fat dairy products. Legumes, low-fat sources of protein and certain types of fish may also help reduce heart disease risk.
• Limit intake of saturated fats and trans fat.
• Watch your weight.
• Excess pounds can lead to conditions -- high blood pressure, high cholesterol and diabetes -- that increase the risk of heart disease.
• Get regular blood pressure and cholesterol screenings.
• High blood pressure and high cholesterol can damage your cardiovascular system, including your heart.

More information
There's more on reducing heart disease risk factors at the American Heart Association.

FDA Panel Backs Celebrex for Kids With Arthritis

(HealthDay News) -- A U.S. Food and Drug Administration advisory panel recommended Wednesday that use of the painkiller Celebrex be expanded to treat children with juvenile rheumatoid arthritis.

The panel, a committee of doctors and other specialists, voted 15-1 that the benefits of the drug for children with juvenile rheumatoid arthritis (JRA) outweigh the shortage of proof on its safety.

However, the panel also voted 8-7, with one abstention, that available data doesn't demonstrate that Celebrex is safe in treating JRA and that a registry should be established to track these young patients for 10 to 20 years.

"The feeling was short-term efficacy looked good and short-term safety was not an issue. Long-term safety is totally unknown and needs to be known," Dr. Joan Bathon, a Johns Hopkins University rheumatologist and panel member, told the Associated Press.

"That's not unreasonable. But the important part, when they considered both safety and benefit, is the benefits outweighed the risks," Dr. Steven Romano, a vice president in Pfizer's worldwide medical division, told the AP.

"This decision means that one additional therapeutic choice is available for patients and doctors," Dr. Jeffrey Greenberg, director of the Arthritis Translational Research Registry at New York University Hospital for Joint Diseases, told HealthDay.

"Any unknown, long-term cardiovascular risk associated with the use of Celebrex will need to be factored into the decision," he added.

The FDA is not required to follow the recommendations of its advisory committees, but it usually does.

It's estimated that as many as 60,000 children in the United States have JRA, which causes painful joint swelling and can affect growth and development.

Currently, Celebrex is approved to treat adults with osteoarthritis and rheumatoid arthritis. In its application to expand that approval to include treatment of JRA, drug maker Pfizer Inc. included a six-month study that concluded that Celebrex (celecoxib) works as well as naproxen in treating young JRA patients.

Bathon said that the panel recognized the importance of expanding the pool of treatment options for JRA. Vioxx, until it was withdrawn in 2004, had been the only FDA-approved drug of its class for the disease.

Celebrex is a member of the controversial group of painkillers called cox-2 inhibitors, which have been linked to an increased risk of heart attack and stroke.

Two other cox-2s, Vioxx and Bextra, have been withdrawn from the market because of heart risk concerns. Celebrex remains available to consumers, but in 2005, the FDA required that the drug carry a "black box" warning on the possible risk of heart attack or stroke.

During public testimony before the advisory committee Wednesday morning, a New Jersey father said Celebrex had worked wonders for his son, who suffers from juvenile rheumatoid arthritis.

Vincent Del Gaizo, of Whitehouse Station, told the panel members that his son Christopher, now 6, had been in such pain from the disease and was taking so many drugs, he could only sleep three hours a day. Each morning, the boy sat in a high chair with his arms raised for hours because it hurt too much to lower them, the Boston Globe reported.

"It's an image that will be burned in my mind forever," said Del Gaizo, 38. The boy's doctor had "the courage" to try Celebrex "off-label," and now Christopher is able to play soccer and T-ball, his father said.

Also Wednesday, British researchers said they've discovered why Vioxx and other cox-2 inhibitors can cause heart attacks and strokes, BBC News reported.

The reason: These drugs -- designed to block the cox-2 enzyme and halt production of hormones that swell joints and cause pain in people with arthritis -- also stop an enzyme called cox-1 from producing blood-thinning agents. This results in a greater risk of blood clots, the news service reported.

The researchers said their findings are significant because they may lead to the development of cox-2 inhibitors that do not increase the risk of heart attack and stroke.

The findings were published in the Federation of American Societies for Experimental Biology Journal.

More information
For more on with juvenile rheumatoid arthritis, visit the U.S. National Library of Medicine.

Foods Fortified With Folic Acid May Cut Stroke Risk

(HealthDay News) -- Cereals and breads fortified with folic acid, mandatory in the United States and Canada to help reduce birth defects, may also help cut your risk of dying from a stroke, a new study suggests.

Folic acid has long been known for its effect on reducing certain birth defects when taken in sufficient quantities by pregnant women. That was the rationale behind the U.S. Food and Drug Administration's 1998 order for folic-acid fortification of enriched grain products such as cereals and breads. Canada made fortification mandatory that same year.

Now, experts have compared stroke mortality rates in both countries before and after fortification and found that death rates, while already on the decline before, dropped substantially after fortification took effect.

"This is the first population-based study of changes in stroke mortality before and after folic-acid fortification in the United States and Canada," said Quanhe Yang, an epidemiologist at the U.S. Center for Disease Control and Prevention's National Center on Birth Defects and Developmental Disabilities.
Yang is the lead author of the new study, which appears in the March 14 issue of Circulation.
The researchers also looked at stroke death rates in England and Wales, where fortification of foods with folic acid is not required, and did not find a significant change in mortality rates between the years 1990 and 2002.

What triggered the study? "There was accumulating evidence to suggest elevated levels of homocysteine [an amino acid in the blood] increases stroke death risk," he said. "It remains controversial." Some research has found that elevated homocysteine in the blood, by itself, can raise stroke risk, Yang said.

"If you have a high level of folic acid [in your blood], the level of homocysteine will decrease," he added.

Not all the evidence supports that view, however. Two studies released early on Sunday by the New England Journal of Medicine found that even after heart patients lowered their homocysteine levels via folic acid and B vitamin supplementation, their risk for heart attack did not change.

