Screening Athletes Could Cut Sudden Cardiac Death Risk

(HealthDay News) -- Including an electrocardiogram in screenings for heart disorders in competitive athletes would improve detection of those at risk for sudden cardiac death and save lives, say Italian researchers.

In the United States, a young competitive athlete dies every three days from an undetected cardiovascular disorder, according to background information in the study. In most of these kinds of cases, the athletes appear healthy and have no previous clinical signs of heart problems.

In the United States and some European countries, authorities have recommended a pre-participation evaluation that includes a detailed family history as well as a physical examination. In Italy, athletes entering competitive sports also must have two electrocardiograms (ECGs), which measure the electrical activity of the heart. One ECG is done while the athlete is at rest, and the other is done while the athlete is exercising.

The use of ECG as part of screening is controversial because of concerns about cost-effectiveness and the number of false positive results.

In this study, researchers at the University of Florence studied the use of ECG in 30,065 athletes who had a complete pre-participation cardiovascular evaluation. During resting ECG, 348 (1.2 percent) of the athletes had distinctly abnormal test results, while 1,459 (4.9 percent) had abnormal results while exercising.

The average age of people with abnormal results only during exercise was 30.9 years, while the average age of those with normal results was 24.9 years.

Of the 159 people who were disqualified from sports due to heart problems, 95 percent would have been missed if only family history and physical examination was used, and 79.2 percent would have been missed if they had only a resting ECG.

ECGs should be added to screening programs for all people taking part in competitive sports, especially those who are middle-aged or older, the researchers said.

The study was published online Thursday in the British Medical Journal.

More information
The MedlinePlus Medical Encyclopedia has more about hypertrophic cardiomyopathy.

What We Can Learn From the Death of Tim Russert

By Dena Rifkin, MD

Like most people, I read about the sudden death of Tim Russert with sadness. Out-of-hospital sudden cardiac death is, unfortunately, still a common event among people with undiagnosed or diagnosed heart disease. In fact, it is very common indeed: 310,000 people a year die this way in the U.S. What’s more, it’s a tough problem to study or treat. How do you treat something that happens out of the blue, far from a hospital, away from medical care? And what’s the point of even worrying about something that is seemingly random and unstoppable? Read More

Heart Failure Raises Risks After Non-Cardiac Surgeries

(HealthDay News) -- Older people with heart failure face heightened odds of complications and death after non-cardiac surgeries, according to the largest study ever conducted on the issue.

"We're trying to draw attention to this major problem," said lead researcher Dr. Adrian F. Hernandez, an assistant professor of medicine at Duke University in Durham, N.C.

Heart failure, the progressive loss of the heart's ability to pump blood, is widespread among older Americans, but it sometimes is overlooked as a risk factor when surgery is needed, he said.

"Most physicians focus on whether [older patients] have coronary artery disease or have a risk of heart attack," Hernandez said. "Heart failure is by far a more important risk factor, but it doesn't usually have greater weight when they want to identify patients at risk of complications or consider how they want to treat them after surgery."

Symptoms of heart failure include shortness of breath, fatigue and swelling of the legs.

Hernandez' group published the study in the April issue of Anesthesiology. They used Medicare data on more than 159,000 people undergoing major surgery not involving the heart, such as hip replacement operations. Past estimates have put the incidence of heart failure in the older population between 5 percent and 12 percent, but the new study found the condition in almost 20 percent of those having surgery.

The study divided the participants into three groups: those with heart failure, with or without coronary artery disease; those with only coronary artery disease; and those with neither condition.

Nearly 98 percent of all those who had surgery were discharged soon afterward from the hospital. But 17.1 percent of those with heart failure had to be re-hospitalized within 30 days, compared to 10.8 percent of those with coronary artery disease and just 8.1 percent of those with neither ailment.

In the month after a surgery, 1.6 percent of those with heart failure died, compared to 0.5 percent for those with coronary artery disease and 0.3 percent of those with neither condition, the study found.

Steps can be taken to reduce the toll, Hernandez said.

"The first thing is to check on what the conditions are that might influence the patients outcomes," he said. "We have to identify therapies that lower the risk of a poor outcome and assure that all patients, when they have surgery, are carefully monitored."

Close attention should be paid to be sure that symptoms of heart failure are kept to a minimum, Hernandez said. Medications such as beta blockers and diuretics can be used to keep heart failure under control, he added.

But he noted that it's not certain how effective such measures might be in reducing risks -- only a rigorous, controlled study could answer that question definitively.

"We are planning to do such studies, but our planning is still in the early stages," he said. "We still need to identify sponsors of such a study."

One expert applauded the new research.