One study did find a "marginally significant" decrease in stroke risk linked to supplement use, while another found no decline in stroke and even a slight increase in heart attack risk after years of supplementation with folic acid and vitamins B6 and B12.

According to experts, the findings cast doubt on the conventional wisdom that folate might help ward off heart disease.

However, Yang's population-based study appears to support the traditional view on folate use. When he and his colleagues examined people before and after fortification became mandatory, they found that homocysteine levels -- and their risk of stroke death -- declined.

The researchers found an association, not a cause-and-effect, Yang emphasized. "The part we don't know is, if the folic acid directly reduces the risk of stroke. It may be that something happens in-between. We do not know yet the mechanism of homocysteine," he said, adding that folic acid somehow breaks down the amino acid.

For the study, Yang and his team reviewed national death statistics in the United States and Canada for the years 1990 to 2002. In the United States between 1990 and 1997, before fortification, the overall death rate from stroke declined by 0.3 percent each year. But from 1998 to 2002, the death rate declined 2.9 percent each year. Those findings translate to about 13,000 fewer stroke deaths each year among U.S. residents over age 40, the study said.

In Canada, the annual decline in stroke-related deaths was 1.2 percent among men and 0.9 percent for women over age 40 before fortification went into effect. After fortification, the declines were 5.6 percent for men age 40 and older and 5.4 percent for women 40 and above -- translating to 2,800 fewer stroke deaths each year after fortification.

Blood levels of folic acid have nearly doubled in the U.S. population since 1998, the authors noted.

Another expert familiar with the study findings called them potentially good news. In the past, researchers have looked at the effects of increasing folic acid on cardiovascular disease, including heart attacks and strokes, said Alice H. Lichtenstein, the Stanley Gershoff Professor of Nutrition at the USDA Human Nutrition Research Center at Tufts University in Boston. "The data for cardiovascular disease has not been encouraging," she said. "This [new study] is looking better."
But, like Yang, she stressed that the study only found an association, not a cause-and-effect. Don't go overboard on folic acid, she cautioned.

Currently, the recommended daily intake of folic acid -- also known as folate -- is 400 micrograms a day for adults and 600 for pregnant women. Many multivitamins contain 400 micrograms. Folate, a B vitamin, is also found in dark green leafy vegetables, fruits such as oranges and strawberries, and in fortified products.

More information
To learn more about folic acid, visit the American Dietetic Association.

Folic Acid Supplements Won't Lower Heart-Attack Risk

(HealthDay News) -- Two new studies question the conventional wisdom that folic acid and B vitamin supplementation lowers cardiovascular risk.

The logic behind supplementation has been that it reduces blood levels of a protein called homocysteine, long linked to heart attack and stroke. But the new research suggests that lowering homocysteine this way has no effect on preventing heart attacks -- and may even trigger a slight rise in heart attack risk.

Both reports will appear in the March 16 issue of the New England Journal of Medicine, but were released early to coincide with their presentation Sunday at the meeting of the American College of Cardiology, in Atlanta.

"Combination vitamin therapies, which do lower homocysteine, have no effect on cardiovascular events, even though the homocysteine level is lowered," said Dr. Joseph Loscalzo, head of the department of medicine at Brigham & Women's Hospital in Boston, and author of an accompanying journal editorial.

There was one glimmer of hope for people taking these supplements, however: One of the two studies did note a "marginally significant" decrease in stroke risk after supplementation.
In the first study, called the Norwegian Vitamin (NORVIT) trial, Norwegian researchers randomly assigned 3,749 men and women who had heart attacks to receive folic acid, vitamins B6 and B12, or a placebo.

Over the three years of the trial, the researchers found that while homocysteine levels dropped an average of 27 percent among people taking folic acid and vitamin B12, this decline in the blood protein had no significant effect on whether people had another heart attack or died from another heart attack.

In fact, people taking all three supplements actually experienced a slightly increased risk of having another heart attack, the researchers found.

"Doctors should not advise patients who have cardiovascular disease to take B vitamins in order to prevent heart disease or stroke," said lead author Dr. Kaare Harald Bønaa, a professor of medicine and consultant cardiologist at the Institute of Community Medicine at the University of Tromsø. "B vitamins do not prevent heart disease," he added.

In the second study, called the Heart Outcomes Prevention Evaluation (HOPE) 2 study, researchers gave more than 5,500 patients who had diabetes or vascular disease folic acid, vitamins B12 and B6, or a placebo.

Over the five years of the study, homocysteine levels dropped significantly among those receiving the supplements, but -- just as happened with the NORVIT trial -- this lowering of homocysteine did not result in significantly reduced risk of death from heart disease or heart attacks.

There did, however, appear to be a slight reduction in stroke among people taking the supplements, the researchers reported.

Overall, however, the researchers concluded that "combined daily administration of 2.5 mg [milligrams] of folic acid, 50 mg of vitamin B6, and 1 mg of vitamin B12 for five years had no beneficial effects on major vascular events in a high-risk population with vascular disease."
They added that "our results do not support the use of folic acid and B vitamin supplements as a preventive treatment."

However, Anne Dickinson, a consultant and past president of the Council for Responsible Nutrition, which represents the supplements industry, said the findings may not apply to relatively healthy Americans who are turning to these vitamins to help ward off heart disease.
She noted that the two study populations involved sicker individuals with a history of heart attack, heart disease, diabetes and other problems.

"These studies did not test whether B vitamins used by healthy people can help keep them healthy," Dickinson said in a prepared statement. "Instead, they looked at whether B vitamins can treat or reverse heart disease in people who already have it. Vitamins should not be expected to perform like drugs -- their greatest purpose is in prevention."

But Alice H. Lichtenstein, director of the Cardiovascular Nutrition Lab at the USDA Human Nutrition Research Center at Tufts University, in Boston, countered that argument. She noted that even outwardly "healthy" Americans develop some level of atherosclerosis -- hardening of the arteries -- as they age, and so the findings would probably apply to the average consumer, as well.