The increase in surgery risk due to heart failure has been noted before, but "this is a big study that involves a lot of people. It solidifies that the risk is real, and the risk is substantial," said Dr. Robert Hobbs, a staff cardiologist at the Cleveland Clinic whose work covers heart failure and transplant medicine.

Measures that can be taken to reduce the risk include simply not performing surgery, if possible, on someone whose life might be endangered, Hobbs said. "If surgery is necessary for someone with heart failure, there should be targeted use of heart failure medications before the operation and an effort to avoid overloading the body with intravenous fluid during the procedure," he said.

"And we would certainly watch them more carefully in the postoperative period," Hobbs added.

More information
Learn about heart failure, its symptoms and treatment, from the U.S. Library of Medicine.

Hormone Therapy Only Helps Some Older Men With Prostate Cancer

(HealthDay News) -- Adding hormone therapy to radiation treatment for fast-moving prostate cancer can save lives, but the benefit often doesn't apply to men who have other serious medical problems, a new study shows.

"The new message from this study is that there definitely is a difference in outcome, depending on the gentleman's health," said Dr. Anthony V. D'Amico, chief of genitourinary oncology at Brigham and Women's Hospital in Boston. His report is published in the Jan. 23 issue of the Journal of the American Medical Association.

The old message, reported in 2004 on the five-year point of the study, was that treatment to suppress the activity of male hormones known as androgens improved survival of older men with aggressive prostate cancer, D'Amico said.

But the new report showed the benefit was limited to men without other serious medical problems. Adding hormone therapy to radiation treatment in the 206-man study decreased the rate of death significantly, but the benefit was confined to men without other health issues.

"This report is important, because it is part of a story that is emerging about hormone therapy in men with prostate cancer who are elderly," D'Amico said. "If a man is 75 and otherwise healthy, adding hormone therapy is likely to help. If the same man has had a heart attack or stroke, or if he is a smoker or diabetic, adding hormone therapy makes it worse."

In terms of clinical practice, the finding means that "before I treat him, I get him to a specialist and try to get his health cleared up as much as possible before giving the hormone therapy," D'Amico said. "If he has heart disease, I would consult a cardiologist; if a stroke, I would consult a neurologist; if diabetes, a diabetologist."

The idea is not anything new in medicine, he added. "It is the same as with a surgical procedure," D'Amico said. "You do not give the therapy until it is cleared by the appropriate specialist."

The study is relatively small and requires further confirmation, said Dr. Durado Brooks, director of prostate and colorectal cancer at the American Cancer Society.

"But for men trying to make a decision about prostate cancer treatment, it provides useful information for the men and their physicians," Brooks said. "A man who has had radiation treatment, if he and his doctor talk about the results of this study, it can help them make a decision about hormone treatment in a more informed way."

The results apply to "a significant percentage of older prostate cancer patients," Brooks said, noting that the average age of men in the study was over 70.

Until now, only general advice about hormone treatment could be given to such men, he said. "Now we can be a little more specific and say, 'If you don't have underlying cardiac disease or other major co-morbid conditions, the chance of having a good response to the treatment is better.' But many men with heart disease or other problems may decide they do not want to deal with the side effects of hormone treatment."

More information
Learn more about prostate cancer and its treatment from the American Cancer Society.

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Advantages and Disadvantages of Alcohol Intake on Cardiovascular Health Reviewed

News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD

The latest American Heart Association guidelines caution people not to start drinking alcohol if they do not already drink alcohol, according to a review of the advantages and disadvantages of alcohol intake on cardiovascular health published in the August 23 Online First issue of the Journal of the American College of Cardiology.

"Accumulating scientific evidence indicates that light to moderate drinking done on a daily basis may significantly reduce the risks of coronary heart disease (CHD) and all-cause mortality," write James H. O'Keefe, MD, FACC, and colleagues from the Mid America Heart Institute in Kansas City, Missouri. "In contrast, excessive alcohol intake and binge drinking are toxic to both the heart and overall health and are the third leading cause of premature death among Americans.

The purpose of the present review is to:
1) outline the specific benefits and risks of alcohol, and the threshold of intake at which drinking becomes a health danger rather than an advantage;
2) detail the mechanisms whereby alcohol confers cardioprotection; and
3) discuss the ideal quantities, drinking patterns, and beverages, and which individuals are most likely to benefit."

Research to date has shown J-shaped relationships between alcohol consumption and several adverse health outcomes, including all-cause mortality, CHD, diabetes, hypertension, congestive heart failure, stroke, dementia, and Raynaud's phenomenon.

Some cardioprotective benefits have been demonstrated for light to moderate alcohol consumption (up to 1 drink daily for women and 1 or 2 drinks daily for men). Most studies have shown that light to moderate drinking is associated with risk reductions for CHD of approximately 30% to 35%.

Alcohol consumed in moderation seems to have an antiatherosclerotic effect, with decreased incidence of peripheral arterial disease and decreased atherosclerotic burden shown by coronary angiography, computerized tomography-detected coronary calcium, and carotid ultrasound.
Like exercise, alcohol consumption seems to be most cardioprotective when done daily and in moderation. However, increasingly excessive consumption is associated with proportional worsening of outcomes.

Because of the beneficial effects on high-density lipoprotein (HDL) cholesterol, insulin action, and inflammation, light to moderate alcohol intake may be particularly helpful for patients with abnormal glucose metabolism and/or insulin resistance. Light to moderate alcohol intake may be associated with reductions in the prevalence and incidence of diabetes, and a large meta-analysis with 12-year follow-up showed a 30% reduction in new diabetes in those who consumed 1 to 2 drinks daily.

The cardiovascular benefits associated with alcohol consumption protection are thought to be mediated by improvements in insulin sensitivity and HDL cholesterol. The major protective component seems to be the ethanol itself, and not the other ingredients found in different types of alcoholic beverages.

In a meta-analysis incorporating data from more than 1 million participants, consumption of 1 drink daily by women and 1 or 2 drinks daily by men was associated with an 18% reduction in total mortality, but daily intakes of more than 2 drinks in women and 3 drinks in men were associated with dose-dependent increased mortality.

Although low-dose, daily alcohol consumption has been linked to better health than less frequent use, binge drinking increases cardiovascular events and mortality, even in otherwise light drinkers.

"Alcohol should not be universally prescribed for health enhancement to nondrinking individuals owing to the lack of randomized outcome data and the potential for problem drinking," the study authors note. "Alcohol (ethanol) consumption is analogous to the proverbial double-edged sword, and perhaps no other factor in cardiovascular (CV) health is capable of cutting so deeply in either direction depending on how it is used."

Guidelines from the United Kingdom suggest that middle-aged or elderly men and postmenopausal women who drink seldom or never might consider the possibility that light drinking would benefit their health. On occasion, the reviewers have made a similar recommendation to patients who do not smoke and who have no personal or family history of substance abuse and no history of depression or bipolar disorder. However, they argue that light to moderate drinking should not be universally recommended to the general public or even to patients with cardiovascular disease.

As an analogy, they point out that observational data and findings from randomized trials using surrogate endpoints suggested that hormone replacement therapy for women and antioxidant vitamins improved cardiovascular outcomes, whereas later randomized trials with larger samples led to the opposite conclusions. They note that no randomized trials of alcohol for improving clinical outcomes have yet been performed. In observational studies, residual unmeasured confounding factors could be contributing to apparent benefits that seem to be associated with light to moderate drinking.

The investigators further note that heavy drinking has caused significant individual and societal problems and morbidity. In the past 15 years, the rates of alcohol abuse and binge drinking have been increasing, according to the findings of some studies. Alcohol abuse causes 100,000 deaths each year in the United States, and it has been deemed the third largest preventable cause of death.

Excessive alcohol consumption has been associated with increased risks for all-cause mortality, motor vehicle crashes, stroke, cardiomyopathy, cardiac dysrhythmia, sudden cardiac arrest, suicide, cancer (particularly of the breast and gastrointestinal tract), cirrhosis, fetal alcohol syndrome and sleep apnea.

"Sobering statistics warn that moderate daily drinking is a slippery slope that many individuals cannot safely navigate," the study authors conclude. "The latest American Heart Association guidelines caution people not to start drinking if they do not already drink alcohol, because it is not possible to predict in which people alcohol abuse will become a problem. Until we have more randomized outcome data, and tools for predicting susceptibility to problem drinking, it would seem prudent to encourage physicians and patients to focus on more innocuous interventions to prevent CHD."

J Am Coll Cardiol. Published online August 23, 2007.
2007;50:1009-1014.

New Drug Fails to Improve Odds for Heart Failure Patients

(HealthDay News) -- A new drug is no more effective at improving the survival rates of people with decompensated heart failure than a widely used medication is, a new international study has found.

Decompensated heart failure is one form of the general condition in which the heart progressively loses the ability to pump blood. It is characterized by a set of symptoms including shortness of breath and intolerance to exercise.

There were hopes that the new drug, levosimendan, would improve survival, because it uses a unique mechanism that makes heart muscle cells more sensitive to the calcium that causes them to contract. However, the study of 1,347 persons with acute decompensated heart failure, done at 75 centers in nine countries between March 2003 and December 2004, found essentially the same death rate for participants who got levosimendan as those who received an established medication, dobutamine, said a report in the May 2 issue of the Journal of the American Medical Association.