Loscalzo thinks that the message from these studies may not be that lowering homocysteine doesn't prevent heart attacks, but rather that vitamin therapy is not the best way to lower homocysteine.

"These trials of vitamin therapy for high homocysteine have all been consistent in their message, namely, [that] combination vitamin therapies, which do lower homocysteine, have no effect on cardiovascular events, even though the homocysteine level is lowered," he said.

Loscalzo said he believes the supplement treatment somehow counteracts the effect of lowering homocysteine. "Some of those adverse affects may have to do with the complex metabolism of the vitamins," he said. "These vitamins are important for cell growth. It may be that the doses used might have stimulated the growth of cell and atherosclerotic plaque."

According to Loscalzo, there's strong evidence that homocysteine does adversely affect blood vessels. So perhaps the answer lies in smaller doses of vitamins.

"These high doses of folic acid don't provide any benefit and shouldn't be used," Loscalzo said. "Lower doses are safe and may provide benefit, but we don't know that yet.

"It's not that homocysteine is no longer a bad actor," Loscalzo said. "It's that lowering it with this simple treatment isn't the answer."

Lichtenstein agreed that high doses of vitamins may not be as beneficial as some have thought.
"This is one of those cases where you see an association with reduced risk of heart disease with levels of vitamins that would normally be consumed, but when you go to considerably higher levels than people could consume from diet, we get disappointing results," she said.

More information
For more on homocysteine and heart disease, visit the American Heart Association.

Health Highlights: Sept. 10, 2006

Here are some of the latest health and medical news developments, compiled by the editors of HealthDay:
Ibuprofen Can Lessen Aspirin's Cardiovascular Benefits, FDA Says

Taking the pain relievers aspirin and ibuprofen at the same time may lessen aspirin's effects in preventing a heart attack, a U.S. government agency warns.

The Food and Drug Administration says that combining low dose aspirin (usually 81 mg) with 400 mg of ibuprofen (e.g., Advil, Motrin) reduces the antiplatelet effect on the heart the low dose aspirin provides.

In its Sept. 8 report to consumers, the FDA said there is no evidence that taking the two anti-pain medications is harmful, but that ibuprofen has been shown to reduce aspirin's cardio-protective benefit.

But, says the FDA, you can take the two drugs within a reasonable time of each other, under certain circumstances. The research showed that a person could take ibuprofen 30 minutes after taking aspirin. Or aspirin could be taken 8 hours after taking ibuprofen.

Most important, the agency says, check with your physician, especially if you're taking aspirin as part of a daily heart regimen.
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Anti-Inflammatory Drugs Could Cause Damage After Hip Surgery

Anti-inflammatory drugs used six months after hip replacement surgery demonstrate no more pain relief than when they're not used, a new study from Australia and New Zealand says. Furthermore, the use of ibuprofen (e.g., Motrin, Advil) may actually cause unnecessary bleeding, the researchers found.

Scientists from The George Institute for International Health studied post-operative treatment of more than 900 patients, concentrating on the development of ectopic bone formation, which can occur 6-to-12 months after hip surgery. This bone develops in about one-third of hip replacement patients, the researchers say. It forms in soft tissue around the operated hip and can cause inflammation and pain.

While ibuprofen can "greatly reduce" the chances of ectopic bone formation, the scientists, said, it also considerably increases the chance of internal bleeding. And, they note, patients who didn't use ibuprofen reported no greater pain and discomfort 6-to-12 months after surgery than those who used the drug.
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Anticipating a Bad Event Can Make the Memory of it Worse, Study Says
Sometimes, too much knowledge can be a dangerous thing.

In a small study, researchers at the University of Wisconsin-Madison have found that being aware that something bad is about to happen is going to make a person remember it more vividly after the event occurs.

BBC News reports that the study, published in the latest issue of the Proceedings of the National Academy of Sciences journal, found that a part of the brain that triggers memory retention activated when people anticipated an adverse event.

Researchers first showed 36 study subjects a series of symbols, followed by pictures depicting gruesome images, BBC news reported. The symbols indicated the subjects either were going to see the bad photos or be spared the experience. The subjects were quizzed 30 minutes after first having seen the pictures and again two weeks later.

The scientists concluded that those who saw the gruesome images were more likely to remember them more vividly than those who saw benign material. "Our study illustrates how the power of expectancy can extend to memory formation as well, the BBC quotes lead author Jack Nitschke as saying. "Just the expectation of seeing something bad can enhance the memory of it after it happens."

The research may be used in developing ways to treat post traumatic stress disorder, the researchers say.
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Polio Vaccination Effort Begins in Parts of Africa
Attempting to counter claims by some Islamic clerics that the polio vaccine is part of a U.S. plot, officials from the World Health Organization (WHO) have embarked on a campaign to immunize almost 3 million children in the Horn of Africa this year against polio.

According to the Associated Press, the crippling disease has re-emerged in parts of Africa in recent years, and WHO officials are targeting children under 5-years-old in Somalia, Kenya and Ethiopia. According to the health organization, Somalia has reported 215 cases, Ethipia has 37 reported cases since 2004, and Kenya has had no reported cases in 22 years.

The problem is that many people in Africa are nomadic, so the possibility of polio spreading is a real threat, the wire service reports. "Nomadic people move between these countries all the time, so the idea is to try to get to these children and protect them," the A.P. quotes Dr. Mohamed Dahir Duale, a Kenya-based doctor with WHO, as saying.

In 2003 some radical Islamic clerics claimed that the polio vaccine, first developed Dr. Jonas Salk in the United States in the 1950s, was part of a U.S.-led plot to render Nigeria's Muslims infertile or infect them with AIDS. The vaccination program was stopped for more than a year, and cases of polio began to appear.
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Major Changes in NYC Healthcare Use After 9/11: Study
There was a sharp decline in healthcare usage in the New York City region during the three weeks after the Sept. 11 terrorist attacks, but usage then rose above expected levels over the following months, concludes a study in the September issue of the journal Biosecurity and Bioterrorism.