The trial leaves cardiologists without a totally satisfactory treatment for decompensated heart failure, said Dr. Robert Hobbs, a Cleveland cardiologist specializing in treatment of the condition. Some 5 million Americans have one form or another of heart failure, and about 1 million of them are hospitalized for it each year.

"The original therapy, which is still basic, is diuretics," Hobbs explained. "They make the body lose water, so people feel better. In the 1980s, ACE inhibitors came along to make people feel better and live longer, and they were added for long-term benefit. The third group of drugs to be used were beta blockers."

Dobutamine is a positive inotropic agent that has been found to improve symptoms, but it has also been associated with an increased risk of death and cardiovascular problems. In the latest trial, participants with decompensated heart failure received levosimendan or dobutamine intravenously.

"The common practice has been to give dobutamine in the belief that the heart is like a battery that has lost its charge," Hobbs said. "By giving dobutamine, you would recharge it. That didn't actually happen [in previous studies]. It appeared to be associated with complications, longer hospital stays and more mortality."

In another previous study, careful analysis indicated that levosimendan was associated with a lower risk of death than dobutamine. "It did have the different mechanism of action, and it was felt that might translate into improved safety," Hobbs said. But it proved to be no better in the new trial.

In the 180 days after drug infusion, the death rate was 26 percent among patients who got levosimendan and 28 percent in those getting dobutamine. There was no statistical difference between other endpoints, such as incidence of breathing difficulties and days spent out of the hospital.

Participants who got levosimendan were less likely to experience cardiac failure but more likely to experience the abnormal heartbeat called atrial fibrillation, low blood levels of potassium, and headache.

"The bottom line on all of this is that it is hard to show benefit for what we do for acute decompensated heart failure," Hobbs said.

More information
All aspects of heart failure are explored by the American Heart Association .

ADHD Drug to Get Stronger Warning

(HealthDay News) -- U.S. officials have asked a pharmaceutical company to add a label warning of a risk for heart problems for patients taking the prescription drug Dexedrine, a stimulant used to treat attention-deficit hyperactivity disorder (ADHD).

The warning describes some instances of sudden death in children and teens with structural cardiac abnormalities or other heart problems. It also mentions various potential psychological side effects, including hallucinations or delusional thinking.

The U.S. Food and Drug Administration could not be reached for comment, and it was unclear what other ADHD drugs might be affected by this new warning.

Back in May, the FDA had asked makers of similar stimulant ADHD drugs to add the warnings.
"This had already been done with other stimulants," said Dr. Melvin Oatis, an assistant professor of clinical psychiatry at New York University School of Medicine's Child Study Center. "Dexedrine is in an older class of stimulant,s and not much new had been done with that."
A letter sent from Dexedrine's maker, GlaxoSmithKline, to health-care providers was posted Tuesday on the FDA's Web site. The letter detailed the planned changes to prescription recommendations.

In March, an FDA pediatric advisory committee had recommended that ADHD drugs not carry the more severe "black-box" warnings and instead use simpler language and include more information on the labels about the heart risks posed by the drugs. But the month before, a different FDA advisory committee had reached the opposite conclusion, and called for a black-box warning on ADHD drugs because of possible cardiac risks.

The FDA has apparently settled for the less-severe advisory.

"This is not a black-box warning," Oatis said. "There's some association [between Dexedrine and heart problems]. They're not making this a causality."

An estimated 2.5 million American children under the age of 19 take ADHD drugs, as do 1.5 million adults.

This represents a huge surge in use, experts said.

"ADHD is being recognized more often than it was before," said Dr. Eugenio Rothe, an associate professor of psychiatry at the University of Miami Miller School of Medicine, and director of the child and adolescent psychiatry clinic at Jackson Memorial Hospital. "When the disorder is being recognized more often, obviously there's more use of medication," he said.

In addition to "serious" cardiovascular side effects, the warnings issued since last spring cite possible suppression of children's growth, as well as heightened risks for psychosis, Bipolar disorder and aggression.

The revisions may have an effect on prescribing patterns, Rothe said.

"On the one hand, it may actually help pediatricians and even some psychiatrists be more careful," Rothe said. "But, on the other hand, it scares people away from getting treatment and also increases the amount of time that one has to spend with parents trying to convince them this is the right thing to do. Doctors are already stretched thin."

Oatis added that the new warning "should remind clinicians to review the side-effect profiles of medications. It reminds you to take more of a history of family issues regarding stimulant use and medical cardiac risk."

According to the U.S. National Institutes of Health, ADHD is a disorder characterized by inattention, hyperactivity and impulsivity. These symptoms typically appear early in a child's life. However, many healthy children may have these symptoms, but only at a low level, or the symptoms may be caused by another disorder. For that reason, many experts believe it is important the child receive a thorough examination and appropriate diagnosis by a qualified professional.

More information
The National Institute of Mental Health has more on ADHD.