Researchers analyzed health insurance claims from January 2000 to March 2002 for more than two million residents of the New York City region.

The greatest decline in healthcare usage in the weeks after Sept. 11 was among people who lived closest to the World Trade Center (WTC) site. For example, there was an overall 11 percent decline in visits to doctors' offices in the three weeks after 9/11, but a 15 percent decline in office visits by people who lived within a 10-mile radius of the WTC.

The decline in office visits in those first few weeks was likely related to disruptions in access to healthcare services or transportation, the researchers said. In addition, many people may have decided to postpone healthcare visits in order to take care of more immediate issues.

Insurance claims for mental health services were lower than expected for the six months after 9/11. The researchers suggested a number of possible reasons, such people taking advantage of free mental health services, or many not recognizing their need for mental health care. Mental stress may have also manifested as physical illness, which resulted in increased healthcare use for conditions such as chest pain, ulcers, fainting, and irregular heart beats.

Between October 2001 and March 2002, the number of visits to doctors' offices was more than 200,000 over expected levels, the study found.

In related news, residents living near the World Trade Center site said the U.S. federal government has ignored health problems they have suffered as a result of the 9/11 attacks.
At a meeting held Thursday, accountant Tom Goodkind, 52, said that while there are programs for rescue/cleanup workers, little has been done for area residents, the Associated Press reported.

"I don't think that any of these groups have looked at the children of our neighborhoods," Goodkind said.

"Collateral damage, that's what I feel like," said tenant group leader Diane Lapson.
Also on Thursday, the Bush administration said it would provide $75 million for health programs for sick Sept. 11 rescue/cleanup workers.

Celebrex Has 'No Role' Against Colon Cancer

(HealthDay News) -- The final word on whether the cox-2 painkiller Celebrex might be used to prevent colon cancer is a definite "no," according to the long-awaited results of two major studies.

Both of the three-year trials found that the drug reduced the occurrence of precancerous polyps called adenomas in people at risk for colon cancer, but it more than doubled patients' risk for heart attack and other serious cardiovascular events.

"The message is that celecoxib [Celebrex] has no role as a chemotherapeutic agent -- in people with adenomas or in people among the general population. The risks far exceed the potential benefits," said Dr. Bruce Psaty, a professor of medicine, epidemiology and health services at the University of Washington, Seattle.

Psaty co-authored an editorial on the two studies, both of which were expected to be published in the Aug. 31 issue of the New England Journal of Medicine. Both studies received funding from Pfizer Inc., the maker of Celebrex.

Cox-2 inhibitors are part of a class of analgesics called non-steroidal anti-inflammatory drugs (NSAIDs), which also include widely used medications such as aspirin, ibuprofen and naproxen (Aleve). Prescription medications such as Celebrex were originally developed because they are safer on the stomach than other NSAIDs.

However, Celebrex is the only cox-2 inhibitor left on the market. Two other related drugs -- Vioxx and Bextra -- were withdrawn in 2004 and 2005, respectively, following reports of heightened cardiovascular risks.

As mandated by the U.S. Food and Drug Administration, Celebrex now carries a special "black box" warning that advises consumers of the potential heart dangers.

Cox-2 inhibitors work by blocking cyclooxygenase enzymes, which are produced by the body in response to inflammation and are also produced in precancerous tissues.

The latter fact left cancer researchers pondering whether or not long-term use of Celebrex might cut risks for colon cancer.

These two latest trials try to answer that question. The biggest study, called the Adenoma Prevention with Celecoxib (APC) trial, was led by Dr. Monica Bertagnolli, of Brigham and Women's Hospital in Boston. It tracked the incidence of polyps called adenomas in more than 2,000 patients with a prior history of these precancerous growths.

"Adenomas are a precursor of colon cancer -- you could consider them a proxy for colon cancer in the context of this trial," explained co-researcher Dr. John Saltzman, director of endoscopy at Brigham and an associate professor of medicine at Harvard Medical School.

Patients in the trial were divided into three groups: a third received a dummy placebo, a third got 200 milligrams of Celebrex twice daily, and the remaining third received 400 milligrams of the drug twice a day.

The team then had patients come in for regular colonoscopies over the next 3 years.
Celebrex did help bring down the rate of adenoma recurrence, the researchers reported.

While more than 60 percent of those on placebo developed these potentially malignant polyps, that number fell to about 43 percent for those on lower-dose (400 mg/day) Celebrex, and 37.5 percent for those taking the higher dose of Celebrex (800 mg/day).

There was a definite downside to the long-term use of Celebrex, however.

"Compared with placebo, celecoxib was associated with approximately a doubling of the cardiovascular event rates," Psaty noted. Specifically, patients taking lower-dose Celebrex for three years had 2.6 times the rate of serious cardiovascular events -- such as fatal or nonfatal heart attack and/or heart failure -- compared to those taking placebo. That risk more than tripled for those on the higher-dose regimen, the researchers added.

A second three-year study involving nearly 1,600 patients -- this time led by Dr. Bernard Levin of the University of Texas M.D. Anderson Cancer Center in Houston -- found similar results.

The Prevention of Colorectal Sporadic Adenomatous Polyps (PreSAP) trial compared patients who took a placebo to those who received 400 milligrams/day of Celebrex.

It found that the drug cut the rate of adenomas by 36 percent after three years. However, long-term use also significantly boosted patients' risk for cardiovascular trouble.

According to Psaty, the take-home message from both trials is that the cardiovascular risks "far outweighed even the most optimistic projections about the drug's cancer-prevention properties."

Saltzman agreed, adding that heart risks associated with Celebrex probably apply to Vioxx and Bextra as well. "My presumption is that it's a class effect," he said.

However, other NSAIDs might still help lower the odds of colon cancer for patients at high risk, the experts said.

"Low-dose aspirin has been looked at already and does show some chemopreventive effects, with about a 20 percent reduction of recurrent adenomas," Saltzman noted. "And certainly low-dose aspirin is used by doctors everywhere to help the heart."

Even though aspirin's anti-cancer benefits aren't as great as those attributed to Celebrex, "I think it is not an unreasonable thing for people to pursue," he said.

The new findings probably won't change the status quo when it comes to the marketing of cox-2 inhibitors, the experts said, since much of the side-effect data had been published before.

"I don't think this gives new or additional information that will help with the determination of whether these drugs should stay on the market," Saltzman said.

More information
There's more on cox-2 inhibitors at the U.S. Food and Drug Administration.

Do you know any substances that May Lower Cholesterol

Interest in the heart-health benefits of fish oil dates back about two decades, beginning with a 1980 study showing that Eskimos in Greenland — who eat nearly a pound of fish a day — have low rates of death from heart disease.

In subsequent years, there has been substantial research on the effects of fish oil on the heart and arteries. Laboratory studies have shown that fish oil, which contains what are known as n-3 or omega-3 fatty acids, makes blood platelets less sticky, helps protect the linings of arteries, and may also lower blood pressure. Population studies from several countries have shown lower rates of heart disease in people who eat fish regularly. In 1998, data from the Physicians’ Health Study showed that eating fish once a week versus less than once monthly halved the likelihood of dying suddenly from a heart attack.

Total heart attack rates were not affected by fish consumption or the amount of omega-3 fatty acids ingested. One year later, a report in Lancet described a randomized trial in which men who’d had a heart attack received either a fish oil supplement, 300 mg of vitamin E, both, or neither. The groups who received the fish oil supplement had significantly lower rates of heart attack, stroke, and death during the next three and a half years.

Rates of sudden death dropped by 45%. Additional support for fish oils comes from a report on nearly 80,000 women in the Nurses’ Health Study. Published in 2001 in the Journal of the American Medical Association, this 14-year study found that eating fish at least twice a week versus less than once a month cut in half the risk of strokes caused by clots blocking an artery to the brain.

The Nurses’ Health Study also found that eating one to three servings of fish per month cut the risk of heart disease by 20%, while eating at least five servings a week lowered risk by 40%. Anyone hoping to benefit from fish oil would probably be better off sticking with dietary sources, primarily from cold-water fish such as salmon, trout, mackerel, sardines, and herring. Forgoing meat for cold-water fish, or any fish for that matter, may lower cholesterol and heart disease risk simply by reducing the amount of saturated fat in your diet.

Three groups of people may benefit from fish oil supplements. One group includes people with arrhythmias, or disordered heart rhythms. The omega-3 fatty acids in fish oil can stabilize wayward electrical activity in the heart and calm arrhythmias. The second group includes people with high levels of triglycerides, especially those who can’t control the problem through diet and exercise, because fish oil supplements have been shown to help lower triglycerides.

The third group includes people with coronary heart disease. The American Heart Association recommends that these people eat one serving of fatty fish a day; recognizing that this may be more fish than most people will eat, the association notes that a supplement can be substituted.

Breast Cancer Risk with HRT May Be Lower Than Thought

(HealthDay News) -- A new study sounds a note of calm in the sea of concern that has surrounded recent findings on the potential risks of hormone replacement therapy for postmenopausal women.

According to this research, a woman's risk of developing breast cancer while taking combined hormone replacement therapy (HRT) is actually fairly low.

"It really confirms what's been known and what good doctors have been attending to since the Women's Health Initiative published their initial results showing that there could be a problem with breast cancer and HRT," said Dr. Julia Smith, director of the Lynne Cohen Breast Cancer Preventive Care Program at New York University Medical Center/Bellevue, in New York City. "[Combined HRT] could be a short-term option after weighing possible risks, but this has to be done as an individual analysis."

The medical community was stunned when, in 2002, investigators pulled the plug on the Women's Health Initiative trial due to evidence that women taking HRT had a higher incidence of heart attacks, stroke, blood clots and breast cancer.

Although HRT is approved to alleviate menopausal symptoms, based largely on observational data, doctors had been prescribing hormones to women to prevent cardiovascular problems.
"For years, doctors told people this medicine prevents heart disease," said Dr. Jay Brooks, chairman of hematology/oncology at the Ochsner Clinic Foundation in New Orleans. "It doesn't. It increases the risk of heart disease."

A more recent study confused matters even more by suggesting that estrogen, when given alone, may not increase the risk of breast cancer.

The authors of the new study, which appears in the Aug. 6 issue of the British Medical Journal, tried to sort through the confusion by assessing risk from an individual perspective.

The researchers, based at the New South Wales Breast Cancer Institute in Australia, estimated the individual breast cancer risk of women up to 79 years of age, something known as cumulative absolute risk.

The cumulative absolute risk of breast cancer declined as a woman aged, as long as she was not taking combined HRT, meaning estrogen and progestin.

For women aged 40 to 79 who are not using HRT, the average risk of breast cancer is 7.2 percent (one in 14); at 50 years of age, it is 6.1 percent (one in 16); and at 60 years, it is 4.4 percent (one in 23).

When combined HRT is added, however, the risk starts to climb. A woman taking HRT for five years starting at age 55 has an additional risk of 0.6 percent. If she takes it for 10 years, the risk climbs to 1.8 percent.

Once the therapy is stopped, however, risk returns to that of a woman of the same age who has never used hormones, the study stated.

The increased risk was even less if the woman used estrogen alone: 6.3 percent (an extra risk of 0.2 percent) at five years.

There are very real, documented problems with using estrogen alone, however.

"If a woman has a uterus, you cannot give estrogen alone because there's no question that it increases uterine cancer," Smith said. "There are also very serious health issues related to giving estrogen, including the risk of stroke."

Once again, it comes down to the individual woman.

"If you have a woman who is going through menopause or has gone through menopause and has severe, severe symptoms and her quality of life is untenable, you look at her other medical problems and you see that she's youngish and has no obvious risk for heart attack, stroke or thromboembolic problems, you may give her a short course of HRT," Smith said.

If not, then you start looking at other ways to alleviate symptoms, such as diet and exercise and other drugs, including certain antidepressants.

"It shows that the risk [revealed in the new study] is small but you have to understand that this is for breast cancer only, not heart disease, which is another risk," Brooks said. "You have to ask yourself, 'Do I want a medicine that may increase my risk for breast cancer, heart disease and stroke to alleviate symptoms that are not going to kill me, that are going to get better in over 85 percent of all women with time.' That's the question individual women have to raise."

More information
To learn more about breast cancer, visit the American Cancer Society.

Timing May Be Key to Hormone Therapy

(HealthDay News) -- While controversy on the safety of hormone replacement therapy (HRT) continues, a new study suggests that when a woman begins the therapy may be key to whether or not it will protect her from heart disease.

According to the new report, women who start HRT when they are younger, near the onset of menopause, have about a 30 percent lower risk of coronary heart disease compared with women who never use hormones. However, women who start HRT 10 years or more after menopause, or after the age of 60, gain no cardiovascular benefit from the therapy.

"The timing of hormone therapy in relation to age and time since menopause may be a key factor in whether these hormones protect the heart or increase risk of heart disease," said researcher Dr. JoAnn E. Manson, the chief of the division of preventive medicine at Brigham and Women's Hospital, in Boston.

These findings may help to address the discrepancies in results from earlier studies, Manson said.

The report appears in the January/February issue of the Journal of Women's Health.
In their study, Manson and her colleagues looked at the association between heart disease and HRT as they relate to age. The women in the study had all participated in the Nurses' Health Study from 1976 to 2000.

The team found that women who started HRT near menopause had a significantly reduced risk of heart disease compared with women who didn't start HRT. In contrast, women who started HRT after age 60 or 10 or more years after menopause gained no protective effect from hormone replacement.

"What we need is a way to identify women who are good candidates for HRT versus women who are poor candidates for HRT," Manson said. "The findings that age and time since menopause may be key factors is an important first step."

A lot of women who are good candidates for HRT may have been scared away by findings suggesting no heart benefit or that the risk of heart disease might outweigh the benefits, Manson said. "The risk of heart disease and stroke are lower in the younger, recently menopausal women," she said.

But in older women, existing damage to vessels may be the reason HRT does not protect them from heart disease. "If a blood vessel already has advanced atherosclerosis, hormone therapy may be more likely to cause a clot," Manson speculated.

"However, if the blood vessel is open, the increase in clotting risk usually will not translate into a heart event, and some of the benefits may predominate as improvement in cholesterol, improvement in insulin sensitivity and antioxidant effects. Estrogen may actually delay the development of artherosclerosis in those women," she added.

One expert doesn't think the findings should change current recommendations.

"This is an important question," said Dr. Nieca Goldberg, the chief of women's cardiac care at Lenox Hill Hospital, in New York City. "However, we would need a randomized trial. The results of this study are not going to change the current guidelines on the prescription of hormone therapy," she said.

Goldberg believes that women who want to lower their risk of heart disease should stick to reducing the known risk factors.

"Women should continue to use proven therapy," she said, noting that lifestyle changes, such healthy diets and exercise, "clearly have been proven to reduce risk." Of course, "that may not be as easy as taking a pill," Goldberg added.

In addition, women who need treatment for risk factors like high blood pressure and high cholesterol should be taking medications that have been documented to reduce the risk of heart attack and stroke in women, Goldberg said. "We still do not prescribe HRT for heart disease prevention."

Concerns about HRT were initially raised by the Women's Health Initiative, a landmark study involving 27,000 participants that caused many women to discontinue their use of hormone therapy.

Researchers halted the WHI study in 2002 after they found the regimen entailed more health risks -- most notably an increased risk for breast cancer and stroke -- than benefits.

Several subsequent studies have also questioned the WHI findings. One study noted some women in the WHI project were in their 60s and 70s who hadn't been on hormones before. Because these women were older, they were already at greater risk of cardiovascular problems, researchers reasoned.

More information
For more on HRT, head to the National Institutes of Health.

Be Skeptical About Alternative Therapies

A number of natural therapies are promoted as treatments for heart disease, but few have lived up to the marketing hype when put to the test in scientific studies. And because herbs and other nutritional supplements are not reviewed for purity or effectiveness by the FDA, you can’t be sure that what you’re buying is effective, or even that the bottle contains the substance on the label. If you take any herbal remedies, be sure to tell your doctor.

These preparations may hinder or exaggerate the effects of prescription drugs used to manage coronary artery disease. Indeed, people with heart disease are more vulnerable than most others to adverse drug interactions.

Antioxidant supplements Some people believe that antioxidant pills provide a way to counter the biological oxidation that activates unhealthy LDL and initiates atherosclerosis. But the research hasn’t panned out.

The American Heart Association in 2004 published an analysis of 15 large trials involving thousands of volunteers who didn’t know whether they were taking an antioxidant pill (either vitamin E or beta carotene) or a placebo. The result?

For the most part, there was no evidence that antioxidant therapies lessen the risk of developing or dying from coronary artery disease. Two studies even suggest that antioxidants might make matters worse. A 2001 study of people who had undergone angiography and had a stent inserted found that those who took antioxidant supplements were more likely to experience restenosis than those who did not — even though both groups were taking statins and niacin to prevent just this occurrence.

A 2002 study found that postmenopausal women on hormone replacement therapy who also took antioxidants were more likely to die than women taking only hormones. The research into antioxidants is continuing, but for the time being the best bet is to obtain these vitamins by eating a variety of fruits and vegetables.

Carnitine This amino acid is found in many foods, especially meat, poultry, fish, and dairy products. Carnitine works with several enzymes as a sort of cellular escort service, ferrying fats into the cell to generate energy and then hauling harmful by-products out for disposal.

Proponents of carnitine believe it can help the heart to generate energy more efficiently.

A handful of clinical trials suggest that taking carnitine supplements might have a modest benefit in treating angina, heart attack, and heart failure. At this point, carnitine is in the "promising but unproven" category. If standard treatments aren’t working to keep your chest pain, leg pain, or heart failure in check, talk to your doctor about adding this supplement to your current therapy.

Chelation therapy (chelation & detoxification) uses infusions, or slow injections, of a chemical known as EDTA. This process is sometimes used to remove toxic levels of lead, iron, or other metals from the body. (The chelated metals exit the body via the urine.) Chelation therapy has also been promoted as a way to cleanse the coronary arteries.

Proponents say a series of 30 or so intravenous infusions will dissolve cholesterol-filled plaque and offer a natural way to ease angina or avoid heart surgery. But so far the research hasn’t substantiated these claims. An analysis of 22 studies found that chelation improved neither objective measures like capacity for exercise nor more subjective outcomes like symptom relief and quality of life. Chelation can also have serious side effects, such as kidney failure, dangerous heart rhythms, and convulsions.

Many experts believe chelation therapy is worthless. Yet thousands of people are paying thousands of dollars each year to receive this treatment. The last word on the subject may arrive in 2007, when the results of a randomized study, involving 100 medical centers and sponsored by the National Center for Complementary and Alternative Medicine, is completed.

Coenzyme Q10 This vitamin-like substance is found in almost every cell in the body, but it is most prevalent in tissues with high energy demands, such as the muscles or the heart. Many advocates of alternative medicine believe that it can strengthen the heartbeat by increasing the cellular fuel available to the heart muscle. And some small studies have suggested that it might help people with angina, heart failure, or other cardiovascular problems.

Other studies, however, report that coenzyme Q10 is of little benefit in these situations. For now, it appears that this supplement is safe, but there is no good evidence that it improves heart health.

Policosanol This product is marketed as a cholesterol fighter. Some small, short-term studies indicate that it lowers harmful LDL and raises helpful HDL levels about as well as a low-dose statin. It also appears to make blood platelets less sticky, thereby reducing the risk for blood clots.

However, almost all studies done on policosanol were carried out by a single research team in Cuba. And no one knows if taking this product will result in fewer heart attacks and strokes. Finally, some policosanol sold in the United States is made from beeswax, which may or may not have the same effects on cholesterol as the product used in the Cuban studies, which was derived from sugarcane wax. At this point, the better bet to control cholesterol is to eat a healthy diet, exercise regularly, and take a statin if necessary.

From the Harvard Health Publications Special Health Report,

The Healthy Heart: Preventing, Detecting, and Treating Coronary Artery Disease.

Copyright 2005 by the President and Fellows of Harvard College. I

llustrations by Harriet Greenfield, M.A., Scott Leighton, Michael Linkinhoker, and Ed Wiederer. All rights reserved. Written permission is required to reproduce, in any manner, in whole or in part, the material contained herein. To make a reprint request, contact Harvard Health Publications.

Used with permission of StayWell.

Journal Editor Criticizes Authors of Migraine Study

(HealthDay News) -- The authors of a new study linking migraines with aura to an increased risk for heart woes came under attack Tuesday by the editor of the medical journal that published their research the same day.

The editor-in-chief of the Journal of the American Medical Association criticized six researchers, led by a Harvard professor, for not disclosing that they have done consulting work or received research funding from makers of treatments for migraines or heart-related problems, the Associated Press reported.

The research, published in the July 19 issue of the journal, came a week after the journal announced a crackdown on researchers who don't reveal industry ties.

Dr. Catherine DeAngelis, JAMA editor-in-chief, said her editors did not know about the ties until the AP brought it to their attention.

"We'll get killed," the wire service quotes her as saying, referring to the potential damage to the journal's reputation.

During the past two months, there have been two cases of JAMA authors not disclosing their consulting relationships with drug companies, one involving antidepressants and the other arthritis drugs.

DeAngelis told the AP that she would have added the authors' financial association with the pharmaceutical companies if she had known about them, especially in the latest incident.
Dr. Tobias Kurth, the study's lead author and an assistant professor of medicine at Harvard School of Public Health in Boston, said the researchers were not trying to mislead the journal because they believed their financial ties were irrelevant. The study does not promote drug treatment, he added.

The research found specifically that women aged 45 and older who have migraines with aura are at an increased risk for heart attacks, strokes, angina and death due to cardiovascular disease but that there was no increased risk for women with a history of migraine without aura.

"This study confirmed an association between migraine with aura and stroke that was previously identified, and also demonstrated that migraine was a risk factor for ischemic heart disease as well," said Dr. Richard B. Lipton, co-author of an editorial accompanying the study and director of the Montefiore Headache Center in New York City.

"We expanded it beyond ischemic stroke," added Kurth. "The heart part is new, but it's not a different mechanism. It just shows a higher risk of overall cardiovascular disease."

About 18 percent of women and 6 percent of men have migraine in any given year, with some 28 million Americans suffering from the condition.

Migraine headaches are especially severe and can involve nausea, vomiting, sensitivity to light and sound. In some cases, the event also involves an aura -- visual and sensory "warning signs" just before the attack.

Migraines with auras, which comprise the minority of migraine attacks, have already been linked to an increased risk of ischemic stroke. Their association with other cardiovascular problems has not been established.

To evaluate the risk between migraine (with and without aura) with risk of vascular events, the authors looked at data on nearly 28,000 women aged 45 and older who were participating in the Women's Health Study.

Women who reported having active migraine with aura had about double the risk of major cardiovascular disease and heart attacks, almost double the risk for ischemic stroke and a 70 percent higher risk for ischemic cardiovascular death.

This translated into 18 additional major cardiovascular disease events attributable to migraine with aura per 10,000 women per year.

Women who had migraines without aura did not face increased risk in any of these areas. That's good news, since most migraine sufferers do not experience aura.

"It's important to understand that, for most migraine patients, this is not an issue," Kurth said. "Migraine without aura was not associated with any increased risk of vascular events, and this is the vast majority of migraine sufferers."

The biological mechanisms linking aura and cardiovascular risk remain unclear.

"There's pretty good evidence that migraine with or without aura have separate genetic risk factors," Lipton explained. "One of the migraine-with-aura genes is associated with elevated levels of high blood pressure and other risk factors. So, one possibility is that there's a genetic link between migraine with aura and heart disease."

For women who do experience aura with their migraines, there are some common-sense strategies.

"Over the last 20 years, there has been an enormous emphasis on knowing your risk factors for heart disease and reducing them," Lipton said. "This study suggests that migraine with aura should be added to that list of risk factors, at least in women over 45."

Scientists don't know, however, if treating the migraine itself will decrease the risk.

While researchers search for that answer, women should pay attention to known risk factors.
"Women with migraine with aura should be especially careful about addressing those risk factors that they can modify for heart disease, such as cholesterol and high blood pressure," Lipton said.

"Patients and treating physicians should be particularly cautious about other modifiable risk factors for cardiovascular disease, in particular smoking," Kurth added.

And research needs to confirm the findings in men and in younger women to see if they, too, should heed heightened precautions.

More information
The National Institute of Neurological Disorders and Stroke can tell you more about migraine.

Can Your Blood Endanger Your Baby?

Can Your Blood Endanger Your Baby?

Provided by: DrWeil.com

Q: My wife and I are both "O Positive" blood types, and I was wondering if it was okay for us to start planning a family. I know some bloods can be toxic if mixed, and I wasn't sure if that also meant the same blood type as well. -- Scott D.

A: Having the same blood type is not a problem when you're planning to start a family. The only concern is your Rh status (and you indicate that both you and your wife are O positive, meaning type "O," Rh-positive), so that's okay, too. Regardless of blood type, 85 percent of all people carry a protein on their red blood cells known as the Rh factor.

They are considered "Rh-positive." The other 15 percent lacking the Rh factor are described as "Rh-negative." (In African-Americans, about half as many are Rh-negative.) If a woman is Rh-negative, her husband should be tested early in pregnancy. If he is also Rh-negative, the baby will be, too, so there's no problem. However, there is potential for trouble when a woman is Rh negative and her baby is Rh-positive (from an Rh-positive father).

Under these circumstances, particularly in a second or third such pregnancy, the mother can develop anti-Rh antibodies that can attack the fetus and cause severe anemia. This can happen whenever the baby's blood comes into contact with the mother's during pregnancy or delivery.
In the past, some 20,000 children a year were born with Rh disease, which can lead to jaundice, anemia, brain damage, heart failure and death. However, sometimes it is so mild that no treatment is needed.

A treatment introduced in 1968 has reduced the incidence of Rh disease among infants born in the United States to 4,000 per year. Injection of a blood product called Rh immune globulin (RhIg or RhoGAM) can block the immune attack and its consequences for the babies in 95 percent of women treated. RhIg usually is given by injection to Rh-negative women (with Rh-positive fathers) at 28 weeks of pregnancy and after delivery.

It is also given to Rh-negative mothers carrying Rh-positive babies after a miscarriage, ectopic pregnancy, induced abortion, or transfusion with Rh-negative blood, as well as after amniocentesis (a procedure during which a small amount of amniotic fluid is withdrawn for testing), or a prenatal test called chorionic villus sampling (CVS).

Rh disease isn't typically a worry during a first pregnancy because the baby usually is born before the mother's Rh-negative blood is sensitized. However, subsequent pregnancies present an increasing risk to the babies if the mother isn't treated with RhIg.

I hope this explanation sets your mind at rest. The fact that you and your wife are both Rh-positive means that you don't have to worry about any of this.


Andrew Weil, M.D. –Author of:
Eight Weeks to Optimum Health
Spontaneous Healing
The Natural Mind
The Marriage of the Sun and Moon
Health and Healing
Natural Health, Natural Medicine
From Chocolate to Morphine (with Winifred Rosen)

New Cholesterol Guidelines?

New Cholesterol Guidelines?
Provided by: DrWeil.com

Q: I understand that there has been a change in what's considered normal cholesterol. Can you explain the difference and the reason for the change? -- Richard

A: Government health officials have recommended that target levels of LDL ("bad") cholesterol should be reduced by 30 points for people considered at moderate to high risk for heart disease.

Up to now, an LDL of 130 was considered acceptable for those with a high risk of heart disease. According to the new recommendations, LDL levels for people at high risk should be below 100. You're considered at high risk if you already have heart disease, diabetes, non-coronary atherosclerosis, or some other condition that increases your risk of a heart attack to 20 percent or more over the next 10 years.

The same reduction was recommended for those considered at "moderately high" risk of heart disease -- anyone with such risk factors such as advancing age, high blood pressure, cigarette smoking, and other lifestyle-related risks such as obesity, physical inactivity, or metabolic syndrome (elevated triglycerides and low HDL).

If you fall into this category, you have a 10 to 20 percent chance of suffering a heart attack within 10 years. If you have no risk factors for heart disease, you're unaffected by the new recommendations.

Under the new guidelines, millions of Americans whose LDL levels range from 100 to 129 will be treated with cholesterol-lowering "statin" drugs with the goal of reducing LDL levels by 30 to 40 percent, no matter what they are at the outset.

The changes were set in motion after results from five recent clinical trials indicated that the old cholesterol goals weren't low enough and that heart attack prevention is more effective when LDL levels are pushed well below 100. In fact, evidence suggests that high-risk patients do best when their LDL is below 70, a level that may be hard to reach even with high doses of statins.

The new recommendations were published in the July 13, 2004, issue of Circulation and were endorsed by the National Heart, Lung and Blood Institute, the American Heart Association and the American College of Cardiology.

Andrew Weil, M.D. –Author of:
Eight Weeks to Optimum Health
Spontaneous Healing
The Natural Mind
The Marriage of the Sun and Moon
Health and Healing
Natural Health, Natural Medicine
From Chocolate to Morphine (with Winifred Rosen)